The Chronicle Herald – September 20, 2013

It is crass to talk about medical practice and money in the same breath. However, it can’t be avoided. Most health care in Nova Scotia is for-profit and half of all government program spending is on health care.

CEOs of health districts are paid handsomely and insist their work is necessary and important. The rest of us, including doctors, nurses and government administrators, must be paid for our work. Essential health services are rarely provided by not-for-profit volunteers. We have several health districts and many paid administrators, yet no one knows the health benefits that are achieved, nor how many people suffer because important services are not available.

Dr. Mike Fleming, the president of Doctors Nova Scotia, announced that his group and the province are entering discussions to decide how your health-care dollars should be spent. (Doctors NS is the organization the provincial government legislates as the sole negotiator for fees paid to doctors for government-insured medical services.)

Unfortunately, patients and consumer groups are never asked how to divide the health-care pie. Consumer groups should be involved. The way the Nova Scotia government spends your health-care dollars leads to shortages of some services and poor quality in others.

Your insurer, the provincial government, is responsible for many of your problems with health care. If government were an independent regulator, it would insist that health insurance become better organized and fairer to patients. However, in its dual role as regulator and insurer, government is free to ignore the consequences of poor oversight.

Does your doctor seem to rush appointments? Do you realize that your doctor receives less than $35 per visit from the province, your health insurer? Out of that, she must pay all overhead costs, including rent, secretaries, materials, electricity, telephone, computer equipment, fees to regulatory authorities and insurance.

The amount per visit is the same for walk-in clinics, where doctors generally do not provide continuous care to manage patients with chronic disease. By giving only immediate advice, they can see more people per hour.

The provincial government recently reneged on a fee increase it had agreed to. The result is that it is economically difficult for family doctors to enter into, or to maintain, full-service practice. The predictable result? It is more difficult to find a full-service family doctor.

Several years ago, Nova Scotia introduced an 811 service in which a nurse who does not know you gives you advice over the phone. The government pays McKesson, the Canadian subsidiary of a private, for-profit, publicly traded American company an average of about $60 per call — approximately twice what your doctor is paid for seeing you in person.

In many places, including California and British Columbia, patients have access to their own health records, laboratory results and Pap smear reports without having to see their doctors.

Your family doctor could easily and safely communicate with you by email and telephone. However, your insurer, the provincial government, insists that talking by phone or communicating electronically is not an insured service. Therefore, for the doctor to get paid, you must inconvenience yourself and have an in-person office visit.

Your health insurer, the provincial government, pays nominal amounts for several other services, including house calls, which means the supply of those services is usually limited.

Elections are about choosing the group that will manage your health insurance. Remember, half of all government program spending is on health care. The provincial government decides which services it will insure and how much it pays for each insured service. Consequently, some excellent services are not available and wait times grow for others.

Citizens must be part of the discussion about which services to insure and how to value medical services — to fulfil the hope that all Nova Scotians will, eventually, have timely access to the full range of important health care.

Health care is not a gift from government. It is a basic service we pay for. Whom and how we pay has a profound influence on the quality, scope, and timeliness of the service Nova Scotians receive.

David Zitner (david.zitner@dal.ca) is a family doctor, a health policy fellow with the Atlantic Institute for Market Studies and a professor in the Dalhousie faculty of medicine.