Doctors’ pay model wasn’t always broken

While doctors weren’t happy with Medicare at first, they eventually approved of the pay model.

Doctors when on strike in Saskatchewan when Medicare was first enacted in 1962.

Saskatchewan doctors complained that they would be turned into civil servants, unable to follow their own judgment about what was best for their patients. The day Medicare was enacted, 90 per cent of the province’s doctors went on strike.

Supporters of doctors strike. image: Canadian Dimension

Months later, much of the support for the doctor’s strike had dissipated. After the government made some amendments to the Act, including one amendment allowed doctors to practice outside the plan, doctors returned to work.

 Saskatchewan became as model for what was become universal health care for all of Canada.

The familiar pay system for doctors -fee-for-service- was born. It worked well for decades. Doctors are paid for each body that walks through the door, regardless whether the patient has a cold or some complex medical problem.

Doctors liked the system because they were independent business operators. No nanny state told them how to run their practice.

Now that pay model isn’t working for anyone: not for doctors and not for patients. With real estate prices going through the roof, with expensive medical diagnostic tools, and the rising cost of wages for staff and the price of utilities, doctors struggle to make ends meet.

Doctors now identify fee-for-service as the path to minimum wages.

Alicia Pawluk became a doctor in 2018 and treats patients at a clinic in Victoria. She says under the current system, the take-home income of a family doctor is comparable to minimum wage.

“The average physician graduates with about $200,000 of debt. Minimum wage is not going to be able to cover the sort of payments that we need to make,” said Pawluk.

Another Victoria physician, Dr. Jennifer Lush, says she works 70-hour weeks and struggles with work-life balance. Half the hours Lush puts in are unpaid because they are spent doing paperwork.

“The minute my kids are tucked in bed, I’m pulling out my computer and I start charting. Often I will chart until two or three in the morning,”

Given that almost one million British Columbians don’t have a family doctor, it’s surprising to learn that there is no shortage of doctors in B.C.  Data compiled by the Canadian Institute for Health Information shows B.C. had 134 family physicians per 100,000 people in 2020, the third-highest in the country. The number of doctors trained in family medicine grew 11.2 per cent between 2016 and 2020.

However, the number of British Columbians without a family doctor is the highest in Canada on a per capita basis. There are two reasons: the population of B.C. is growing and fewer doctors are willing to slave away at the fee-for-service model.

British Columbia has about 6,800 family doctors by training, but less than half of them are practicing traditional family medicine.

New graduates are choosing more hospital-based work instead and specialized practice, which provide a predictable income, team supports, a vacation and maternity leave.

Doctors no longer detest being employed by the state. With improved working conditions, who can blame them?

The solution is to build provincial clinics and hire doctors to operate them. It’s expensive but so is a pay model that no longer serves British Colombians.  

Attitude adjustment would solve our homeless problem

Our attitude towards the homeless is a barrier to solving the problem. The old notion is that the poor deserve to be so:  if people would just apply themselves, they wouldn’t be homeless.

image: KamloopsThis Week

Finland’s experience shows how a shift in attitude makes a difference.

In 1987, Finland had a homeless population of about 20,000 out of a population of five million –a rate of four homeless per thousand.

To address the problem, Finland adopted a “Housing First” philosophy, said Juha Kaakinen (Globe and Mail, August 13, 2021).

 Kaakinen, chief executive officer of Finland’s non-profit Y-Foundation, was addressing a panel convened by The Canadian Urban Institute.

Another panelist, Leilani Farha, said that part of Finland’s success is the result of shift in mindset. For Finns, homelessness is not an option.

“People have a right to housing as part of their constitution.” said Farha,

Finland’s solved the problem with a partnership between federal and state governments, lottery corporations, and non-governmental organizations (NGOs).

The Y-Foundation, a non-profit organization, started buying private apartments in 1985 with grants obtained from the government run Finland Slot Machine Association.

In turn, the Y-Foundation subleased the apartments out to municipalities and NGOs. The rent plus the grants paid for the apartments.

Finland’s homeless rate is now one-fifth of what it was.

It’s tempting to think of housing the homeless as an expense when, in fact, it’s savings. Housing for all everyone has proven to be the most effective remedy for improving lives and saving money.

A study published by Journal of the American Medical Association in 2009 found that costs to Seattle’s public health system dropped by 60 per cent in the first six months after chronically homeless people with severe alcoholism were found homes.

Canada is not beyond hope. Our homeless rate is just above what Finland’s was in 1987 –about six homeless per thousand.

All levels of government are working on the problem.

The City of Kamloops’ Affordable Housing Reserve Fund allows for up to $150,000 per project for low income earners.

The B.C. government built 3,200 new affordable housing units last year and more are being built this year. (Full disclosure: I am the president of a non-profit organization that will take possession of the largest project in the interior built by BC Housing, opening in downtown Kamloops this fall.)

The federal government is working with Canada Mortgage and Housing Corporation (CMHC) to build affordable housing. This year’s federal budget provides an additional $2.5 billion over seven years to CMHC.

Dignity and financial security are restored when the homeless are given homes.

Tina Dawson, 52, from Victoria, told the Institute’s panel about being homeless for first-time in the past year:

“Being newly homeless, I am gob-smacked at the way things are out of sight, out-of-mind, and the machine that is in place to keep people homeless. How on earth am I going to get out of this position? I’ve managed my entire life. I’ve raised three children. And I have no address. The problem is [putting together] the damage deposit. I’m on permanent disability. That’s hand to mouth.”

Those who work full-time at minimum wage jobs should be able to afford a place to live.

Surely that’s not too much of an adjustment in attitude to make.