by Yan Xu
Published, April 1, 2015
In 1987, a high-profile and unpopular doctors’ strike over reimbursement shook the profession, leading to the creation of CanMEDS roles framework studied by every Canadian medical student. 18 years later, income is again the focal point in the latest negotiations between the Ontario Medical Association and the provincial government. As former Chief Justice Warren Winkler observed in hisConciliator’s report, without significant changes, both groups are on a “collision course” that will jeopardize the future of collaboration between providers of health care and those who fund it.
Current negotiations have largely evolved around the physician services budget, and this is an important discussion in its own right: Canadian physicians are generally paid well compared tocountries with similar health systems, even after adjusting for overhead costs. However, budgetary considerations must also take into account another component less prominent in public discourse: thevalue of physician services. In other words, how much health benefit do we gain from our $33 billion annual investment in Canadian physicians, and are there ways to improve it? Here, the results are not what one may expect.
One of the first experiments looking at this question took place more than 40 years ago in Burlington, Ontario, involving the use of nurse practitioners, registered nurses with 1-2 years of additional training, compared to doctors in the setting of primary care. The result? Patients assigned to nurse practitioners were seen without physician involvement two-thirds of the time, and health outcomes and care quality were similar whether they were seen by MDs or NPs. A 2012 Cochrane systematic review combined a total of 16 similar studies and arrived at the same conclusion. The results were not restricted to primary care: another review looking at control of asthma saw no difference between nurse-led compared to physician-led care, while a trial involving patients with atrial fibrillation saw higher use of evidence-based guidelines and better survival among patients cared for by nurses.
It might be tempting to infer from these studies that additional training of physicians does not improve patient outcomes, and that our investment in physicians is therefore unjustified – but that would be an inaccurate conclusion. Instead, the current level of evidence in this area suggests the need to urgently explore and implement the most efficient mix of skills and providers to deliver the most effective care for Canadians in need of health care each day.
More importantly, I believe these findings represent the ongoing misalignment between the full scope of a physician’s training and their actual medical practice in the current model. The Medical Council of Canada Qualifying Exams, for example, contains approximately 190 types of clinical presentations, illustrating the breadth of knowledge in diagnosis and management graduating physicians attain. Meanwhile, it has been observed that in 2010, the top 20 presentations at a physician’s office made up 46% of all encounters. There is a widening rift between the expanding diversity of diseases learned during medical training and a select number of diagnoses seen predominantly in the current model of care delivery by physicians. This in turn supports the integration of allied health workforce with specific training to deliver many aspects of routine clinical services, enabling each profession to practice at the full spectrum of their knowledge-base and clinical experience.
Despite Canada coming in last place on timeliness of care across a group of 11 high-income countries, it has one of the lowest utilization of nurse involvement in routine primary care. As teams are increasingly recognized as the preferred model of health delivery, an important opportunity exists to re-examine the outdated roles of health care providers in Canada, and to embed rigorous evaluation into modernizing professional scopes of practice such that each can perform at the top of their education and practical training.
It has been observed that scopes of practice regulations are steeped in historical factors rather than an evidence-based examination of current population-based health needs. While we have made considerable progress in addressing the shortage of health care workforce by increasing the number of physicians, the fact that these shortages can be further alleviated by leveraging the use of non-physicians will be an added incentive for action.
By creating a practice environment where value can be effectively measured and demonstrated, the income of health care providers can be based upon their unique niche within the system. This would be the first step towards an evidence-based discussion of provider remuneration, with input from additional factors such as educational expense, specialty income disparity and practice demographics.
Health care, a social service provided to all Canadians, requires accountability. Canada has a long and rich history of assessment for drugs and medical devices, a process that despite limitations, promotesefficient use of finite financial resources. As a sector that consumes 15% of health spending whose growth is outpacing those of hospitals and pharmaceuticals, the glaring evidentiary gap in the value of physician services can no longer be ignored.
Yan Xu is a third year medical student at Queen’s University. Follow Yan on Twitter at @IMYanXu.
Link to original article on: Healthy Debate Website