The classic Mad Magazine comic strip Spy Vs. Spy featured nearly identical spies – one dressed in black, one in white – constantly scheming to harm each other, usually with some incendiary device. The two alternated between victory and defeat in a clever visual representation of the Cold War.
Today, their ultimately pointless battle could just as easily serve as a metaphor for relations between Canada's provincial governments and their physicians.
The situation is especially intriguing – and reminiscent of Spy Vs. Spy – in Ontario and Quebec, two provinces trying to rein in the cost of physician services by assigning the task to provincial health ministers who happen to be high-profile physicians.
After talks between Ontario and the Ontario Medical Association (which represents 33,000 family doctors, specialists and residents), Dr. Erik Hoskins imposed a 2.65-per-cent fee cut.
In Quebec, Dr. Gaétan Barrette has introduced Bill 20, which would introduce a series of restrictions on the practice of that province's 22,000 doctors, notably establishing a minimum caseload for family practitioners, and increasing demands on specialists working in hospitals.
Predictably, doctors in both provinces have reacted angrily, while both health ministers have held firm.
The discussion of the finer points of Quebec's legislation and Ontario's imposed contract and the accuracy of the overheated rhetoric that has followed can be left for another time. But it's worth taking a few moments to ponder what's at the root of these disputes, and why governments are choosing to crack down on doctors even though, historically, that has proven to be a foolish political gambit.
To begin with, increased payments for physician services have been the principal driver of increased health costs in recent years, outpacing spending on both drugs and hospitals. Physicians bill $33.3-billion a year in Canada, with virtually no accountability. In other words, we don't know if we get value for money. That's not a knock on individual physicians, but a comment on how our system is not well-managed overall.
The reality for governments (and the public) is that there are more doctors than ever and they are more costly than ever, but access remains poor and waiting lists are a constant problem.
In Quebec, Dr. Barrette has argued that quotas are justified because, as the number of doctors has increased (5.6 per cent over five years), the number of patients seen has dropped (6.9 per cent over the same period). The minister also noted that 59 per cent of doctors work fewer than 175 days a year, a disputed number but one that irks doctors because it suggests they're lazy.
In Ontario, Dr. Hoskins raised hackles by saying doctors' pay has increased 60 per cent in the past decade. In fact, it's gross billings that have soared, a figure driven mostly by population growth and increased utilization.
Ultimately, contract talks are supposed to be about negotiating fair wages for workers. But we have no idea whether doctors are paid fairly.
We know that average billings are $328,023 but, taken in isolation, that number is meaningless. We don't know how many hours individual physicians work or their overhead costs, and those vary wildly. We don't even know if the services individual physicians provide are useful or cost-effective.
What we do know is that the current method of remuneration – paying a set fee for individual medical acts – is largely unwieldy and inefficient. In Quebec, the fee schedule is 498 pages long for GPs and 832 pages for specialists. In Alberta, it's a whopping 1,281 pages.
The way to deal with that monstrosity is not to impose an arbitrary 2.65 per cent cut, the way Ontario has done, and it's not to force doctors to see patients while continuing to bill in a ridiculous way, the way Quebec has done.
We need a fundamental rethink of the method used to compensate physicians – with an emphasis on the how, rather than on the how much.
What's required is a new social contract with a common goal – better patient care – not a black-and-white labour contract that gets revised in an incendiary war every couple of years.
To return to the metaphor, remember that in the slapstick of Spy Vs. Spy, neither of the two adversaries came out ahead. Like them, the provinces and the doctors need to find new ways of doing things – compromise and co-operation, instead of a constant exchange of bombs.