The health care payment game is rigged

I’m trying to not get too fussed over the current fee negotiations between the Ontario government and physicians. That’s because my concerns over payments are focused on a much larger issue. It’s called relativity, or the gap between what different types of doctors are paid. And it can be striking.

Famed economist Thomas Piketty’s bestseller Capital in the 21st Century challenged us to look at the problem of inequity through a new lens. His analysis argues that the advantage of equity and capital income growth over labour income growth, supported by unequal taxation and financial policy, keeps wealth distributed unequal. These structural inequities mean the societal divide between the “haves” and “have nots” continues despite a person’s hard work, education, value or merit. In other words, the game is rigged.

In health care we have a similar unfair structural divide — the advantage of procedural care over cognitive care. This divide supports an inequity that is out of keeping with population health needs and the major causes of disability that keep people out of the workforce and impact to our GDP. It’s out of keeping with value.

Procedural care includes activities like colonoscopies, cataract extrac- tions, injections, etc. Cognitive care refers to activities like taking a history, reviewing test results, making a diagnosis, recommending treatments, starting medications, as well as health counselling and therapy. Most medical disciplines involve both cognitive and procedure-based activities to varying degrees. But as highlighted in a 2013 Journal of the American Medical Association study by U.S. researchers Christine Sinsky and David Dugdale on payment disparities between cognitive and procedural care services, procedural care pays three to five times more than cognitive care, regardless of value.

The article’s authors note, for example, that “an ophthalmologist will receive more revenue from Medicare for four cataract extractions, typically requiring one to two hours of time, than a PCP (primary care physician) will receive for an entire day of delivering complex care for chronic illness to Medicare patients.” While the study used U.S. data, those of us working in the Canadian system will surely agree that the situation here is much the same.

I recognize that the world is not a fair place and free markets can decide the payment for services. But this disparity is not a result of market forces. It is Piketty’s structural inequality — a disparity set up and supported through our public insurance plan, policies and legislative processes, and completely out of keeping with value.

Turns out the medical payment game is also rigged.

One way the consequences of this structural inequality reveal themselves is through physicians’ practices. I have watched in my career, first as a family physician, then as a psychiatrist, how my colleagues’ practices skew over time to emphasize, at times exclusively, procedures. Despite a shortage of primary-care physicians, I’ve noticed many colleagues reduce the time they spend providing traditional cognitive-care services (i.e., family medicine) to spend part or all of their professional time providing sleep studies, cosmetic vein treatments, Botox or injections at pain clinics. Similarly, I’ve seen the competition for specialty training spots drift towards those with the highest procedure payments such as ophthalmology, cardiology, radiology and plastic surgery. And with technological advances, many procedures take a fraction of the time or effort they used to, allowing marked increase in volume (and remuneration) for those providing these procedures.

And who can blame them? Physicians are only doing what the system is encouraging them to do.

But it’s not just those who provide cognitive care services who are inequitably disadvantaged. The much bigger disadvantage is to patients and the public.

What about the consequences of this structural inequality for population health outcomes, economic productivity and GDP? When we align ourselves with the fact that a leading cause of workplace disability and reduced GDP is mental illness, we can see that the economic consequences are massive. A 2008 article titled ‘“A new population-based measure of the economic burden of mental illness in Canada” estimated the economic cost of mental disorders in Canada to be $51 billion, largely due to productivity losses and reductions in health-related quality of life. And that was using 2003 data. Couple that with the fact that psychiatry is amongst the lowest-paid medical specialties (hardly unsurprising, as most of what psychiatrists do is cognitive-based), and the issue becomes quite crystallized.

Not that I am against procedural care. Indeed, procedures are an important part of medical practice. In fact I’m overdue for my colonoscopy and boy do I hope the physician is skilled. And I am eternally grateful to my colleague ophthalmologist and gastroenterologist who skilfully performed procedures on my mother, although thankfully not at the same time. I used to enjoy providing procedures as a family physician. Procedures are “fun” for a doctor and quite satisfying to provide. As a psychiatrist I wish we had more procedures in psychiatric medicine.

The procedural vs. cognitive care inequity, especially as it pertains to mental health care, is what sociologists Bruce Link and Jo Phelan refer to in a 2001 article as “structural stigma” – basically, a systems-level value decision that places mental health care, along with other cognitive-care based health needs, as bottom-of-the-barrel priorities. Take an analytic view of the situation and it seems to me that the perpetuation of structural stigma comes at a major cost to population health, economic productivity, and the bottom line.

It’s time to take a good hard look at whether current policies and remuneration systems incentivize and support the activities that lead to the best outcomes and provide the most value (they don’t). Thus, in as much as Piketty’s analysis argues for structural reforms to address economic inequity and redistribute wealth for societal good, health care requires a similar kind of structural reform. We need to address the gap between procedural and cognitive care. We need new policies and legislation. We need a revamped physician remuneration code. We need to focus on value, and start addressing counterproductive inequities. These are great opportunities.

It’s unlikely the physicians will lead this, as there’s too many of us with much to lose. As a cognitive-care provider I can come off as sounding like self-interested sour grapes. What surprises me most is that the consumers, our patients, haven’t yet led the charge. Maybe it’s because those with brain illnesses can’t easily advocate for themselves. Perhaps the economists and business types will write this prescription and heal this one for us.

I recognize that the world is not a fair place and free markets can decide the payment for services. But this disparity is not a result of market forces