To Save Big Health Dollars, Put Doctors on Salary

A retired nurse says profit-seeking doctors order far too many visits and tests.

By Judy Smith 28 Aug 2009 | TheTyee.ca

Judy Smith is a retired nurse, freelance writer, and teacher. She lives in Vancouver.

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Patients need to ask some key questions.

British Columbia's government says it had no choice but to force deep budget cuts to health care -- and now various health authorities are scrambling to close operating rooms, eliminate elective surgeries, kill hundreds of jobs by dropping contracts with agencies serving seniors and the mentally ill, limit MRI scans, and more.

The government blames its cost overruns on a growing and aging population.

As a retired nurse who has seen first hand the health system's inner workings, I propose a different reading of rising costs, and a different way to cut them:

Let's take the business out of medicine and put the doctors on salary.

I offered this same advice last year when the provincial government conducted a "Conversation on Health" survey, during which many people voiced their opinions and solutions. Here is my logic.

Pulling in patients

The Ministry of Health itself points the finger at the rising costs of rates paid to physicians and the increased usage of lab and x-rays services. Such costs rose by a whopping seven per cent in 2007, and have continued to escalate at an alarming rate.

Having worked in a medical clinic, I saw the physician spend an inordinate amount of time and energy figuring out how to get paid more from MSP. It seemed to me that if the business were removed from his practice, his time would have been spent practicing medicine, and everyone would benefit from it.

Needless to say, my voice is barely a whisper in the grand scheme of things. We need someone who has the courage and vision to face down the Canadian and American Medical Associations and save our health care system from extinction. Where is Tommy Douglas when we need him?

A General Practitioner is paid $33.89 per office visit, for which only one condition can be billed. In other words, if you have two or more problems, he or she will treat you for only one; you will be asked to decide which is the most important, and return to be treated for the rest. Furthermore, since he or she doesn't get paid for phone calls, you will need to return to the clinic to get lab and x-ray results that are perfectly normal. We all need to see a doctor to get renewals of chronic medications. There is no medical justification for these visits. The only reason to go into the clinic is that the physician needs to get paid. How many times -- at $33.89 a shot -- have you had to see the doctor for no logical reason?

If you don't have medical insurance, by the way, you will have to pay $100 to a walk-in clinic for the privilege of seeing a doctor for five minutes. Imagine the scenario when we lose our government medical insurance. How much will it cost to see a doctor?

Tests that aren't needed

We need to do whatever we can to save the Medical Services Plan, which means as recipients, we need to question the feasibility of costs, understand our own health issues, and refuse expensive and unnecessary diagnostic tests.

For example, I recently went to see a doctor about a strained knee. It was painful and swollen from walking up and down stairs too much and from beginning Tai Chi lessons. The doctor agreed that my knee was strained; nevertheless, he ordered an x-ray and MRI. I refused the MRI. Five days later, I had to return to the clinic to learn that the x-ray report indicated there was swelling around the knee. By that time, the swelling had reduced considerably.

Now, even though I used to be a Nurse Practitioner, it doesn't take a medical genius to determine that, based on signs, symptoms and history, my knee was simply strained. There was no need for an x-ray, let alone an MRI. Using our senses -- including common sense -- costs nothing, and is often just as accurate as using expensive diagnostic equipment. It seems to me that the predominate attitude is, "If we build it, they will come." Since the equipment is there, we must use it, particularly when the costs can be billed to MSB. From my point of view, if I'd had to pay out of pocket, I would have refused both the x-ray and MRI.

A few weeks later, I went to the clinic to get a renewal of my diabetic medication. It annoyed me to have to do so, since a) I needed the medication, b) I had been taking it for over ten years, during which time I had to see a doctor every three months to get it renewed and c) I had to wait for over an hour for the appointment, stewing over the fact that apparently my time is of no importance.

My Diabetes Type 2: A case study

Along with over 200,000 other British Columbians, I have Diabetes Type 2, which is controlled by diet, exercise and oral medication. I check my glucose levels regularly and know when I need to adjust my diet and get more exercise. As recommended by Health Canada, I have a routine Hemoglobin AIC test done every six months, which gives an average glucose level over that period of time. The last one was done three months ago and was within normal range; however, the doctor wanted me to have another one done, and ordered a host of other lab work as well.

I took my requisition to the lab and asked how much the tests would cost. The technician and I discussed the cost and necessity of each test that was ordered:

Test: Fasting Glucose.
Cost: $16.
Why I don’t need it: I do it myself at home.

Test: Lipids (Cholesterol)
Cost: $40.
Why I don't need it: I had this done three months ago. There will be no change.

Test: Urinalysis/Urine culture.
Cost: $42.
Why I don't need it: Not necessary, as I have no symptoms.

Test: HgB AIC.
Cost: $23.
Why I don't need it: I had this done three months ago.

Tests: BUN (Bilirubin), Creatinine. Other liver tests.
Cost: $73.
Why I don't need it: Neither I nor the technician could determine why these tests were ordered. I have no symptoms of jaundice, liver disorders, or other internal organ dysfunction.

Total cost: Add on the lab costs of $8 and the total is $201.

In summary, it cost MSP $33.89 to get the renewal of a chronic medication plus $201 for unnecessary lab work: $234.89.

This might seem to be a small amount within a budget of $11 billion, but if all patients (200,000 total) are being ordered unnecessary blood work ($201) once a year, the potential cost to MSP would be $40,200,000 per year.

If medications could be renewed every six months, MSP could save the costs of two doctor's visits per year. In other words, there are at present two unnecessary visits to the doctor per year to get medications renewed. (In many countries the medication is sold over the counter, but I won't go into that.)

At a cost of $33.89 per visit, this adds up to $66.78 per patient.

The cost to MSP of 200,000 Diabetes Type 2 patients being unnecessarily seen by the doctor twice a year is $13,556,000. Add to that the cost of unnecessary lab work and we get the total cost paid out by MSP: $13,556,000 + $40,200,000 = $53,756,000.

In theory, then, it costs MSP $53,756,000 per year for unnecessary doctor's visits and lab work for Diabetes Type 2 patients alone.

It keeps adding up

Of course, some people do require a physician's care and lab work four times a year, some doctors might be more fiscally responsible, and patients can be more or less diligent, so these figures are an estimate at best. The calculations are stated simply to point out that, while the cost for one person might be minimal, when we apply it to many people with the same condition, the costs are astronomical.

Furthermore, MSP pays an additional $125 per year to physicians who are deemed to monitor diabetic patients. The justification is an incentive for physicians to care for diabetics who presumably take up more time than other clients. One wonders if "monitor" means simply ordering blood work, because when it comes to Diabetes Type 2, the person who can and must do the monitoring is the patient him or her self. If we need help with diet and life style, the Diabetic Association offers a host of expert advice which we are not likely to receive from a physician.

The primary mandate of the Ministry of Health is "to guide and enhance the province's health services to ensure British Columbians are supported in their efforts to maintain and improve their health."

It further states that, "By keeping people healthy and out of the health care system, we win on two fronts: people have a better quality of life, and valuable resources are freed up for treating non-preventable diseases."

I would argue that we also need to curtail costs and physicians need to allow people to have more input into their own health care.

Patients need more control

Since it does not serve physicians' financial interests to decrease patients' dependence on them or decrease the number of office visits, it falls on us -- the recipients and potential victims of a collapsed health care system -- to ensure that our medical insurance premiums are being used to support our efforts to maintain and improve our health.

We also need to learn more about how our bodies work and how to fix them, and we need to explore alternate means of maintaining our health. Most importantly, we need to ask questions:

Why? Why is this being done?

How? How will I benefit from it?

How much? How much will it cost?

In some cases it is helpful to know why the doctor advises you to go to a specific lab. Is it because he or she has part ownership of it?

When getting prescriptions filled, we need to ask the pharmacist: How much is your dispensing fee? (Fees vary from $6 to $13 per prescription.)

If cost is a factor, we need to request a generic brand of medications. Cost of medications can vary greatly depending on the manufacturer.

In other words, as patients, we sometimes forget that, for all their professional appearances, pharmacists and physicians are businesspeople. They will charge whatever the market will bear.

Until a governing body has the courage to take the business out of medicine, we must remember that we are the market.

We are the consumers, and we can choose to buy something, or not. We have the right to just say no.  [Tyee]

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