The Nova Scotia Department of Health is intent on enrolling uninformed Nova Scotians in an ill-conceived health-care experiment — one that will reduce patient and physician choice and reduce access to family physicians.
No one seems to have reported on the scientific merits of the experiment, bothered to ask people if they want to enroll, sought ethics approval or provided information about the expected benefits or harms of the proposed new model for primary care.
Government supported payment systems (MSI) encourage doctors to provide episodic walk-in services, rather than full-service comprehensive and continuous care. The problem of reduced access to family practice is a special problem for many people, particularly those with chronic disease.
Nova Scotia is proposing to remedy the problem, which government created, by copying a failing American model.
In the American case, insurance companies believed they could reduce costs and improve access by insisting that every insured person enrol with a particular primary care practice, a medical home.
For patients in Nova Scotia, the suggestion from the Nova Scotia Health Authority is to encourage patients to commit to use a single medical practice as a “medical home” and not attend physicians in other practices.
Proponents think this administrative change will improve service and lower costs because lower-cost clinicians will provide some of the care. Patients fortunate enough to have access will have a wider range of free services that include consultations with primary care nurses, physiotherapists, psychologists, massage therapists, doctors and other important clinicians.
The Nova Scotia Health Authority asserted there is strong evidence supporting the idea that medical homes are useful and less expensive. However, the Journal of the American Medical Association and Dr. Sanjay Gupta, a neurosurgeon and acclaimed medical journalist, report scant or no evidence of improved care and some evidence of increased cost.
The American Medical Association reports: “Despite widespread enthusiasm for the medical home concept, few peer reviewed publications have found that transforming primary care practices into medical homes produces measurable improvements in the quality and efficiency of care.”
The experiment in Nova Scotia has already begun. The Nova Scotia Health Authority, a child of the provincial government, is insisting that government, not communities, decide how many doctors are needed in a particular area and what work they will do.
The government organ is claiming the authority to credential (approve) all doctors in Nova Scotia and to decide where doctors practise. Communities, including those that have suffered from repeated emergency department closures, will not be able to add to their complement of clinicians without permission from the health authority.
The health authority could refuse to credential a doctor to practise in an area it believes is overserved, even if the community considers there is a shortage of services and the physician recognizes that demand for her services will be sufficient. In addition, highly qualified physicians will not be able to practise in communities without approval from the health authority.
The Nova Scotia Health Authority has suggested medical homes and credentialling as ways to reduce costs. Unfortunately, the health authority could not explain how, and by how much, the proposed change would improve care, improve access or reduce costs. Normally, researchers and any organization proposing a major change will have at least speculated on what the change is likely to achieve.
Insurers in the United States can adopt, holus bolus, various schemes that purport to save money and maintain or improve care because Americans have a safety net. If service from an insurer is unsatisfactory, the insurer loses business to more satisfactory providers.
Canadians have no safety valve in this regard. We must accept the menu of insured services defined by government. Consequently, government, as a monopoly insurer, has a greater obligation to assess and report on the proposed benefits and harms of administrative experiments financed by the taxpayer.
Discussions around improving health services must support ordinary citizen participation in their own care and in health system governance.
This article appeared in the Halifax Chronicle-Herald.