What would you rather have: Too many doctors, or too few?

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In 2016, Ontario’s Auditor-General found that the average family physician working in a popular practice model known as a Family Health Organization was working just 3.4 days a week, despite being paid for a full week.

These FHO clinics were also required to be open for patients on some nights and weekends – taxpayers were paying for that – yet 60 per cent of them were not living up to that bargain either.

Which may explain why 40 per cent of their patients had sought treatment from a walk-in clinic or other family physician.

A source with long experience in the system, as both a doctor and an administrator, told me that provinces need to find the courage to fire non-performing family doctors. In any other workplace, you’d be terminated for not performing. But with millions of Canadians without a family physician, the idea of reducing the physician supply, by so much as even one doctor, sounds like counterproductive madness.

Under our current circumstances, it is. But we can change our circumstances.

Canadian medicare is designed to remove health decisions from the vagaries and abuses of the market, at least for patients. With rare and usually illegal exceptions, you don’t negotiate with your doctor over how much you will pay.

But health care is still a market. The government is the buyer. Physicians and other providers are the sellers. Medicare doesn’t operate outside the realm of economics – a realm of human behaviour, marked by interests and incentives, and forces such as supply and demand.

When the system uses those to the public advantage, medicare succeeds. When it does not, it fails.

That’s why I wrote earlier this month that Canada must quickly and dramatically increase the number of family doctors. Up supply to meet demand. Ideally, get supply higher than demand.

Thousands of Canadian citizens are attending or recently graduated from medical schools in places such as Australia and Europe. Most are prevented from practising in Canada, though surveys suggest that’s what most would like to do.

I also wrote that Canada should double or triple the number of residency positions, which are apprenticeships for medical-school grads. In response, one physician e-mailed to say it’s not possible, because we don’t have enough physicians to train more physicians. But others wrote to tell me that more residents would be a big help, since a medical-school graduate is a highly trained – albeit not yet fully trained – physician. They’re a junior doctor.

Provinces should set the goal of ensuring that every resident is registered with a family doctor or family clinic, ASAP. Today, somewhere between one in eight and one in five of us do not have a family doctor.

What would happen if Canada had a lot more family docs? It would change the relationship between supply and demand. All else equal, it would be a lot easier for Canadians to find a doctor and get an appointment.

But all else won’t be equal unless governments pay attention to incentives and outcomes. There’s more than just supply and demand.

Back in the early 1990s, provinces cut medical-school enrolments to reduce health care costs. It sounds insane, and it was. But there was a logic to it.

Under the billing model known as fee-for-service, a physician charges the province for every patient seen and every procedure performed. That offers potential for abuse: The more patients a doctor sees, the more they get paid. The doctor who churns through a series of two-minute perfunctory visits is rewarded; the conscientious physician is punished.

To address what was called induced demand, the provinces chose the very blunt instrument of limiting the number of doctors. They created a doctor shortage.

In the early 2000s, some provinces began encouraging family docs to move off the fee-for-service model, to salaried compensation. Physicians would get a salary in return for being responsible for a large roster of patients. Doctors would also work in teams, enabling them to offer after-hours appointments. The aim was to give every patient a doctor, control costs, incentivize for better care and reduce emergency-room visits.

It was and is a good idea. But it also contains economic incentives for abuse. As Ontario’s auditor discovered, instead of seeing too many patients under fee-for-service, some doctors on salary were seeing too few, while cashing a full paycheque.

There is no perfect system. There is no getting around the need for incentives and management to discourage abuses and encourage good service. That’s what every business has to deal with, every day.

But the task of fixing our health care system would be a lot easier if there was less of an imbalance between physician supply and demand. A lot more supply would give public-health authorities more room to drive hard bargains with the suppliers: doctors.

We should also be fostering competition for family docs, from the only competition they have – nurse practitioners.

I believe in medicare. I believe in universal health care. But I also know that you can’t suspend some basic facts of economics, or how humans operate. To save medicare, we must get the incentives right.