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Melissa Anderson, PT

Recently, a commentary by Dr. Louis Francescutti was posted on the Canadian Medical Association’s (CMA) website.  In it, he suggested there is a lack of accountability in the health system, and physicians need to take some responsibility to fix the problem.  He proposed one potential solution: make all physicians sign a contract, be paid a salary, and have their contract reviewed and renegotiated annually based on their outcomes, rather than the current fee-for-service model.

For those engaged in conversations about health system change, this suggestion is not outrageous. In fact, patients might applaud this altruistic approach to reform. His proposition was based on a patient-centred approach to care that is motivated by cost-containment and accountability. While it is not entirely surprising this was an unpopular suggestion amongst some of CMA’s members; what is surprising was the decision, by CMA, to remove the comments from their website.

Dr. Francescutti almost certainly knew that his comments were controversial.  It was likely he used his discussion to start a conversation, which could have led to ideas, innovations and positive changes to health care.

Shutting down the debate only silenced new ideas and gave power to the status quo. Changes to the way we deliver health care will be painful. However, sometimes disruption is necessary.  What conversations does CPA and the rest of the physiotherapy community need to start in order to facilitate change?


How did we get here?

While there are many issues facing health care today, one of the most pressing is the current funding model.  Much of health care is paid solely based on quantity rather than quality.  Many practitioners are paid a fee-for-service rate by their individual health care funders, with no regard to the quality of service provided.

This is fundamentally wrong.

The universal health care system in Canada has not kept pace with the changes in Canadian society.  When first introduced in the 1950’s and 60’s, Canada was a young nation. These were the days when child’s polio diagnosis could literally bankrupt the family farm.  Medicare services were designed to provide physician and hospital services for acute care issues.  This was the appropriate solution for the time.

Times have changed, but the system has not.  We are now a substantially older country, and much of the care we need to provide is for chronic illness.  The established fee for service model is no longer appropriate.  Canada is one of the highest spenders in the OECD countries on physician services, but achieves some of the poorest outcomes.  And the cost of physician services continues to rise.

In his report on Healthcare Innovations, David Naylor recommends that it is time to look at our fee-for-service funding model, and consider another form of remuneration for physicians.  The report highlights some successful “bundled payment” models that reward providers for improved healthcare outcomes.

To come up with the best solution for this, we need to have open dialogue where members can express their opinions.  Hopefully, this post will get people thinking of creative and innovative solutions to improve the efficiency of the health care system.


Outcomes can be part of the solution

As physiotherapists and physiotherapist assistants, we are good at measuring what we do.  However, we need to become better at collecting outcome measures in a way that allows us to clearly demonstrate the value we provide to the health care system. We need outcome data to prove that the care we are paying for is giving the results that Canadians need.  It is through these measures that we can effectively communicate our worth.

For example:

Suppose we are comparing two primary care providers.

Provider A sees 12 patients per hour.  In order to achieve this, he has a sign posted, explaining that each patient may only bring one health care issue to each appointment.

Provider B has a belief that he has to treat the whole person, which means he often gets involved in patient education and counselling about a number of issues at each visit.  This is time-consuming, and only allows for six patient appointments per hour.

According to the fee-for-service model, Provider A is able to charge the provincial health plan twice as much as Provider B.

Is this fair?

Which patients are getting the best treatment?

Which patients have the best health outcomes?

Are we getting better value for our health dollar in scenario A or B?


Assumptions vs reality

We could make some assumptions, but in truth the real answer is that we have no way of knowing who is giving or receiving the best care.  Without risk-adjusted patient reported outcomes, we are literally trying to compare apples and oranges.  Perhaps the patients in one setting are mainly elderly, with several chronic diseases, while the others are a younger, healthier group.


So let’s talk

As taxpayers and health consumers, we need to have open dialogue around health care funding models. We need frank discussions, where even the “sacred cows” of health care are analysed and evaluated.

We need to demonstrate how the care provided relates back to outcomes, and create advocacy campaigns to get the message out.

We need to collect the data that shows physiotherapy is efficient and effective.  Physiotherapy has cost-effective solutions to some of the most pressing issues in health care today.

We need to start paying for health care quality (#QualityPT) rather than just quantity.

So let’s start: What conversations do you think CPA and the rest of the physiotherapy community need to start in order to facilitate change?



About Melissa

Melissa received her physiotherapy degree from Dalhousie University.  She spent the majority of her career working in public practice in NB, as a clinician, professional practice leader and manager, before returning to Dalhousie University to complete her Masters of Public Administration.  She has volunteered with both the NB Physiotherapy Association and College of Physiotherapists of NB.  Recently, she joined the team at CPA as the Senior Policy Advisor.

Melissa is a recovering hockey-mom to three teenaged daughters, and is rapidly becoming an empty-nester as the girls transition to university living.

Follow Melissa on Twitter @CPA_Melissa Opens in a new window