Health Committee on Feb. 28th, 2013

[Dr. Jason Sutherland]

I'd be happy to start off with that.

I think there is evidence that fee-for-service works for getting more. Paying on a piecework, patchwork basis provides an incentive to work more, to see more patients. For those doctors who have an above-average case mix or acuity in their patients, certainly it's a disadvantage to them when they're paid on the average.

On the other hand, there is some evidence that salaried physicians certainly back off in terms of the amount that they're willing to work. They're less willing to work on call, they're more willing to go home at 5 p.m., things like that.

First, this is why my recommendations are around defining what we want to achieve first and then aligning the funding incentives behind it. I think that a mix that will probably work in Canada is a model that achieves a salary plus a partial fee-for-service payment that encourages people to work more, if that's what we want.

[The Chair, Conservative, Joy Smith]

Dr. Fry, do you have a question?

[Hedy Fry, Liberal, Vancouver Centre, BC]

Dr. Carrie asked a very interesting question.

[The Chair, Conservative, Joy Smith]

Excuse me. I'm sorry. I missed something.

Did you have a question, Dr. Carrie?

[Colin Carrie, Conservative, Oshawa, ON]

I had a second question for Dr. Guirguis, but if I was out of time....

[The Chair, Conservative, Joy Smith]

Sorry about that. Go ahead.

Sorry about that, Dr. Fry.

[Dr. Emad Guirguis]

I want to start with some good news, and that is innovations in health care can save money. We often don't think about it that way, but when I was at the University of Ottawa, we were in transition from performing gallbladder surgery from an open procedure with a large incision and hospitalization for seven days and a six-week recovery from work to laparoscopic gallbladder surgery.

We started with an overnight stay with two nursing visits at home, and then we scaled it back to one nursing visit. Then we realized with the innovation we could do minimally invasive surgery as a day surgery procedure. We looked at social and health care costs and found we were saving a substantial amount of money on social costs, recovery, and getting back to work, just looking at Ottawa as a general experience.

With that I believe the next level is to take that innovation further, and now take outpatient surgery, and perform it in out-of-hospital facilities. I believe we can save costs, and as I mentioned before, wait times.

We are inundated with phone calls from across the country to be on this. Obviously with online availability of access to information at least, we're getting phone calls on a regular basis from patients from several provinces asking if we can perform their gallbladder or hernia surgery in a timely fashion because they have to wait nine months, 12 months, and sometimes even longer for procedures such as that or carpal tunnel surgery.

We would love to be able to do that. We have no limits, if you will, as far as how often our operating room is open so in an out-of-hospital facility we could provide more timely access in a cost-efficient fashion and in a bundled fashion, as you mention.

[The Chair, Conservative, Joy Smith]

Thank you.

Dr. Fry, did you have a question?

[Hedy Fry, Liberal, Vancouver Centre, BC]

Yes, thank you.

I was going to follow up on Dr. Carrie's question with regard to payment schedules and whether you pay on a salary basis or on a fee-for-service basis. I'm really glad to hear Dr. Sutherland suggesting a mix really works because it has been shown that low productivity occurs.

You get a salary, fill the day, you go home at five, you don't want to do house calls, you don't want to do any kinds of other emergency surgeries, and your productivity drops. So you're going to need more people to perform the same work. Salaries are going to be paid to those more people.

At the same time some things lend themselves to salaried work. A lot of cognitive work like dealing with a geriatric patient or dealing with a psychiatric patient lends itself to spending that time. So I was really glad to hear you suggest that, because there used to be the sense a while ago that there was this either/or, one was better than the other, and that was it, or one was worse than the other.

Do you have any studies going on right now here in Canada on looking at those models and how they work? That's my question to you, Jason.

You then opened a can of worms, Chair, because my question is simply this. We all know one of the five principles of medicare and of the Canada Health Act has to do with public administration, not necessarily public delivery. There is evidence to show that private delivery of services can ease the burden on the public sector, providing that this private service deliverer follows the Canada Health Act to a T and contracts out based on that and doesn't do extra billing.

How do you see that working with expanding the kinds of services you are talking about?

I'd like to hear Jason's answer first on the work on this.

[Dr. Jason Sutherland]

Two researchers in Canada are looking at the use of incentives for physician-based productivity, and I can certainly refer you later and send in those studies.

[Dr. Emad Guirguis]

First of all, I think one of the issues we haven't discussed is medically necessary services. For example, the Ontario government has looked at the schedule of benefits of what is insured and what is not insured, and they have determined certain procedures were publicly funded that are not medically necessary, if you will, for example, a lipoma benign cyst, a benign mole that has no threat on the patient's medical health.

I think we need to look at that federally and provincially. What is medically necessary? Because certain services are currently on the fee schedule that may not be medically necessary.

Second, should 100% funding be provided for privately owned out-of-hospital facilities? There would be total compliance with the provinces as far as the Canada Health Act is concerned. That said, one of the challenges is how we come up with a balance as far as autonomy while at the same time being respectful of the Canada Health Act, for example, restricting the number of procedures. How would you come up with that number? I think those all have to reviewed in a dialogue.

[The Chair, Conservative, Joy Smith]

Thank you so very much.

I thank you for coming here today and being our witnesses. It was nice to have the two of you because you had more time for your answers. I want to thank you for your insightful comments.

Committee, I want to thank you as well.

The meeting is adjourned.