Patient Accountability II

In January, I wrote a brief introductory essay on the reasons I feel patients must be included as full partners in health care, having not just the right to good care, but also responsibility for certain facets of the health care system.  There were so many comments and concerns raised by that introduction that I felt it was important to follow up with a bit more information to think about and clarification of why, in my view, patients need to be full partners in accountability.

One of the striking facts about the Canadian provincial health plans is that government documents and websites highlight patients’ rights and never mention patients’ responsibilities. I looked through the documents for each province and territory. Here are links from the British Columbia website and an Ontario government website for new immigrants as examples. I attempted to find a document for Ontario similar to the British Columbia Document, but this did not seem to exist, except for new Canadians. The document for new Canadians does list responsibilities but I was struck by the fact that the website also contains this phrase: “You are entitled to all of the patient rights that are described in Ontario laws, even if you do not follow these “responsibilities.”  The other document I have included is a Government of Canada comparative overview of patients’ bills of rights from around the world. Note once again that rights are noted without mentioning responsibilities.

Contrast this with the fact that other countries with a publicly funded system do list both patients’ rights and responsibilities. This is also true of many physician practice groups in Canada and hospitals. Both hospitals and physicians’ practices absorb the costs in their budgets if time or resources are not productive. In my hospital’s Youth Psychiatry program, missed appointments or late arrivals mean delays for another patient’s assessment or treatment. That’s why we have a rule that, if a patient misses more than two appointments without 24 hours’ notice, we close the file. Given that Ontario’s healthcare budget covers the cost of the therapy provided in the Youth Program, most patients and their families understand that missed appointments affect access to care and accept the rule.

The emphasis of patients’ rights, in the absence of a consideration of any responsibilities, makes physicians uneasy. It also makes many physicians, including me, feel as though the responsibility for stewardship of the system is not shared by patients.

All physicians have days when we feel as though every appointment consists of reviewing with patients that the tests they want are unnecessary and treatments they would like are proven to be ineffective. Physicians honestly want to follow best practices, and improve system efficiencies and these discussions with patients about necessity prove that. Physicians could have much less conflict in our days if we just agreed to order every blood test, consultation or x-ray that patients request. At the same time, every physician I know is very understanding when a person’s living conditions or financial situation make it impossible for them to follow the recommendations they’ve received for examinations or treatment.

One reader of my last Patient Accountability essay commented that defining patients’ responsibilities was a “slippery slope” to blaming patients for their health problems. My experience is that anything less than a full discussion of a patient’s history, examination and diagnosis, along with an outline of the best practices for further tests and treatment is a “slippery slope” to an old style of medicine in which the patient was expected to “do what the doctor ordered”. That kind of paternalism is no longer acceptable in medical practice. The standard of care today is to review the diagnosis and recommended tests and treatments thoroughly so that patients understand the options for further evaluation and treatment and consider with their doctor and other care providers what would best for them. Patients no longer want to be patronized by the doctors providing their care.

Canadians are aware that their much-celebrated health care system is not keeping up with demand and it would be a relief for most people to know that there was something they could do to preserve and improve their health care. We are all aware that many Canadians can no longer afford necessary medications, but we also realize as our national and provincial deficits increase that we cannot spend away the health care system.  Providing good care in the context of excellent information about best practices is what all doctors try to do. My experience with patients is that they want this information so that they can do whatever it takes to get well. How is that not taking responsibility? Why can governments in Canada not accept that this is the right thing to do?

Patient Accountability: Is it reasonable?

I am puzzled by Canadian federal and provincial governments’ collective reluctance to make patients partners in their own healthcare by expecting them to accept certain responsibilities for their own health and for the sustainability of the healthcare system. Why does it seem unreasonable to governments to ask citizens to meet a minimal set of expectations in relation to health care? All Canadians pay taxes, follow traffic laws and remember to get their passports renewed. Why would they not manage similar expectations in relation to their healthcare? Healthcare is thought to be a right by many Canadians – don’t we expect to have responsibilities related to rights? Why wouldn’t we be as accountable for our health care as we are for our taxes?

The issue of patient accountability is important for me as a physician. Whenever I see resistance by the government to patients accepting reasonable accountability, it feels as though the government is saying that the responsibility for the sustainability of the health care system mostly rests with frontline providers, especially physicians.

The Government of Ontario seems to like many aspects of Kaiser Permanente’s model for health care delivery so I thought I would see what Kaiser expects of patients registered in their programs, just to see how far-fetched my notions of patient accountability are. This is a link to the section of Kaiser Permanente’s website called Your Rights and Responsibilities. The section has a list, first of all, of rights. A quick read through this will show that these are the same expectations of any Ontarian of the Ontario Health Insurance Plan, although some of these include such statements as: “Receive emergency services when you, as a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed.” The next portion is about patients’ responsibilities as a client of Kaiser Permanente. There are sixteen expectations in all, grouped under three broad categories: Promote your own good health; Know and understand your plan and benefits; Promote respect and safety for others. All are reasonable; all would be easily adaptable to the Ontario situation.

So what is the big deal? Unfortunately, Minister Hoskins has often said that health care is “free” – he did this last flu season, suggesting patients get their “free” flu shot at their nearest pharmacy. Leaving aside the fact that health care is not at all “free” from a financial perspective, it sounds as though governments believe that “free” should also mean “free from any inconvenience or expectation of the patient”. But we don’t say this for other government programs – try being free from the “voluntary” aspect of your income tax, or paying a parking ticket. You’ll soon learn that the government has ways of making you meet these expectations. When health care is the single largest budget item for a provincial government, why not expect the same attention to missed medical appointments, or seeing multiple doctors through walk-in clinics? It almost seems as though the government knows that this is one of those places where you can let someone else be the bad guy. You can let me be the one to say, “You missed two appointments with no notice and, as you were told at the outset, we will not continue to see you at the clinic if you miss appointments without letting us know.”

Now that Ontario’s ability to provide health care is being limited by the resources available to fund it, now that all other efficiencies in the system have been found, is it not time to turn to patients to ask them to contribute to the system? Is it not time to say, “There are some ways you could make the system more sustainable”? This is true in Ontario, but it’s also true in the rest of Canada as well.

The Ontario government is so desperate to find resources for health care that cuts to both physician and hospital services are continuing. However, it seems that legislators are not so desperate as to risk the anger of voters by asking patients to be accountable for those elements of health care that they control. I think that most citizens are committed enough to the health care system that they would welcome the chance to make it better. As baby boomers see how cutbacks are affecting health care, either through their own experience or that of family members, they are realizing that there is a role for them to play. It’s time to ask everyone to embrace accountability.

The Auditor General, The Minister of Health and The OMA

In the next week or so, there will be so much detailed analysis of the Auditor General’s Report on Physician Billing in Ontario that the small observation I am making here today here will be lost. As I reviewed the 57 pages, the details and references convinced me that the analysis had been seriously undertaken.

Some conclusions seemed quite inaccurate to me, e.g. “Our review of Ministry data noted that for the 2014/15 fiscal year, each physician in a Family Health Organization group worked an average of 3.4 days per week, and each Family Health Group physician worked an average of four days per week.” Most of my colleagues in these models work at least a five-day week.

Other conclusions really did reflect what I have heard from colleagues in all parts of the province, e.g. “A large number of the physicians who responded to our survey emphasized that patients’ demands are the driving force behind health-care costs. Many suggested that patient accountability is required to ensure that only necessary services or procedures are performed and costs are not duplicated.”

I want to focus, however, on one observation about the 14 recommendations, or specifically the Ministry’s response to them. Ten of the 14 recommendations require the Ministry to work with the Ontario Medical Association and, in each case, the Ministry confirms this. The recommendations are simple enough as statements but they are complex with respect to the knowledge and understanding of physicians’ practices that will be required to implement them.

Here is that common theme running through the Ministry’s responses:

“Adjustments to the capitation rate will require the Ministry to engage with the Ontario Medical Association (OMA) through the negotiations and consultation processes of the Ontario Medical Association Representation Rights and Joint Negotiation and Dispute Resolution Agreement (OMA Representation Rights Agreement).”

“Contract amendments, including minimum number of regular hours and consequences for not meeting contract requirements, will require the Ministry to engage with the OMA through the negotiations and consultation processes of the OMA Representation Rights Agreement.”

“Enabling these recommendations would require contract amendments and will require the Ministry to engage with the OMA through the negotiations and consultation processes of the OMA Representation Rights Agreement.”

The problem for the Minister of Health and Long-Term Care is that his preferred way of “engaging” with the Ontario Medical Association and Ontario physicians for the past two years has been through unilateral imposition of cuts and contract amendments. With Bill 41 as the last straw, doctors collectively and the OMA are informing the Minister and the public that working without a contract and being dictated to by legislation do not further a productive relationship.

So the Minister has a problem. By the Ministry’s own admission, 10 of the 14 recommendations in the Auditor General’s Report on Physician Billing will require him to work with his physician partners and the OMA. Over the years, only the Ontario Medical Association has provided realistic ideas about how to implement government recommendations. This is well illustrated in the various examples of real practice situations outlined in the Auditor General’s report. Developing payment models and incentives that improve access for patients is necessary for the health care system to work properly. These models of care promote both a healthy population and a stable, fairly remunerated physician workforce.

Ministers pay attention to the Auditor General’s Reports. I hope the Minister of Health and Long Term Care keeps this report in mind and that he reaches out to the OMA. I hope he does, but I’m not optimistic.

86 Doctors

This past month, 86 doctors from across Ontario have received the devastating news that their practices are being assessed by the College of Physicians and Surgeons of Ontario because of the extent of their opioid prescribing. No patient complaint was made against them but they are all now in the process of preparing their patient records and their offices for the assessment.

I have had a complaint to the College made against me by a former patient. I recall receiving the letter regarding the complaint and how anxious I was as I read it. No matter how effectively we work, or how thorough we are, we all feel as though complaints to the College threaten our career and our livelihood. The period of investigation is stressful and it is difficult to focus on continuing to do a good job with other patients while an investigation is ongoing. I know enough readers have had a complaint made against them to understand the stress I’m describing.

Who are these 86 doctors? From reading the coverage of this story in various news outlets, one is lead to believe that the prescribers are at fault. The Minister of Health describes that the doses some are prescribing “are equivalent to roughly 150 Tylenol 3’s being consumed in one day”. While this may be the equivalent, I doubt that this is actually the form in which these painkillers are being used.

As a psychiatrist, I absolutely agree that we have a serious problem across Canada because of addiction to opioids. As a psychiatrist who treats adolescents, I know that the access to these drugs is so easy that addiction to them is becoming more and more problematic. At the same time, I am concerned for the physicians who are prescribing painkillers in justifiably high doses to patients whose care depends upon them.

So, again, who are the doctors whose patients legitimately require high doses of opioids? Palliative patients, patients with serious addictions who are being weaned off opioids and chronic pain patients can all reasonably receive high doses of opioid drugs. These are all patients with special needs and there are very few doctors in Ontario with the expertise to look after them. We know there are long waits for palliative care. Many of those being weaned of opioids because of addiction problems are in shelters or prisons. Both shelters and prisons are underserved, with vulnerable populations and it is stressful to work in these environments. Chronic pain conditions are also difficult to manage and many doctors do not want this work.

A complaint was made against me to the College by a parent who was unhappy with a report I wrote for the Family Court that was unfavourable toward them having custody of their children. My response to the complaint was that I stopped doing any work where my opinion might be sought for court purposes. Imagine what it would mean if these 86 doctors stopped the work they are doing. What if they stopped doing palliative care, or work with the homeless or people in prison, or those experiencing chronic pain?

The stress of a College complaint is difficult, just one more thing to cope with in a practice of patients with special needs and in which there are few colleagues. I can understand giving up this work over time to avoid these stressors, as much as I know we desperately need these doctors who do this work.

In this special circumstance, where we do need to understand opioid prescribing and opioid addiction better, might there not have been a better way to find out more about those who prescribe high doses of opioids? To find out more about their patients? I am not saying that the College is insensitive or arbitrary. I do think the College of Physicians and Surgeons of Ontario works very hard to take an educational approach. I am saying, however, that good doctors, who strive to provide the best care to the point of perfectionism, become so anxious when they hear from the college that it affects their sense of wellbeing. A person can only put up with this for so long before they do give up, and it is some of the most vulnerable patients who will be affected.

Bill 41: Infrastructure Investment??

Minister Eric Hoskins’ Bill 41 continues to be confounding for many physicians, but possibly the most consistent question I am hearing is: Why do we need another layer of bureaucracy? How will sub-LHINs improve the system? One very intriguing twitter answer that I received suggested that this extra bureaucratic layer will serve as “administrative infrastructure” for primary care. That is something worth considering since I agree that Family Doctors need much more support than they are currently receiving.

Before I move directly into the discussion, I want to stress that I am not including those primary care providers who are not physicians in this consideration. The reason is that I want to focus on the infrastructure resources needed to deliver primary care and the Nurse Practitioner- led clinics are tremendously well-resourced, with all expenses already covered by the government, a luxury that physicians cannot access to the same degree which is the point here. https://www.aohc.org/nurse-practitioner-led-clinics

Remembering that the point of Bill 41 is better integration within the health care system, one of the tools that can best assist with this is the Electronic Medical Record (EMR). At its best, the EMR can facilitate a patient’s health information being updated quickly, accurately and efficiently, hopefully from every care provider and facility generating information. This, unfortunately, is not at all the case with most EMRs in Ontario. For example, wouldn’t it make sense that anytime a patient has lab tests completed anywhere in the province that the results of these tests would be immediately sent to the records in each of their doctors’ offices? Wouldn’t you expect that discharge summaries, consultation reports, and other documents related to a patient’s hospitalization would automatically be sent to their family physician? Wouldn’t it be great if, no matter where you were, a doctor looking after you could access your health record with your permission from anywhere? Well, that is certainly the vision but it is not at all the reality for most patients in Ontario. As a practicing physician with the best Electronic Medical Record that my underfunded hospital can afford, my patients do not have access to any of the above elements of an EMR. The electronic medical record is administrative infrastructure that can facilitate improved integration for patients in Ontario today and the funding for this important tool has been cut by the Government. Doctors are now expected to fund all improvements to the functionality of the EMRs in their offices.

How will another layer of bureaucracy solve the problem of insufficient funding for electronic medical records?

Let’s think of other administrative resources that could improve integration of primary care in Ontario. Many patients may suddenly need housing and financial supports after falling ill and become unable to work. Social workers might be able to assist them in navigating Ontario’s complicated social welfare system, or Canada’s employment insurance supports. But no social workers are being funded for patients.

The Community Care Access Centres are being transferred to the Local Health Integration Networks (LHINs) in Bill 41. The CCACs provided services while the LHINs provide administration. It is not yet clear how the services are to be developed. What is even more worrying is that the Registered Nurses Association of Ontario (RNAO) is concerned that nursing jobs will be lost with the transition. I would like to be assured that nursing is not being replaced with administration –  what Family Health Group, or Family Health Organization or Family Health Team would not benefit from more nursing support?

These are just three examples of support services that would help primary care physicians better integrate patients’ care within the larger system of health care in Ontario. The last support, nursing care, cannot be seen as “administrative infrastructure” in the same way as EMRs and Social Work are, but they are a resource that would be a great benefit to patient care.

These are the kind of practical resources that would help family physicians in Ontario feel confident that the Government of Ontario understood their day to day struggles integrating their patients’ care. If the Government of Ontario had asked doctors what would help, these are the kind of answers they would have gotten, I believe. I still have not heard any doctor say that more administration was the answer.

Medical record concept using stethoscope in front of pile of paper. Selective focus

Command and Control and Bill 41

It’s clear that Bill 41 is what it’s come to for Ontario Liberals. I thought I would read through the Bill and try to come up with some insights into it that could be published at all rationally but, really, I’m just not good at working these things out. If you have a look at the text of Bill 41, you’ll see that it seeks to amend a number of other acts. Just to give you an idea of how sweeping the Act is, here is the list of Acts that will be amended if Bill 41 passes:

  • Local Health Integrations Networks Act.
  • Broader Public Sector Accountability Act
  • Commitment to the Future of Medicare Act
  • Community Care Access Corporations Act
  • Electronic Cigarettes Act
  • Employment Standards Act
  • Excellent Care for All Act
  • Health Insurance Act
  • Health Protection and Promotion Act
  • Ministry of Health and Long-Term Care Act
  • Ombudsman Act
  • Personal Health Information Protection Act
  • Poverty Reduction Act
  • Private Hospitals Act
  • Public Hospitals Act
  • Public Sector Labour Relations Transitions Act
  • Retirement Homes Act
  • Smoke-Free Ontario Act

To completely determine the full impact, one would have to see what the recommended changes mean in total and I do not have the patience to methodically figure out what all is being tinkered with in Bill 41.  A quick glance reveals the Government’s intention to close down Community Care Access Centres (CCACs) in favour of the Local Health Integration Networks (LHINs), a move that has many wondering how effective that will be at providing care. The further addition to LHINs of smaller administrative units (the so-called “Sub-LHINs”) is also evident, a measure that has front line care providers wondering once again how more administration favours patient-care. Other measures are the beginning of health care system changes, and, of course many are concerned that their impact will not be as positive as anticipated. Complex, extensive changes are being proposed for health care in Ontario. It doesn’t take any special skills to work out that Minister Hoskins is trying to shift a lot of legislation to bring health care more and more under his control.

He is seeking to affect Local Health Integration Networks, Public Health, Public and Private Hospitals, Doctors’ Practices. He’s even seeking changes in areas where he already has significant control such as the Nurse-Practitioner-Led clinics and with the Medical Officers of Health.

When I set out to consider Bill 41 for myself, I remembered that all this tinkering had something to do with Patients First: A Proposal to Strengthen Patient-Centred Healthcare in Ontario, a report released late last year that sought to address the need for better integration of Ontario’s healthcare system.

As a hospital-based psychiatrist who treats only adolescents and young adults, better integration sounds like a good idea and, in that context, I would love to have an opportunity to consider how integration might benefit my patients. Would it give a young man with Schizophrenia access to a Psychiatrist and Family Doctor in the town where he’ll attend university? What about access to care for street-involved youth? My colleagues and I have lots of ideas about how this might work. When I read the Patients First Discussion paper and Bill 41, I can see the parallels and how the Government is trying to do with legislation what would more effectively be done by discussion before implementation.

I know that the Ontario Medical Association and doctors in general have many concerns about Bill 41, but so did hospitals as evidenced by this report on the Bill when it was Bill 210 before the legislature was prorogued. While generally supportive, even Ontario’s nurses expressed concerns about the loss of nursing jobs because of the closing down of CCACs.

But it seems that the Ministry of Health and Long-Term Care is really only willing to discuss the situation on their terms. Because of this, it is left to doctors, nurses, and hospitals to write reports, appear before parliamentary committees, visit Members of Provincial Parliament and resort to social media in order to discuss legislation that will affect healthcare profoundly for years to come.

Goodness knows, change is absolutely necessary in the health care system in Ontario. Without all the Command-and-Control, Ontario doctors and nurses and hospitals are working toward better integration. But it seems as though our pace or our proposed direction are not good enough or fast enough, or something, for Minister Hoskins. So this is what it’s come to. There is no need to analyze Bill 41 extensively. The government will tell you what to do.

 

Patient Accountability

The Ottawa Citizen published my letter on patient accountability. This is one very important aspect of the tentative Physician Services Agreement, that the government finally acknowledges a need for patients to take responsibility for their own healthcare.

Here is the text of the letter:

Thank you to Mr. Reevely for interviewing Dr. Walley and reporting so reasonably on the tentative Physician Services Agreement.

 I do want to take issue with Mr. Reevely’s characterization of “patient accountability” as “code for giving people reasons to go to the doctor less”. To me and my colleagues, this means that my patients will be asked to take some responsibility for their health care and its cost. It means they will ensure that their health card is up to date, that they will go to their own doctor’s after hours clinic and not a walk-in clinic, that they will honour their specialist appointments. My physician colleagues and I believe that patients should realize the role of unnecessary tests and procedures in driving costs in the system and work with their doctors to limit these.  Most of my patients understand this. Since the sixteen year olds who are my patients understand these concerns, I believe everyone will. 

Including patients as accountable partners in health care is very important for the sustainability of the health system.