LETTERS * CORRESPONDANCE
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Too many physicians doing too much? am an expatriate Canadian physician practising in an academic medical centre in the United States. After reading the media communique on the January 1992 meeting of the ministers of health and the information about the Barer-Stoddart report and the CMA's response in CMA News (1992; 1 : 1-5) I had a deja vu feeling. My thoughts came full circle when I read the report "Can physicians afford not to get involved in hospital administration?," by Dr. Peter P. Morgan and Lynne Cohen (Can Med Assoc J 1992; 146: 75 1-754).
The report states that Robert Evans, a health economist at the University of British Columbia,
Vancouver, has argued the "need to standardize methods of care by assessing patient outcomes and mortality rates and then policing individual doctors to make sure they conform to standards. There should be appropriate penalties [my emphasis] if standards aren't met." Robert Evans is of the Vancouver health economics school of thought. The views of this group are well represented in the BarerStoddart report. Numerous publications have blamed the escalating cost of health care on a supposed oversupply of physicians. They state that the very presence of a physician who has set up shop at a street corner creates health care dollar consumption, as though ailing patients will not initiate visits unless they walk by a physician's office. This notion of physicians generating cost or business is clearly implied in the first three items of the communique, which call for reductions of 10% in medical student enrolment and postgraduate training positions and curtailment of the recruitment of overseas visa trainees into Canadian postgraduate training. These policy recommendations are all based on the assumption that the fewer physicians produced, the lower the cost of health care over the long haul. This untestable hypothesis is already being incorporated into health care management thinking at a national level. The interesting part of the hypothesis is that it goes against classic economic theory, in that fewer physicians in practice will create a cartel, and thus the cost for their services is likely to be higher and less subject to control.
The health care industry is peculiar in not behaving according to or obeying any of the usual economic rules. For instance, despite the excess capacity (of hospital beds and health care providers) in the United States, costs are still rising at a phenomenal rate; the Canadian system has less capacity and long waiting lists, yet health care costs are also out of control (accounting for about 30% of most provincial budgets). No attempt to reduce physician production is going to lead to reduced health care costs unless the proponents are planning to scrap fee-for-service arrangements or cap physician earnings down the road. With the same level of health care consumption and reduced physician numbers there will be extremely long waiting lists. Evans seems to be labouring under the delusion that every disease can and should behave the same way in every patient. It is possible to predict how long it will take to assemble a new car on an assembly line, but it is difficult if not impossible to make predictions for ailing patients. The condition of a 23-year-old intravenous drug user admitted with pneumonia that is complicated by a lung abscess cannot be expected to have the same outcome (in terms of duration of hospital stay or costs generated) as a nonabuser of drugs admitted for lobar pneumonia. The idea of penalizing the caregiver of the first patient for not achieving the same outcome as the caregiver of the second seems ludicrous. Members of the Vancouver school of health care economics and the provincial ministers of health should go to medical school CAN MED ASSOC J 1992; 147 (3)
for 6 months and do a medicalsurgical rotating internship for another 6 months to see what life is like in the medical trenches. Hearing the views of the people at the coalface and working there are two different experiences. I believe that Evans and his group are mistaken in their assumptions. Joshua 0. Atiba, MB, FRCPC Assistant professor of medicine and pharmacology University of California Irvine, Calif.
The review process described in "Controlling overservicing by physicians: review of office practices in Manitoba" (ibid. 723728), by Dr. Michael Wahn, was sophisticated in its methods. However, Wahn's thesis that utilization review by the Manitoba Medical Review Committee is effective is by no means demonstrated by his study, which has no control group and thus cannot comment on cause and effect. There are many reasons why a physician's costs could be high in a specified year and lower in subsequent years. An underlying assumption in the study's methods is that all general practitioners draw randomly from the same homogeneous pool of patients, who should all require the same number of services. This is clearly false, particularly in urban settings, where patients have a wide choice of physicians. A psycholog-
ically oriented physician might atpatients who require counselling, and a physician oriented to physical pathology might attract more physically disabled patients; both physicians would have high costs in their preferred sertract
vice areas but average costs overall. It is not the business of economic review committees to dictate patterns of practice when total patient costs are reasonable. A greater concern is Wahn's failure to mention quality of care. Any service provider can lower 286
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costs by lowering quality, but the consumer is likely to suffer. Quality of care must be addressed by
economic review committees. James M. Warren, MB, BChir, CCFP Vancouver, BC
Dr. Wahn's conclusions are accurate, but he misses a major point. He states that physician services increased 22.4% to compensate for a 15.9% reduction in the real value of their fees. Ergo, physicians had to see and bill for more patients to keep up with the cost of living - something that is denied them by grossly inadequate fee schedules negotiated in every province. There is a very real danger that vigilante committees on this model could spring up in other provinces and start penalizing everyone for "overservicing" as a means of rationalizing limited access to services. It seems crazy to me that we are looking at further ways of restricting physicians' incomes when they have already been eroded by capping and years of increases at less than the inflation rate or of no increases at all. If provincial governments want to reduce overservicing they should pay physicians a fair fee for service. Overservicing, in the absence of dishonesty, is a patient-driven phenomenon that most physicians have exploited to earn a decent living. To restrict physicians' practices and prevent them from working harder, as will inevitably happen if other prov-
inces follow Manitoba's lead, can only serve to further restrict our incomes and add to our hardships. Let us have a fair deal from provincial governments and overservicing will disappear overnight. Miles W. Ellis, MD Dartmouth, NS
Dr. Wahn concludes that the Manitoba Medical Review Committee saved $2 million through its activities. This was estimated
from the decrease in costs of services rendered by 44 physicians. Unfortunately, there was no attempt to determine what effect this may have had on the health of the patients or on the costs resulting from secondary effects, such as loss of income. Neither was there any effort to consider what might have happened to these practices had the committee not intervened. If some of the practitioners were beginning in their practice this overservicing might well have decreased as their knowledge and experience increased. It is important to perform such statistical analyses of practice profiles; it is equally important to review the profiles to determine why there are outliers and to suggest to these physicians that their costs may be excessive. It is somewhat simplistic, however, to state simply that as a result of these measures $2 million was saved. In these days of quality assurance we must determine that there has been no impairment in the quality of health care delivered as a result of reductions in overservicing. Bernhard E. Driedger, MD, FRCSC Cranbrook, BC
In "Can medical review committees control overservicing?" (ibid: 693-694) Dr. David K. Peachey and colleagues ask a pertinent question. The answer seems to be Yes, but the effects of such control would be at best short-lived. A more pertinent issue, however, is whether the cost of service is truly reduced. To give a complete answer to this question account must be taken of the cost of the reviews as well as that of the "reduced" service. If we must provide additional employment there should be a better (more innovative and more productive) way to do it than to invent review committees. LE ler AOUT 1992