Monday, April 5, 2004
National Post

Beyond Face to Face Doctor Visits

By Dr. David Zitner

In response to the recent federal budget, cash-strapped Nova Scotia Premier John Hamm despondently claimed that his province may soon have to start imposing user fees in the health care system. Other premiers are doubtless having similar dark thoughts. Such an action would probably lead to a battle royal with Ottawa over the Canada Health Act.

At the same time, Canadians across the country are having more and more difficulty getting on a physician’s roster. The number of GPs actually accepting new patients seems to fall daily, and the supply of new doctors into the system, in a great victory for central planning, is clearly inadequate.

Even if you can get into a doctor’s practice, in this world of e-mail, voice-mail and video-conferencing by webcam, you can’t get advice from your doctor by phone or e-mail. Maybe a quick telephone conversation with a primary care nurse in the doctor’s office will get you the information that you need about your test results, or a referral to a service that will solve your health problem. But to be an insured service (and hence for the doctor to get reimbursed by the government), provinces insist that there be a face-to-face encounter with a physician, so your doctor can’t deal with you in a convenient form, and she can’t specialize in higher value activities and let professional assistants help her and you.

Yet health care would be improved and waiting lists shortened if doctors worked with primary care nurses or other assistants (just as dental assistants help dentists concentrate their time and expertise where it is most valuable). Ditto for appropriate IT support for physicians and their patients. Physicians’ pay is inadequate to support the modern health information infrastructure that Canadians routinely expect from banks, airlines, hotels and other service industries. We would be astounded (and lose confidence) if a bank teller used a pen and paper to enter information into a ledger, but we think it’s normal that doctors keep handwritten records, give us illegible prescriptions on scraps of paper, and exchange information with other professionals and health institutions by snail mail.

But wait. Maybe in the situation I’ve just described lie the elements of a solution to at least some of the health care system’s problems.

Only a face-to-face visit with your doctor is an insured service and therefore subject to the restrictions of the public sector health care monopoly. There is no legal bar to people paying for a service that is not “publicly insured” by medicare. So what if we encouraged the creation of patient co-ops within medical practices, so that patients who wish to do so may pay a monthly or annual fee for these IT and other non-insured professional services that make doctors more productive and efficient?

Cooperatives are formed to meet the members’ needs, allowing patients to get the service and care they need in the ways they want it. Such co-ops could only charge for services not available through medicare, but as soon as you add the services of non-physician professionals and services delivered via technology rather than face-to-face provision, the range of uninsured services expands remarkably. Members of a health care co-op might each pay ten, fifteen or twenty dollars per month and use the money to support modern health information technology, access to reports by telephone and e-mail, and access to primary care nurses.

In practical terms, we might see people sign up for a package offering up to two telephone or e-mail consultations with their GP per month, plus a few primary care nurse contacts. You’d be able to ask for a renewal of your prescription by phone, or get your lab results back by e-mail. The money would go to employing support professionals, plus augmenting the almost unbelievably primitive information technology doctors now have.

Like many co-ops, low-income people could benefit from reduced membership costs or else decide that they are happy to continue receiving services in the traditional way at no cost. Health care co-ops are one way to insure that Canadians receive the care they value at a time when provincial governments are crying poor while insisting on inefficient service delivery.

Best of all, rather than giving yet more money to government to spend on health care according to their politicised priorities, health co-ops would empower patients by allowing them to direct their money to services and efficiencies that work for them and to choose the health co-op that offered the most attractive package of services. And because these services are not insured by medicare, this proposal is totally consistent with the Canada Health Act, so Ottawa’s permission is not necessary.

Patient co-ops are a way to inject more money into the health care system without raising taxes; to improve the quality, speed, efficiency and convenience of contacts with medical professionals via technology; and to encourage more specialization among various levels of professionals like primary care nurses working under a physician’s supervision. Patient power starts here.

Dr. David Zitner is the Director of Medical Informatics at Dalhousie University and is the Health Policy Fellow at the Atlantic Institute for Market Studies, a public policy think tank in Halifax, Nova Scotia