Private Clinics Discussion

[future_doc]

I'd still rather be a family doctor than work in a burger joint. I use to work at a fast food place (no burgers) and I hated it. If for no other reason, I'd still prefer treating people even with crap quality rather than feeding them crap. Besides, even though there hasn't been a paid study for it yet, if all things being equal the guy with a MD is more likely to get the girl. =p

 

Off-topic: I think there was some story going around recently that some hospital janitor took a pic of a surgeon, brought it home, photoshopped his head over the original, posted it on his eharmony page and instantly had like 40 dates that same week.

 

You sure know how to make us laugh. And I am sure the 2nde paragraph is true. I know o f a plastic surgeon who married a trophy wife and sent her to Arizona so as to be in charge of the decoration of the home. The 'pool boy' gave her more attention than her physician doc, and the pool boy is now living in the home with the ex-wife.

 

 

Anyways, the reason that capitation is so appealing for so many people considering family meds and even current GPs is because we're lazy and greedy. We want to see less patients but still get paid the same or more. When doctors start to see less patients, these patients still have to go somewhere. If a doctor who had to see 100 patients a day before suddenly can see just 20 patients a day then the 80 patients become a burden for someone else.

 

One could argue that capitation would draw in more people to family medicine so we'd have more family doctors... the problem with this is that we can't afford more doctors.. otherwise we'd have been paying the current GPs much more and probably not have such a shortage of GPs in the first place.

 

There is a reason why there is a shortage in FM and there needs to be a practical solution. Logic dictates that incentives, financial incentives, would help and there are incentives available to make patients more efficient in use of the health care system (discussed in one of the websites I had referenced above).

[Rayven]

There is a reason why there is a shortage in FM and there needs to be a practical solution. Logic dictates that incentives, financial incentives, would help and there are incentives available to make patients more efficient in use of the health care system (discussed in one of the websites I had referenced above).

What website? And what incentives for patients? Be more clear. I already said that the last 2 links weren't working.. the 2nd last one isn't even a link I think.

 

The reason why there is a shortage of people going into FM is because the money sucks. Stay in school for 2 or 4 more years and you'll make twice as much. Pretty much everyone knows that. So what do you do? The competitive specialties are so competitive because either the lifestyle is attractive or the money is.. or the work I guessss... >.>

 

So what do you do? If you raise FM pay up (which will have to come from somewhere...) then we'll have less people going into the specialties because they could be done and working 2-4 years sooner and still be making fistfuls of cash. If you cut specialty salaries then they'll go to the States which will cause even more wait times upon referrals.

 

Personally I like the fee-per-visit setup because it's the most capitalistic and it drives doctors to see more patients which is pretty vital when we've already got a shortage of family doctors. Capitation, in essence, rewards laziness.

[tooty]

You're right about your post being really simple. I don't think FourtyTwo nor I misread anything... FourtyTwo actually did propose an idea in his or her reply. However, I was just agreeing with his or her first statement that there's nothing wrong with us criticizing an obviously terrible idea without us having to provide another idea. I can understand that it's frustrating having your own idea(s) shot down without having anything to attack back. But the way I see it is more like you're defending your thesis. I don't need to present my thesis in order to question yours in order for a "balanced" discussion.

 

 

If not taxes then what else do you call forcing every citizen to pay a little more to the government for a government-paid service? "Premiums"? lol...

 

Your idea from what I gather is that:

1. If we pay family doctors more then we'll have more people choosing to become family doctors.

*Well.. duh. If you paid me 6 figures to flip burgers at McDonald's then I'd probably do that for a few years before even considering medicine. Being a broke ass student while your friends are already starting their lives seems like a very depressing prospective.

 

2. It'll improve quality of care.

*I actually don't know about this. Basically we're assuming that family doctors will have to see less patients in the future to make the same income as they are generating now (lets say ~120k-150k). But what's stopping the natural greed of the doctor from continuing to see the same high volume of patients to make more money? (~200k+)

 

3. Less burden on government

*Well.. duh. If you all Canadians agreed to pay an extra $1000/year to the government then yeah... I imagine that would help lessen the burden on the government.

 

 

Because like a good politician, I don't think tooty wants to call it a "tax" lol.

 

But to address your point, I don't think more taxes is the answer. I doubt people would be willing to pay more and raising taxes can't be the answer to all our problems.

 

yes, an obviously "terrible" idea that FRANCE uses.

 

you two did misread my post. i wasn't trying raise new ideas in defense of my own, i was doing it for the sake of discussing. you can write what you want on this forum. if you just want to bash other people's ideas and keep using "obviously it's bad" as an argument, that's your freedom to do so. it's also your freedom to misread posts.

 

and stop going against everything i'm saying. it sounds desperate.

[future_doc]

Sorry Rayven, I tried to find the site but could not (I had thought by giving the refernce I did not need to keep a copy). The article went into detail of incentives for the patients, however, I did not really focus on that aspect, so sorry again. I agree with Alastriss who makes the argument better than I have.

[Rayven]

yes, an obviously "terrible" idea that FRANCE uses.

Way to address none of my points... But fine, if you're just going to say that another country uses it and it's working well for them then please define what is considered successful and would it be as successful in Canada and why.

 

you two did misread my post. i wasn't trying raise new ideas in defense of my own, i was doing it for the sake of discussing. you can write what you want on this forum. if you just want to bash other people's ideas and keep using "obviously it's bad" as an argument, that's your freedom to do so. it's also your freedom to misread posts.

 

and stop going against everything i'm saying. it sounds desperate.

Stop crying. It sounds desperate.

 

We're not "bashing" other people's ideas. We're discussing the pros and cons. It just happens that some of us chose to discuss the flaws (otherwise there wouldn't be much of a discussion) and now you're trying to paint us as bullies picking on you. Not cool. I think it's rather hypocritical of you to accuse the other side of using simplistic arguments like "obviously it's bad" when clearly the points I raised in my post went unaddressed and your best response was "Well, FRANCE does it!"

[Rayven]

responding to rayven:

 

2. It'll improve quality of care.

*I actually don't know about this. Basically we're assuming that family doctors will have to see less patients in the future to make the same income as they are generating now (lets say ~120k-150k). But what's stopping the natural greed of the doctor from continuing to see the same high volume of patients to make more money? (~200k+)

 

 

It will improve quality of care because the GP is now a coordinator. In other words, they select the best hospital, best specialist in their eyes so their patients can get the best care. They will also follow up and keep tabs on the patient because they have incentive to.

I don't understand.. how is the GP the coordinator now? Do you mean like the gate-keeper? If so, hasn't the GP always been the gate-keeper in this country?

 

Don't doctors already select the best hospital and the best specialist for their patients...? On a side note, I have to say, the best specialist in the country would be pretty busy huh? Sucks to be anything less than best. =p

 

If they treat the patient well then they patient is happy and stays on the roster. It also means that they can nip problems now so that they can not escalate in the future.

With the current shortage of family doctors, I doubt there's too many roster jumpers. Most would be happy just to have a family doctor. I think, presently, choosing your family doctor has always had a lot more to do with geographical convenience and language options.

 

I agree, though, that under a capitation system that doctors would have an incentive to nip problems and thus have to deal with the patient less than if they had let the problems escalate. But of course, another way around this would be just to pick healthy individuals which you address later on.

 

Payment scheme is such that, remuneration = n(e)[k - C(e)], where n is the number of patients on the roster, e is effort put in by the gp, k is the amount you get/ patient, and C is the cost you put in. C decreases with increasing e and n increases with increasing e.

lol.. interesting formula. I'm curious.. why does cost © decrease with more effort (e) inputted by the physician and how does the more effort you put in as a physician automatically increase number of patients (n)? I would think that the more effort you put in translates to more time and thus a cost to your potential income which is the big problem with capitation. Under capitation, you're already paid in advance and thus every patient you see actually reduces your earning potential.

 

ie

You get $150,000/year

If you saw 1 patient in that year you made $150,000 per visit.

But if you saw 100 patients in that year then you made $1,500 per visit.

Etc.

 

The problems with this scheme is you can get cream skimming (doctors want healthy patients that they dont have to spend much effort on) and one other thing I can't remember.

 

it isn't completely flawless.

Yup. I guess the question is if it's better than the current system we have now. The fee-per-visit system is flawed because logically doctors plow through visits in order to maximize their earnings. The capitation system is flawed because logically doctors try to see as few patients as possible to maximize their earnings. That's basically what I end up seeing.

[Rayven]

1) A gp can be a coordinator or a gatekeeper depending on the remuneration scheme. We have gatekeeper gp's because we have a ffs scheme. If we had a capitation scheme we would have a coordinator gp because of the incentives in place. There are no incentives for GPs to actually refer a patient to the best possible facility. But if you were given x amount of dollars to take care of a patient and were responsible for THEIR COSTS, you would make sure that your patient got the best treatment. That way, they don't have to cost you extra because the job wasn't done to perfection the first time.

So basically a "coordinator" is a gatekeeper that cares..? I would think that even under the FFS system family doctors still refer their patients to the best specialists and facilities for their patient. Usually this means the best nearby specialist because it's the most practical. If the best dermatologist in Canada works in Toronto, I doubt every family doc in BC would refer their patients to Toronto.

 

I'm not too sure what you mean by that the doctor would be responsible for the patient's cost. Could you explain that more please?

 

And again, I agree that doctors under the capitation system would want to treat their patients well because ideally they'd never want to see them again.. lol

 

Cost decreases with effort because you take preventative measures to make sure they don't get sick further.

 

I think its just better if you PM me your e-mail and I will send you all of this. It has a fair deal of economic jargon but if you can manage to push through it you can get a real good idea of what I have been trying to echo.

Oh I see. I was thinking more of the standpoint of how much you effort you put in and how much you get paid for said effort. I'd like to make a point that although it's true that some extra effort can prevent some patients from getting sicker or coming back for repeat visits, not every patient visit usually deals with such matters. You can't really prevent patients from getting the fever or a cold or vaccinations.. etc. I actually wonder if more time spent with your GP is really that important in most cases.

[Rayven]

If you really care to know, then pm me and I can sort it out.

Responded.

[tooty]

Way to address none of my points... But fine, if you're just going to say that another country uses it and it's working well for them then please define what is considered successful and would it be as successful in Canada and why.

 

 

Stop crying. It sounds desperate.

 

We're not "bashing" other people's ideas. We're discussing the pros and cons. It just happens that some of us chose to discuss the flaws (otherwise there wouldn't be much of a discussion) and now you're trying to paint us as bullies picking on you. Not cool. I think it's rather hypocritical of you to accuse the other side of using simplistic arguments like "obviously it's bad" when clearly the points I raised in my post went unaddressed and your best response was "Well, FRANCE does it!"

 

lol okay son

[Rayven]

lol okay son

lol okay daughter.

[future_doc]

Then is he gay? b/c your daughter is a guy!

[marshan]

Didn't read the whole thread, saw the article. Still a little undecided on this topic.

 

However, it's interesting that they charge $2900 a year, because I'm not gonna lie, that's probably how much my family spends on cable, Internet, and movie tickets a year...

 

Anyone else invest approximately $240 a month on something "indulgent" that they would put towards better access to a doctor and all these services?

 

Further, I wonder if tax payers wouldn't mind paying that extra little bit per year either, and if it would help at all? I think it would be fantastic if we could spend a full hour covering our patient's issues, the current system doesn't allow that, and sometimes...that too feels unethical.

[A-Stark]

If you're asking whether taxpayers wouldn't mind paying almost $3000 more in taxes every year, I'd say that you have a talent for asking really obvious questions. I don't consider cable, internet, and the odd trip to be the movies as anything other than things inherent to an adequate standard of living, particularly in light of the fact that a substantial portion of existing tax revenue goes toward physician services.

 

I can't speak for matters elsewhere, but in Nova Scotia the billing schedule allows for seeing some patients for different lengths of time for different purposes. And unless a patient is particularly complex, even a half hour of time is excessive; facilitating the worried well and well moneyed in their attempts to have "elite" health care is deeply neglectful of those patients who are far more in need, keeping in mind of course that poorer health status and outcomes go hand in hand with lower income.

[apache]

I'd find this type of practice desirable, I'd love to be able to keep a low volume of patients and give them the best I can everyday, unfortunately, the specialties I have in mind don't tend to have high SES patients .

[moo]

Sorry to be late to this discussion, but here's my bit.

I am a Community Medicine resident right now (public health and epidemiology) and am taking a health care policy course for my MPH degree. Our health care system is publicly financed (one big government insurance plan for each province) but predominantly privately delivered. Yes, PRIVATELY DELIVERED. Family physicians are all private practitioners. That means, family docs do not work for the state (unlike the UK). The majority (95 percent) of hospitals are private not for profit. Some (usually psych hospitals) are entirely public. The debate between "two tier" health care really is private not for profit versus private for profit. Private not for profit hospitals usually get their funding from their provincial government, health authority in which they reside and also from private donations and gifts. For example, in Vancouver, Delta Hospital recently got a new CT scanner--paid for not by the government but from their hospital foundation, raised through private funds. A lot of Catholic hospitals in Canada do not offer abortions or other contraceptive services, and they can do this because they are a private institution.

 

Anyway, just thought I'd like to introduce this to this discussion. People need to know that our system is not completely "public." The UK's system is completely public. Physicians work for the state. Hospitals are all public. The US has a conglomerate of government payer (medicare, medicaid, like our system), private payer (insurance companies), government run (the VA system, which is like the UK), and private for profit hospitals, although most (80 percent) are private not for profit, just like here.

 

As an aside we do have private for profit hospitals already here. Brian Day's Cambie surgical is private for profit and caters mostly to WCB, ICBC, out of country and private payers who do not have public health insurance (MSP) in BC.

 

I hope this clarifies things a bit.

[Neptune]

Thanks for the informative post, it's always nice to read contributions from people who know more about policy than your average bear.

 

The debate between "two tier" health care really is private not for profit versus private for profit.

 

I'm not sure this is how most people see it. If all of a sudden hospitals and doctors started charging more for their services in order to pull a profit and the government was willing to pay, but the level of care/wait list times/ etc. remained identical to what they are now, there would be no two-tier system even though it would be 'for profit'.

 

In a 'two-tier' system there are two different levels of service, one for those who pay privately, and another for those who go through the public system. This exists in England for both medicine and dentistry, where wait times for treatment are much shorter if you pay privately as opposed to going through the NHS. Physicians can bill private patients at a higher rate than they can bill the NHS, and this is leading to a big discrepancy between the level of care between public and private clinics.

 

Patients can already pay privately in Canada, but the cost is the same and the treatment is the same as if you use government insurance. I know this one well: during one of my recent trips to Canada I ended up visiting the ER due to a sporting accident, and after treatment I had to ring my credit card through the till to pay. (I am currently living overseas, so no Canadian health care for me!). I also know of a foreigner who was living in Ontario for awhile, and when he developed back problems he paid for the initial consulation, CT scan, and follow-up appointment with the specialist out of his own pocket.

 

However, the fact these services were paid for directly didn't make any difference in regards to the quality of treatment or the total cost. No one got bumped up the waitlist, and no one got an appointment with a specialist they wouldn't have otherwise been unable to see.

 

If physicians are allowed to give preferential treatment to patients in return for receiving money over and above what they would receive from government insurance, this is where the problem comes in. So a two-tier system is certainly related to profit, but it's more than just who makes money, it's who gets better treatment based on how much they can pay.

 

My 2p.

[moo]

Thanks for the informative post, it's always nice to read contributions from people who know more about policy than your average bear.

 

 

 

I'm not sure this is how most people see it. If all of a sudden hospitals and doctors started charging more for their services in order to pull a profit and the government was willing to pay, but the level of care/wait list times/ etc. remained identical to what they are now, there would be no two-tier system even though it would be 'for profit'.

 

In a 'two-tier' system there are two different levels of service, one for those who pay privately, and another for those who go through the public system. This exists in England for both medicine and dentistry, where wait times for treatment are much shorter if you pay privately as opposed to going through the NHS. Physicians can bill private patients at a higher rate than they can bill the NHS, and this is leading to a big discrepancy between the level of care between public and private clinics.

 

Patients can already pay privately in Canada, but the cost is the same and the treatment is the same as if you use government insurance. I know this one well: during one of my recent trips to Canada I ended up visiting the ER due to a sporting accident, and after treatment I had to ring my credit card through the till to pay. (I am currently living overseas, so no Canadian health care for me!). I also know of a foreigner who was living in Ontario for awhile, and when he developed back problems he paid for the initial consulation, CT scan, and follow-up appointment with the specialist out of his own pocket.

 

However, the fact these services were paid for directly didn't make any difference in regards to the quality of treatment or the total cost. No one got bumped up the waitlist, and no one got an appointment with a specialist they wouldn't have otherwise been unable to see.

 

If physicians are allowed to give preferential treatment to patients in return for receiving money over and above what they would receive from government insurance, this is where the problem comes in. So a two-tier system is certainly related to profit, but it's more than just who makes money, it's who gets better treatment based on how much they can pay.

 

My 2p.

 

Yes patients can pay privately but ONLY if you're not covered by the government plan. For example, you did not have health insurance, so you had to pay. I see a lot of Americans as a family doc because I work near the border (near Pt Roberts where they don't have a doctor and it's a 40 minute drive through Canada before they can see another US doctor) and they pay privately.

 

To have a completely two-tier system would require the re-writing of the Canada Health Act, as paying for any insured medically necessary service is prohibited under this act. The erosion of public health care as portrayed in the media and by politicians is really the introduction of private for profit clinics and hospitals like Brian Day's in Vancouver. These private for profit institutions can still operate legally as the patients they see are insured under different plans (like WCB and ICBC). The private patients they see are predominantly those who have no health insurance in Canada, for one reason or another. Believe it or not there are many PRs in Canada who have no health insurance. I once admitted an older Filipino lady for a stroke, and took care of her in the hospital. I was following up on her in clinic when she subsequently lost her health care and was trying to get it back. I ended up treating her for free in clinic but if she ever needed hospital services she would end up bankrupt.