Here in Ontario, the government has gone to war against the doctors again. This happens every time we are in the hole and the government has to rein in health care costs. The Health Minister goes on the radio to explain, more in sorrow than in anger, that the doctors' demands are completely selfish and unreasonable. The doctors retaliate by reminding the public how kind, hard-working and compassionate they are, and warn that if the government makes life miserable for them, they'll leave. (Actually, they don't have to leave. They can just cut back on their practice and start doing Botox.)
Politicians and bureaucrats are always attracted to simple ways to control health-care spending. In the early 1990s, they decided the best way to control spending was to cut down on doctors. This brilliant idea resulted in a doctor shortage that has taken the past decade to fix.
The reach for the quick fix has made fundamental change in health care all but impossible. It has given us the worst of all possible worlds – a system in which everyone behaves as if the competition for resources is a zero-sum game and no one is rewarded for acting in the collective interest. The system virtually guarantees turf wars. As a result, the medical professions resemble medieval guilds – fiercely protectionist, rigidly conservative and jealous of their status and perks.
This explains why all the sweeping top-down master plans to fix our health-care system will never work. As one insider puts it, "At each step, you find the structural impediments to change are extraordinary."
There are lots of cheaper, more effective ways to do health care. But the system is rigged to squash innovation. Take a simple thing like colonoscopies. This procedure – the single most effective screening test for cancer – is conducted in Canada by gastroenterologists. In other countries, it's done by nurse-clinicians. Why can't we do that too? Because the barriers erected by the various professional silos are almost insurmountable. Who would pay? Who would be ultimately accountable for the procedure? And so on.
Or take prescriptions. Do you really need to see a doctor to renew your Lipitor? Why don't we give prescribing powers to pharmacists? In fact, much of the work that family doctors do – ordering tests, taking your blood pressure, lecturing you to lose weight, even treating your bladder infection – is routine. Nurse practitioners and physicians' assistants could do it just as well. Don't try to persuade the doctors, though. (The last time I tried, they told me I might have bladder cancer and could die.) Besides, they need the fee income they get from seeing you.
But doctors are defeated by the system too. One group of doctors came up with a way to improve care for breast-cancer patients. Instead of sending a woman on an endless round of specialist appointments to the radiologist, the plastic surgeon and so on, they arranged for all the specialists involved in her care to meet with her all at the same time in order to lay out a treatment plan. When they told the hospital CEO about this breakthrough, he begged them not to spread the word. He feared the hospital would be flooded with patients it had neither the space nor the operating-room time to treat.
What kind of room is there to do things more effectively and efficiently? Here's one suggestive statistic. We spend around 12 per cent of our GDP on health care. Singapore spends around 2.4 per cent. By almost any measure, Singapore has better health-care outcomes than we have.
Everybody knows that health-care costs cannot continue to rise at the current rate. Everybody in the system can point out lots of ways to do things better. We have a highly trained work force full of talented, hard-working and dedicated professionals. But until we can figure out ways to get them to work collaboratively together, and to reward innovation – not punish it – genuine reform will be impossible. Doctor-bashing is not the place to start.