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.

Ministers

I am getting pretty fed up with Health Ministers. Ontario’s Minister of Health and Long Term Care, Eric Hoskins, dumped a “deal” on the table for Ontario doctors at 8 a.m. last Wednesday morning. He was in a press conference by 9 a.m. letting the public know that he had offered Ontario doctors more money than he had in August 2016. Not mentioning that the doctors had rejected that August deal, the Minister also neglected to say that he had decided to pit groups of doctors against each other with his most recent offer. His latest “deal” seems to give family physicians an increase at the same time as it cuts the highest paid specialists.

The “increase” to family physicians is very questionable since the terms and conditions to which extra funding is tied are so stringent that doctors would take a loss in order to meet the Minister’s demands. The timing of the offer is also suspect. It follows hard upon the passage of Bill 41, the so-called Patients First Act, which seeks to address problems in Ontario’s health care system with additional bureaucracy and a Command-and-Control approach that is totally unnecessary given the work ethic and devotion of most doctors. The Board of the Ontario Medical Association unanimously condemned the actions of the Government of Ontario and the Minister of Health and Long Term Care.

Hard upon this, now consider the federal government’s “Take it or leave it” offer to the provinces of an “increase” of $11.5 billion for home care and mental health. That’s meant to be an investment over the next TEN YEARS, for all Canadians. That’s an investment of about $300 for every Canadian. This is not more than a week’s worth of home care or 2 sessions with a clinical psychologist. Dr. Granger Avery, the President of the Canadian Medical Association, said, “The Groundhog Day-type discussions where political leaders bat around percentages and figures at meetings in hotels have to stop.”

Really, Ministers, doctors would like to be able to have a real discussion about a health care proposal that you introduce that does not require the use of quotation marks to alert the public to the fact that health ministers and doctors speak a different language, especially where money and patient needs are concerned.

As a physician, I would like to think that there is an opportunity to discuss why these proposals will not meet the needs of my practice. As a patient, I want analysis that demonstrates to me that the investment of my money has been careful and methodical and that investments are linked to outcomes that both my doctors and the government agree on. As a citizen, it is distressing to be a bystander to this grandstanding by legislators. This is people’s healthcare. You are governing. Please consider your proposals with the seriousness they deserve. Please talk with me, not at me.

Bill 41 – What about Specialists?

Here is my last question about Bill 41 before it goes to Committee: Once Minister Hoskins finishes bringing family doctors “into line”, what has he got planned for specialists? One might get the impression from the government’s reasons for introducing Bill 41 that family doctors are sitting around their offices eating bonbons all day but, really, that just isn’t the case.  Watch the activity in your family doctor’s office while you’re waiting for your appointment and you’ll realize that they are run off their feet.

But access is also problematic in the offices of community specialists, and especially the specialists in medical and pediatric and mental health specialty care. Internal medicine specialists, pediatricians and psychiatrists are the system’s experts in chronic disease management. These specialists look after babies with failure to thrive, children with diabetes, youth with schizophrenia, adults with chronic obstructive lung disease and the elderly with every chronic condition imaginable. We are the consultants family physicians seek out when a patient’s chronic illness suddenly becomes acute.

In my practice, I hear from family doctors when a young person with major depressive disorder begins to feel suicidal after months or years of being symptom-free on the correct medication and successful cognitive behavior therapy. Because I work in a hospital setting with a full team of clinical psychologists, social workers, psychiatric nurses, recreation therapists, occupational therapists and child and youth workers, my youth program has no waiting list. We can bring youth in quickly and settle what is happening, or work on it with a young person and their family, offering a limited choice of treatments.

A psychiatrist in a community setting, however, is in a very different situation. Because they have no team and limited access to community resources, that specialist is often monitoring highly complex patients performing to the best of their ability all the functions of a team working with the family doctor. This is an essential service in medicine since these are often the only people available to provide therapy to those who could otherwise not afford it. Every community medical specialist performs similar services in their own specialty areas and benefits many patients. These doctors are valued by patients especially because the practice setting is “private” and can sometimes afford a level of individualized care that might not be available in a hospital setting.

The reasons a specialist works in the community and not in a hospital setting are varied. I worked in private practice when it was impossible for me to be on call. My three children were born within two and a half years and, for the years I was a single parent, it would have been impossible, of course, to leave them to assess a patient in the emergency room.  For all the years that I was in private practice in Ottawa, my patients had my home number in case there was a problem. This is true of many of the community specialists that I know, and many of them do provide call in community hospitals. In small communities, they are often the only expert in their specialty that the Emergency Room physicians can access. These doctors are vital to the health care system that patients depend on.

For the last four years, the Government seems not to have considered community medical specialists at all – which means that the patients these specialists care have also been overlooked by the government. Many medical specialists have seen the resources some primary care practices have been able to access and wondered whether the government might ever consider resources for their patients.

Dialogue between doctors and the government does not exist, however, except on the government’s terms. We have watched as the Government of Ontario cut off resources and even began to limit entry into certain family practice groups. Despite the increased access family doctors have provided to Ontario patients, it has not been enough to satisfy the government and so they have begun to unilaterally impose the organization they want through cuts to fees and now legislation via Bill 41.

Bill 41 focuses everyone’s attention on primary care, and doctors and patients depend on family physicians to be the stewards of patients’ overall care. When the government begins to realize that patients also need more specialist care for their chronic diseases, it seems likely that they will also try to shape how community specialists practice. When that happens, can the individualized, patient-centred care that these doctors provide survive? Bill 41 tells us both patients and physicians come after administrative concerns.

The system of community consultants isn’t perfect, but patients value it. Specialists have ideas about how to improve community care, but is anyone listening?

bill41

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.

 

Words, Words, Words

“Dr. Beck, do you make $6.6 million a year?” My 16 year old patient asked me as I weighed him in the examination room in the outpatient department where I work.

I looked up suddenly and used every bit of my strength not to laugh or appear to shocked.

“I don’t make nearly that much money – did you read about the doctor who makes $6.6 million?”

“No, I heard about it on the news – and then at the commercial they showed that ad about a woman becoming an activist because it will be too hard for her parents to get health care.”

“What did you think?” I asked.

“Well,” my patient said, “it’s kind of like my Mom, except that my Mom also has a sick kid and sick parents – she has even more appointments and more people to worry about. You’re not going to leave or do anything so that I lose you, are you, Dr. Beck?”

“No, not ready to retire or move just yet.”

“You probably could if you made $6.6 million,” my patient laughed, “but, seriously, my Mom said when she saw the ad that she could just see how you could get so mad that you’d stop work. Please promise me you won’t.”

“I can’t promise you,” I said. “If someone in my family became really unwell or I became unwell, I would stop work immediately. You know there are lots of good doctors, though. There would be someone to look after you.”

“Dr. Beck, it took me six months to start coming here because I was so afraid people would judge me, or ignore me. I would understand if someone was sick and you had to look after them, or look after yourself but I would not want to lose my Doctor because the government is worried about one or two doctors who make $6.6 million. I’d become an activist first.”

“What would you do to be an activist?” I asked,

“My Mom made us sign the petition to send to the government – you should get the group to write letters. I don’t think Moms should have to worry about their families not having doctors. My mom has enough trouble already. I would also go to all the government peoples’ offices and wait to talk to them. I wouldn’t get an appointment, I’d just wait because it would bother them. I’ve been thinking about it. I’ve been thinking about being an activist since the ad. ‘I voted Liberal but I didn’t vote for this’.”

“So that ad makes you feel brave enough to go out to your MPP’s office and sit and wait for them. We’ve been working to get you to feel braver for months. What did an ad do to change that?”

“Dr. Beck, the government is threatening mothers trying to look after everyone. I have to help. Also, as you can tell in these groups, I need health care.”

I finished the steps of my exam: blood pressure, weight, and a quick check for signs of parkinsonian side effects and sent the 16 year old activist back out to the group. Nothing else happened. But since I have been stuck that two small pieces of information – a doctor making $6.6 million and being an activist – had an impact on one young person.

A legacy of exchanged words is not what the healthcare system needs from the Minister and doctors. This is what happens when there is no good way for doctors and the government to solve disputes. It’s time to put a proper dispute resolution system in place, and get back to our real work of health care renewal.