Sunday, January 13, 2013

Queue jumping

In Canada we have waiting lists.  This means that depending on the procedure or service you want, you may wait anywhere from 2 days to 2 years.  There is much hand-wringing about this, however life goes on, overall we get pretty good care and except for a few of what our former premier called victims of the week, nobody suffers all that much.

As a poison pill for his successors Stephen Duckett the former CEO of our health authority mentioned that in Alberta, there were members of the administration who were the "go to" guys for important people or squeaky wheels to get the head of the line and not have to suffer along with the great unwashed.  Dr. Duckett did this sometime before he got fired for doing this.

As a result of promises made during her leadership campaign plus desperate promises made when it looked like she was going to lose the election, we now have a commission into preferential access or as we commonly refer to it, "queue jumping".   This is enriching at least one retired judge and multiple lawyers to the tune of about $10 million,money that will never be spent on patient care.  It has to date been tremendously unproductive with people testifying that they had heard rumours of influential people getting special treatment but nobody is naming names.  This is not surprising as physicians and most health care workers are prohibited by various codes of ethics from divulging patient names and in fact the first doctor or nurse to name names is going to be getting a letter from their professional body.

But of course we all know that queue jumping goes on and that influential patients do get treated sooner than ordinary patients.  This is partially controlled by doctor's offices who after all decide in what order their surgeries will be done or whether or not to squeeze another patient into their busy day.  From conversations in the doctor's lounge many surgeons have stories about being asked to assess or treat an important person in a more timely fashion and who would disagree as after all they are important people.

As an anaesthesiologist I have very little to do with waiting lists (except that we all know if only anaesthesia would worker harder for more hours we wouldn't have waiting lists), however I do run a pain clinic with a fairly significant wait list.   And I let people queue jump all the time.  If a nurse asks me to see her or a relative early, I always try to help.  Likewise other doctors.  If we can't help each other, nobody is going to.  If a family doctor takes the time to phone me about a patient (instead of the usual unhelpful letters I get), I often put their patient in early.  Some family doctors, I know provide good service so I am more favourably inclined towards their patients.  I also try to take care of the patients of my fellow specialists in my hospital.  When another pain specialist wants a second opinion (this doesn't happen very often) I see them sooner.  Further I try to review my referrals and certain cases get seen urgently (this is actually triage which I will talk about below).  Face it another healthcare worker or relative of one is likely to actually attend their appointment and might even take your advice.

Further I have myself taken advantage of queue jumping.  When my kids broke a bone (or I thought they had broken a bone), instead of sitting in the emergency room  I just phone or talk to an orthopedic surgeon.  When my son broke his ankle on a Friday afternoon and I got the phone call at work I had visions of spending my Friday evening in the ER, until I thought why don't I just talk to the ortho on call who told me to just come to the ER as a direct to him.  As it turned out the ER was not very busy but the orthopod was very helpful for my son's non-displaced ankle fracture.  This is as opposed to the 2 or 3 times I decided to play by the rules and took my son to the ER and learned how badly the general public gets treated.  (After being spoken to very condescendingly by the family doc covering ER, I mentioned "Oh did you know I am a doctor, too?".  It was almost worth it,  just to see the look on his face).

When I needed a screening colonoscopy I could have wasted time going to my GP, and getting a referral.  Why would I do that.  I just phoned the gastroenterologist who got me in the following Monday (I would have been happy to have waited longer, honest).  Five years later, I sat down next to one the General Surgeons in the doctor's lounge and arranged my second screening colonoscopy.  When I hurt my shoulder, I got an MRI within two weeks of the surgeon requesting it; I never asked why that was.

The fact that doctors do this is one of the things that has come out in the inquiry and judging by letters to the editor, some of the public are upset that this happens.  My advice: get over it.

It was a sports medicine doctor who during the inquiry pointed out that with the long wait lists for various procedures, that it was only natural  that some degree of queue jumping would go on and that this wasn't necessarily a bad thing.   He hit the nail on the head.  This isn't in fact queue jumping, it is called prioritization or triage.

Imagine if the ER just saw everybody in the order in which they checked in.  MIs would wait for hours while all the colds got seen.  An extreme analogy?  That is how elective surgery and imaging is triaged in most of Canada.  This effectively means the young active patient needing say an ACL repair waits behind the octagenarian waiting for a total hip even though the young patient is an active member of society whereas the octagenarian may just be turning food into shit.  Every time I get the BMI of 50 or the cardiac cripple presenting for a total joint, I ask the surgeon, "I thought you had a waiting list?"  (or I think I so ask them).  It is the unwillingness of physicians to triage or prioritize patients that exacerbates the effect of the wait list.  People cry foul when a professional hockey player gets an MRI or surgery toute de suite.  I have absolutely no problem with this.  Notwithstanding whether I agree with how much a professional hockey player earns, they do depend on their body for work and I would rather they have their knee MRIed  than somebody with migraines getting an MRI that everybody knows will be normal.  Likewise if the surgeon wants to do their ACL repair instead of doing 3 arthroscopies on obese patients in their 60s, more power to him.  The same applies to elite athletes, I have no problem with their getting seen and treated sooner.

I am 55 and proudly got my first senior's discount last month.  If however I tore up my ACL I would happily take my place in line and wait a little if I knew that at least more useful members of society were getting treated a little sooner.   Not every 55 year old thinks this way.

Because of  perceived unacceptable wait times for total joints we now have an aggressive program to reduce those wait lists.  I was at one of the meetings related to this.  Patients when they are booked are given exercises to do that will help them rehab.  According to one of the physiotherapists, only 20% of patients actually do the exercises.  "There", I said, "your wait list problems are solved, you can take 80% of the patients off the list."  "Yes... well" said the nurse chairing the meeting and that was that.  I no longer go to those meetings.

Meanwhile, our Tea Party opposition who advocate patients being able to pay to get to the head of the queue are outraged by patients getting to the head of the queue without paying.

Saturday, January 5, 2013

Hitting the bricks

A very wise and now deservedly retired anaesthesiologist and medical politician told me the following many years ago:

"Negotiating with the government is like having a farting contest with a skunk."

While doctors in Canada are fee for service and some hospitals are nominally private entities; close to 100% of the money we get for medical fees and what the hospitals get for patient care (which affects how much we can bill in a fee for service system) come from various arms of the the government.  Medicare in Canada in Canada now dates back to the 1960s.  This means there is a whole generation of doctors in Canada myself included who have never given a Canadian patient a bill for a medically necessary service.  The odd patient with no coverage that I have to ask for money makes me feel weird, I suspect quite a few doctors just eat the bill and don't even bother billing.  When the rare boob job patient we get at our hospital pays me in $100 bills, I feel really dirty (for a while).  Getting paid almost exclusively by the government is not necessarily a bad thing; having a single payer makes billing really easy and we rarely get stiffed.  And after everything most doctors in Canada do okay and quite a few do very well.

Dealing with the government means every 2-5 years our union, which some people insist on calling a medical society, has to negotiate with the government.  Originally a fee schedule was arrived at with increase that usually more or less followed inflation and no upper limit on the total amount that either individuals or the entire profession could bill.  Predictably as doctors realized how to play the fee schedule and as patients realized that medical care was actually free the amounts spent on physician fees (or salaries as the press and politicians like to call it) exceeded the inflation rate.   Therefore around the time that I started in practice, governments started restricting the amount of money spent on physician services.  Attempts at restricting the amounts that an individual could earn fizzled out when it was realized that people would just stop working when they had reached their cap.   A global cap on physician services was arrived at with the threat of clawing back or pro-rating fees if the cap was exceeded (this to my knowledge has rarely happened in Canada).  Medical associations eventually arrived at sectional caps so that I, for example would not be penalized the the profligate ways of the plastic surgeons.

Periodically it is announced that doctors have gotten a X% fee increase.   This does not mean that I am going to get X% more money next year.  I might get more, I might get less.  Our union, oops medical association takes the money and allocates it to various specialties and procedures.  For example specialties like paediatrics and neurology may get a higher percentage of the fee increase because their overall incomes are less.  Over the last 10 years more of the fees have been directed towards after-hours premiums which are great for people like anesthesiologists who do a lot of work after hours.  We recently negotiated a 25% surcharge for obese (BMI over 35) patients.  Our own section of anaesthesia now has two hourly rates reflecting the various complexities of different cases.  We were also in the process of phasing out our procedure based billing which occasionally allowed anaesthesiologists to make huge fees for a single case.  Not a perfect system but better than what existed 20 years ago.

For those of us not involved in medical politics, while we noticed that our union and the government hadn't yet reached an agreement, we kept on getting paid and nobody was really that worried.  That was until the Minister of Health unilaterally imposed a deal on the medical profession.  At face value and according to the talking points issued by the government we were about to receive a 3 % increase with cost of living increases in the next few years.  That was until the small print was looked at.

Affecting anaesthesia was the elimination of the our higher tier of hourly rates and a 10% reduction in after hours premiums.  The procedure based billing which we should have eliminated years ago is also gone.  Other specialties got hit as well in different ways.  Somebody presumable is getting the extra 3% the government keeps talking about we just haven't figured out who.

This has put our society/union on high alert.  It has resulted in multiple emails from the president; an ad campaign from the government  and talks of striking or withdrawing services.

There is no question that some procedures pay way too much for what is involved, and some specialties make way more that they should for the hours they work and the complexity of the service they provide.  Some could argue that we as anaesthesiologists are over-valued.  Everybody looks at everybody else and undervalues what they do.  It is also true that our medical association has done very little to address these inequities assuming they exist (and they do).

I really don't like getting paid less for the same amount of work and on top of this just before this announcement, I finally figured I could afford to work less and actually quit one of my jobs.  I have a little sympathy with some of my younger and not so younger colleagues who have got themselves into huge mortgages based on the assumption of a certain income.  On the other hand I am a little bemused by the attitude of doctors.

Face it,as a bleeding heart liberal I usually keep my mouth shut when a political discussion breaks out in the doctors lounge.  Quite a few doctors still think that Genghis Khan was a bit of a leftie.  The  past 20 years have been a time of union busting no less in Canada than in the US and announcement of this have usually been received with glee in the forum of the doctors lounge.  All while it is gratifying to learn of the support the general public has for us either in the letters to the editor or in polls commissioned by the medical association; the public is better off not knowing how little the doctors have supported them in the past.
It is all too tempting to quote Martin Niemoller at this time; way too tempting in fact:

First they came for the communists,and I didn't speak out because I wasn't a communist.
Then they came for the socialists,and I didn't speak out because I wasn't a socialist.
Then they came for the trade unionists,and I didn't speak out because I wasn't a trade unionist.
Then they came for me,and there was no one left to speak for me.

Doctors of  course will argue that they are not a trade union but independent professionals and they of course are welcome to that delusion.  Some will even argue that without medicare, they would be able to make incomes equal to or exceeding what they make now from the patient's pocket.  This is of course true for  some, however quite a few of my colleagues would starve if patients had to dig into their pockets for the crappy service they provide.  

In the end, I suspect everything will work out, the government will give up something, our union will give up something and life will go on as before.  On the other hand I have gone 55 years without walking a picket line.  

Not that that was on my bucket list.