The One-sided Social Contract

When it comes to primary care delivery and care accessibility, Canada’s performance is way below what one could expect. Given the amount invested, the quality of the human resources it can rely on and the tax-based funding model it is built upon, one could have expected Canada to perform roughly at the level of most European countries. But it does not. From its depressing incapacity to reform primary care delivery in any meaningful way, to the worst ERs in the Occident and chronic accessibility problem to elective surgeries Canada really punches under its weight in many dimensions.

Because health is (mostly) a provincial responsibility, Canada is actually made up of ten quite different provincial health systems (plus the territories, many First Nation models, the Federally run things, etc.). So the question of what exactly Canada is doing wrong is all the more interesting to look at.

First, let’s clear the way. No, Canada’s poor performance isn’t explained by the limitation it imposes on private funding for medical services. Actually this idea that private funding could help isn’t even an answer. That’s a zombie and something that would necessitate blog post of its own. But if Canada is doing anything right, it is its reliance on a tax-funded, free to the patient model.

Second, international comparisons are tricky and nobody can pretend to be sure to have the right answer. The best that one can provide is probably an informed hypothesis. And here’s mine, Canada’s biggest mistake was the decision to give medical associations the status of a single mandatory “union” with bargaining rights for all doctors. This was the core element leading to our current  one-sided social contract.

Physicians’ associations  are powerful political players everywhere and there are many good explanations of why this the case. But whether it is the AMA, the CSMF or my ex-friends at the FMSQ, organized medicine is never something to take lightly in the policy world.

Canada is relatively unique in the fact it combines three elements 1) It has mandatory association bargaining rights (and compulsory membership at least in Ontario and Quebec) for physicians through the Rand formula. 2) There is a single provincial body that is both the association and the professional association (except in Quebec where there is a GP Federation, a specialist Federation and no professional association anymore). 3) And all this in a single payer public system where the government foots the bill for all medical care.

The combination of those three elements makes Canada absolutely unique. It created bionic physicians’ associations. Nowhere else do physician associations loom as large in health policy making. In Canada they literally own the place. From micro co-management to power politics and sitting on every committee that matters, our uniquely Canadian physician associations monopolize the conversation in every health-related policy. In technical terms, physicians’ associations in Canada have effectively captured the health policy field. To an extent this situation comes to be perceived as normal by most Canadian physicians

And I believe that this might be one of the root causes of some of our care delivery challenges. In the causal chain going from bionic physicians’ associations to mediocre performance, one central link is the pathological attachment to an over-reliance on fee-for-service (FFS).

When the “Medicare” system was slowly rolled in place in Canada during the 1960’s and 1970’s, the physician associations’ opposition to what they labelled as “socialized medicine” varied from all-out wars to stubborn lack of collaboration. During that period, the physician associations were often very close to killing the idea of a public health care system. In order to salvage this project, one element government had to compromise on was FFS.

Despite the Canadian government being the “sole insurer” for all medical services, and running the hospitals as part of the public sector, physicians were kept aside. Physicians were to remain autonomous self-employed “entrepreneurs” (oh my! those quotations marks have a lot on their shoulders) who would directly bill the government for whatever services they provided.

All this created the conditions for a remarkably one-sided social contract. A system where Canada’s society offers its physicians a guaranteed job, a guaranteed high income (to the tune of many times the median income) and the freedom to work mostly when and where they want (there are some limitations here). Canada even grant physicians specially designated tax loopholes (incorporation) to help them keep their new Tesla tax-free. In the eyes of any non-physician, all this sums-up to a quite generous offer.

The FFS model allows doctors to have full control over whom they treat and who they don’t. And there are too many truly appalling anecdotes as well as very disturbing hard data about who is left untreated not to take this seriously. In the same way, pure FFS allows for granting doctor total control over when and where they make their services available. And this is connected to accessibility challenges (macro and micro geographic as well as opening hours). FFS is also the most central barrier preventing the implementation of interprofessional teams in primary care, thus driving primary costs up, accessibility down and overall performance to the very bottom of the pack. Let’s also not discount the growing body of evidence connecting FFS practice with inappropriate care which both has serious implications for the health of patients as well as driving massive cost increases.

So overall there is a lot to discuss and not to like in FFS. Actually in any minimally rational or evidence-informed policy system, FFS would have been challenged and replaced by other compensation models.

And this is where our bionic physician associations are instrumental. History has shown us, if there is one thing, they will fight to death for, it is FFS. In their view, FFS is the sine-qua-non condition of “autonomous” medical practice. And when you have a bionic political player who decides that a given issue is off the table, well… it is. From making sure proposals that could challenge FFS never make it to the decision-making stage, to strong-arm techniques aimed at muzzling those who criticize FFS to being able to count on hordes of useful idiots on social media that will harass anybody voicing a criticism of FFS. On that last issue I could provide a whole compendium of examples. As a researcher I have worked on many topics over the years, but there is only one for which, as soon I publicly voice an opinion, as predictable as clockwork, medical trolls will write complaint letters to my university asking that I get educated, censored or fired (it seems public quartering isn’t as fashionable as it used to).

As stated earlier, Canada’s reliance on FFS physician compensation impedes the implementation of the changes necessary to improve care accessibility, appropriateness and affordability. At the same time, FFS is inexpugnably defended by our uniquely Canadian politically-bionic physician associations. That’s a bad case of Catch-22. We can’t improve our care systems while relying on FFS and, politically, we can’t challenge the FFS model.

Historically, FFS was embedded as a core feature of the Canadian health-care systems to make its transition to a universal, public model politically possible. Now our pathological attachment to FFS threatens to bring that same model down. The one-sided social contract Canada’s population signed with its physicians won’t last forever. Something will have to change. And the change we need is a new social contract. One that is double-sided. One where the medical associations are held accountable to the achievement of population health goals. One where FFS stops being a religion.

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