When you have a public health care system (as we have in Canada), it can lead to inefficiencies.Carleton University's Health and Counselling Services provides a great example of this (hat tip to my fiancée, Laura). They have a rather strange policy: "Only one issue per visit will be addressed."
Let's say I have two issues I want to discuss with a doctor. Perhaps I'm concerned I have strep throat. Since I'm going to the doctor anyway, it would probably make sense to discuss a refill on a prescription that is expiring soon. Is it more efficient to tackle both these issues in one visit or in two separate visits?
One visit is clearly more efficient. That's because there are significant fixed costs associated with each visit. Regardless of whether I want to discuss one issue or 20 with the doctor, I have to travel to and from the clinic and wait in line once I get there. From the clinic's perspective, the receptionist has to greet me and deal with my paperwork each time I visit, clean the doctor's room, put a new one of those tissue paper coverings on the examination bed, and the doctor has to introduce themselves and review my file. These are fixed costs because they occur for each visit, regardless of how many issues are addressed.
In addition, the quality of medical care will likely decrease when doctors can only tackle one issue per visit. What if my strep throat-like symptoms are actually caused by a side effect of my prescription? That might not come up if I'm not allowed to discuss multiple issues with the doctor.
Of course, the doctor will need to spend more time with me if I wish to discuss more issues. But they'll have to eventually spend this time with me, whether I address the issue this visit or with a future visit.
So why would the health clinic of a university, which is supposed to be a bastion of knowledge, limit students to one issue per visit when it is clearly an inefficient system? Absent any explanation on Carleton's website, my bet is it's about the bottom line. Under a fee-for-service model, the government reimburses doctors based on the services they provide. With this system, the clinic gets $77.20 for each consultation a doctor does, whether it's about one issue or many (although doctors are paid more if the consultation goes over 50 minutes). If the clinic makes you come back twice for two problems, they earn twice as much.
If health care were privately provided, this probably wouldn't happen. When individuals have their own money at stake, they're going to make more efficient decisions than when everything is free. And in a competitive system, health care providers must operate effectively, or people will take their health care business elsewhere.
If patients had to pay twice as much out of their own pockets to deal with two problems (even though the total cost of treating two issues at once is less than treating them in two visits), those doctors would probably start losing their patients to ones who are willing to deal with multiple issues in one go. And society would be better off for it.
Biden takes a wrong step
1 day ago
Just to make something clear: a public system does NOT necessitate fee-for-service. Therefore, the solution of a privately-funded system does not necessarily follow.
ReplyDeleteFurthermore, physician clinics are private in Canada, but paid for with public funds.
Finally, why would a service have to be privately provided in order for things to change? Canadians are paying for this service anyway, why not push the politicians to make the change?
Or better yet, go see another doctor that will let you discuss multiple things in one visit - something you can do now. (I know first-hand that they exist, but you might have to leave campus).
You don't have to have a privately-paid system to fix these issues.
In BC, there are new (well, a few years in now) fee codes that allow doctors to bill not just per visit but for patient needs. It's made it more efficient for doctors and patients. And a program trains doctors to have a more efficient office booking system so they can see more patients without having them wait longer for appointments (the longer you wait, the more issues you have to discuss). This is a client of mine, hence all my knowledge, but you can read about it at http://gpscbc.ca/. Once again, BC trumps Ontario. :-)
ReplyDeleteSorry to hear Laura isn't well.
@Anonymous: True, there are other public options besides fee-for-service, which may create better incentive structures for doctors.
ReplyDeleteAnd sure, you could try to make changes within a public system, or find a better doctor who will deal with multiple issues in one visit. But if the $77.20 is coming out of people's pockets directly (as opposed to through income or sales tax, where the link is far less direct), their incentive to seek out good service, or push politicians for change, will be much stronger. When health care is "free," people have much less incentive to invest the time to research better medical options.
@Carla Thanks for your concern, but I'm happy to report Laura's fine (she doesn't go to Carleton's clinic — we have a family doctor who doesn't have a one-issue-per-visit policy).
Nice to hear B.C. has some more innovative systems in place. I conveniently failed to mention that Ontario also has some compensation schemes aside from fee-for-service that probably result in better outcomes (http://www.healthforceontario.ca/Work/OutsideOntario/PhysiciansOutsideOntario/PractisingInOntario/family_practice_models.aspx).
I'm just saying, confusing public with FFS issues to conclude that a privately-funded system will solve them is not sound.
ReplyDeleteI think a lot of people confuse the issues related to public funding/financing with delivery and other issues, and don't realize they would also appear in a privately-funded/financed system.
It all has to be in context.
To put an economics spin on an alternative explanation, the clinic is trying to help students address their limited forsight regarding their health.
ReplyDeleteA "one issue, please" policy creates an incentive for students to:
1) Get prompt attention when they have medical issues, instead of "saving up" issues until they can go at once. In general, people have a hard time accurately judging when they should see a doctor, and an ounce of prevention...
2) Not consume too much of a doctor's time with a litany of complaints and provide better patient throughput and see a GP or specialist if they have a serious concern.
Why should it be up to the patient to shop around for the "best" physician? How would we know if the price isn't justified with better quality?
ReplyDeleteWouldn't a lot of "health care consumers" take the price for the service as a signal for higher quality? When we don't pay at point of service, we judge quality on other things like "one-problem-per-visit".
@7:19 PM Anonymous: This is a creative counterargument. Let me start with proposition B. Under a one-issue-per-visit system, I am less likely to visit the doctor about minor issues, since I will encounter a fixed cost to the appointment each time. There would be situations where it'd be worth tacking the minor issue on to a major issue that I'm willing to foot the fixed cost for, but if I just had the minor issue itself, I wouldn't be willing to foot the fixed cost to get it resolved.
ReplyDeleteI tend to disagree with preposition A. Yes, they will have a greater incentive to visit promptly with a one-issue policy, but as I just discussed, there will be minor issues for which they will not seek medical attention, where they would tack the issue on to another visit in the absence of the policy. If people are bad at judging what is major and what is minor, as you suggest, then you're going to run into trouble.
@4:10 PM Anonymous: Yes, there could be challenges to identifying good physicians. But it's kind of like identifying a good mechanic, if you don't have much knowledge about cars. Sure, price might be a signal, but there are other tools you can use: word-of-mouth recommendations, internet ratings (e.g. www.ratemymd.ca), whether or not their previous advice resolved our problem, how well they communicate, how friendly they are, how on-time they are…
Unfortunately, doctors enforcing the “only one problem per visit” policy are prostitutes, exploiting the system. It is nauseating to know that they are allowed to do that. These criminals are not doing it because we need more doctors, but because they want you to book subsequent appointments and come back, so they can make extra money. Canada’s family doctors represent the National Rifle Association in the United States. The NRA not only scares law-abiding citizens, by telling them that the government wants to hijack their second amendment, but also bully lawmakers into timidity. As a result, guns continue to fall in the hands of criminals and crazy people, so they continue massacring innocent victims, including children. In Canada, family doctors want us to believe they are restricting patients to "only one problem per visit" because we need more doctors. While it is true that we need more doctors, those that we have should not neglect their patients; thus turning us into martyrs and their victims.
DeleteBut why should the patients have to do that research? This is our health here, our very well-being. Shouldn't we just worry about where the closest clinic is? Why would you want to put so much burden on the patient, when there are alternatives? Like, APP, salaried physicians, informing patients of the cost of services.
ReplyDeleteI mean, we have privately-funded drugs, and 13 systems in place to cover costs for the elderly and poor (and in some provinces, catastrophic coverage), but I mean, I don't think anyone in their right mind would argue that this is efficient. And sure, patients can choose (in some cases) generic drugs which lower costs, and they do, but this could easily occur in a publicy-funded system too.
I'd love to live in a utopia where all doctors are amazing and equal, where there would thus be no point for patients to do any research. But that's an unrealistic scenario. Doctors are human, so there are always going to be good ones and bad ones.
ReplyDeleteInforming patients about the cost to the provincial treasury of services is not going to change behaviour. Salaried physicians removes some incentive problems associated with fee-for-service (providing unneccessary services), but it creates a new incentive problem (a disincentive to provide onerous but useful medical services).
There are reasons why you might want to have a public system (equality, for example), but it would be very difficult (if not impossible) to design a public- or quasi-public system where there wouldn't be some perversion of incentives.
Same goes for the private system, only now it would occur in a less socialistic society - you would be on your own.
ReplyDeleteWhy are there still 'bad mechanics' in business? The private market doesn't fix that problem. They still enter the market, even if others exit.
And furthermore, it's like you are arguing that patients can not and do not shop around right now. You seem to think that having the patient pay up-front is the only way to make the physicians behave. I think wait times and other rationing really irritate people enough now to do something about it - especially when you don't have to pay a higher fee to see a different doctor that will address more than one issue per visit! (likely to happen in a privately-funded system).
As in, there might be a trade-off. People who can not or are not willing to pay the extra $ to see that physician that will address more than one issue will still see the doctor that doesn't - keeping 'inefficient' doctors in the privately-funded system, while increasing total expenditures.
ReplyDeleteFinally: the U.S. (privately-funded) has this one-issue-per-visit problem too. Therefore, it would appear that a "privately-funded, competitive physician market" would not fix that problem.
ReplyDeletehttp://www.sacbee.com/2011/10/09/3966418/one-problem-per-visit-is-this.html
http://www.doctors-look.com/usa-tx/orthopedist/jay-stuart-bender_583804.html
http://webpages.charter.net/oldpostpublishing/oldpostpublishing/Section%202,%20Principles%20of%20Public%20Health/Sect%202,%20Electronic%20Health%20Records%20and%20Public%20Health%20Informatics%20by%20Jackson.pdf
----search "per visit"
I'm curious to hear your reply to these last three comments.
ReplyDeleteSorry, I've been busy the last few days.
ReplyDelete@7:04 PM Anonymous: You're going to have good and bad doctors (or good and bad car mechanics) whether you have a public system or a private system. At least with a private system, the price mechanism will generally let good workers charge more, and bad workers charge less, which gives consumers more choice. But this is, as you point out, less socialist, so if your goal is a socialist outcome obviously this will not be desirable. And yes, there is still an incentive for patients to seek out quality doctors in a public system — just less so (there's also less of an incentive for doctors/clinics to provide quality care, since they can't be rewarded price-wise for this).
@ 7:07 PM Anonymous: Not sure I understand how total expenditures would increase. Under the public system, Ontario pays a flat rate of $77.20 per issue to the one-issue doctors, so even if a few patients were to migrate to a doctor who could deal with two issues at once for, say, $100, expenditures would go down.
@ 8:09 PM Anonymous: I maintain that a private system would help alleviate the one-issue-per-visit policy. I am not arguing it would eliminate it entirely. So the fact that you've found anecdotal evidence that it exists in the U.S. (as per your first two links) is not surprising. The third link makes me scratch my head a bit more. They don't really elaborate on why the U.S. "reimbursement system strongly encourages doctors to address only one problem per visit." If that's the case, off the top of my head I'm guessing it's because insurance companies are not setting a high enough per-visit deductable to give patients an incentive to demand their doctors deal with multiple issues at once. But I'd be curious to learn more.
re: why private is more expensive
ReplyDeleteWhen comparing nations with predominantly private insurance vs. those with public insurance, private is more expensive. Also, within nations that switched a service from publicly funded to privately-funded, the total expenditure for that service increased. Australia provides a good example of the latter - (it switched from purely public to having parallel private insurance), and it did not save the system money, the public system actually ended up subsidizing the private system, and among other problems there was just no way to keep the two systems separate.
Private systems are just more expensive. What the real question becomes is, will it provide better quality (i.e. better value for money). Clearly, the U.S. does not. Just compare life expectancy with per capita health expenditures among nations. Canada does not get good bang for its buck either, but to suggest that a private system is better is not based on evidence - there is a lot of ambiguity out there. But generally, we know private is more expensive.
Unfortunately, doctors enforcing the “only one problem per visit” policy are prostitutes, exploiting the system. It is nauseating to know that they are allowed to do that. These criminals are not doing it because we need more doctors, but because they want you to book subsequent appointments and come back, so they can make extra money. Canada’s family doctors represent the National Rifle Association in the United States. The NRA not only scares law-abiding citizens, by telling them that the government wants to hijack their second amendment, but also bully lawmakers into timidity. As a result, guns continue to fall in the hands of criminals and crazy people, so they continue massacring innocent victims, including children. In Canada, family doctors want us to believe they are restricting patients to "only one problem per visit" because we need more doctors. While it is true that we need more doctors, those that we have should not neglect their patients; thus turning us into martyrs and their victims.
ReplyDelete