eric hoskins has a mas­ter plan

Toronto Life - - Tech Boom -

Eric Hoskins is a doc­tor by train­ing, but medicine was never his true call­ing. Af­ter re­ceiv­ing his MD from McMaster, he ended up in Su­dan in the late 1980s, work­ing at the Uni­ver­sity of Khar­toum’s School of Medicine. “I was the only white guy out of a stu­dent pop­u­la­tion of 25,000,” he re­calls. Hoskins wit­nessed the mil­i­tary coup d’état that in­stalled the bru­tal Is­lamist regime of Gen­eral Omar al-Bashir. When the med stu­dents protested the dic­ta­tor­ship, al-Bashir’s men ar­rested dozens of them, in­clud­ing Hoskins’ of­fice­mate. His life­less body was re­turned a week later, with his fin­ger­nails pulled out and burn marks on the corpse.

Watch­ing such hor­rors gave him a stoic char­ac­ter, which serves him well in his deal­ings with out­raged physi­cians. Hoskins is the most hated doc­tor in On­tario. When he was ap­pointed health min­is­ter, a rumour im­me­di­ately cir­cu­lated about him in hos­pi­tal hall­ways—and per­sists to this day—that he’s never prac­tised a day of medicine in On­tario. When I asked him about it, he de­bunked the myth: since the 1990s, Hoskins has prac­tised part-time at a fam­ily clinic in Toronto that serves east African refugees and im­mi­grants. (He still does oc­ca­sional shifts there with­out charg­ing OHIP, to avoid any con­flict of in­ter­est.)

He says he sym­pa­thizes with the physi­cians—his wife, Sa­man­tha Nutt, is on staff at Women’s Col­lege Hos­pi­tal— but his job is to de­fend the in­ter­ests of

tax­pay­ers, who want a pub­licly funded health care sys­tem but can’t af­ford its run­away costs. And from a big-pic­ture per­spec­tive, what he’s ask­ing doc­tors to do isn’t that bad. Ev­ery com­par­a­tive rank­ing of health care sys­tems rates Canada among the worst in the de­vel­oped world. One re­cent study by the Com­mon­wealth Fund listed Canada sec­ond-last among 11 wealthy na­tions. It beat out only the United States, and got low marks for time­li­ness of care, safety and ef­fi­ciency.

The fact that doc­tors bill more than $11 bil­lion an­nu­ally makes them some­thing like a cor­po­ra­tion—their rev­enues are roughly the same as Air Canada’s or Cana­dian Tire’s. When com­pa­nies of that size have to deal with rev­enue freezes or short­falls, they re­spond by find­ing ef­fi­cien­cies, elim­i­nat­ing du­pli­ca­tion and waste, low­er­ing wages or prices, squeez­ing sup­pli­ers for dis­counts. They take a hard look at how they run their busi­ness, and they usu­ally be­come bet­ter com­pa­nies as a re­sult. Doc­tors refuse to do this work. Hoskins is de­ter­mined to force them.

He has made it clear that only some doc­tors are over­paid, and that it’s time to up­date the fee codes to re­bal­ance things. Among physi­cians, this dis­par­ity is called “rel­a­tiv­ity,” and it has grown out of pro­por­tion as a re­sult of tech­no­log­i­cal ad­vances. Some med­i­cal im­ages used to re­quire ex­ten­sive study to reach a di­ag­no­sis. To­day, soft­ware can take those im­ages and con­struct a three-di­men­sional model of your in­nards in min­utes, and ra­di­ol­o­gists can read them from home on their com­put­ers. The work is much faster than it used to be and has be­come dis­pro­por­tion­ately lu­cra­tive.

Twenty years ago, cataract surgery took a full hour to com­plete. Now it takes 20 min­utes. The OHIP fee code values the pro­ce­dure at $397.50, which means that oph­thal­mol­o­gists can earn $1,000 per hour. Mean­while, as one emer­gency room physi­cian told me, “If you come into the ER dead and I re­sus­ci­tate you, that takes as much time as cataract surgery, and I get $70.”

Ev­ery doc­tor knows rel­a­tiv­ity is a prob­lem, but they can­not find a way to fix it be­cause the wealth­i­est spe­cial­ties, which hold a lot of sway within the OMA, will al­ways ag­gres­sively de­fend their sweet deal. The last time the OMA agreed to curb rel­a­tiv­ity, in the late ’90s, in part by cap­ping a num­ber of ra­di­ol­o­gist fees, they were sued by the On­tario As­so­ci­a­tion of Ra­di­ol­o­gists, who tried, un­suc­cess­fully, to break away com­pletely from OMA rep­re­sen­ta­tion.

An­other way to save money is to elim­i­nate un­nec­es­sary treat­ments and pro­ce­dures. Pa­tients aren’t sup­posed to get ev­ery X-ray, CT scan, MRI or mi­nor surgery they think they’re en­ti­tled to based on their We­bMD search. Their doc­tor is sup­posed to de­cide what’s ap­pro­pri­ate. There are hun­dreds of pro­ce­dures that doc­tors rou­tinely do but shouldn’t. There’s no point in or­der­ing screen­ing chest X-rays and ECGs for pa­tients at low risk of heart dis­ease; in fact, a false pos­i­tive on such a test can lead to ad­di­tional un­nec­es­sary pro­ce­dures for ar­te­rial stents. De­pend­ing on a pa­tient’s age, surgery to re­pair a torn menis­cus in the knee ac­tu­ally does noth­ing to al­le­vi­ate pain, yet the pro­ce­dure is still per­formed.

When I spoke to Hoskins, he raised the ex­am­ple of methadone treat­ment. Some doc­tors who pre­scribe the drug bill OHIP for their pa­tients’ urine tests, which are used to make sure they are tak­ing their dose. “It’s a urine dip­stick test that I could teach you to do in 14 sec­onds,” says Hoskins. There are two dozen methadone-pre­scrib­ing doc­tors in On­tario, who billed OHIP for over $1 mil­lion last year, and they de­rive most of their in­come from that test. Methadone is both over­com­pen­sated and over­pre­scribed in On­tario, cost­ing OHIP more than $150 mil­lion an­nu­ally.

By and large, doc­tors don’t do un­nec­es­sary pro­ce­dures to bilk the sys­tem. They or­der the ex­tra X-rays to make sure they haven’t missed any­thing; they do the knee surgery be­cause the pa­tient is in pain; they pre­scribe the methadone so an ad­dict doesn’t re­lapse. That doesn’t make it any cheaper. Re­searchers are only just be­gin­ning to quan­tify the cost of in­ap­pro­pri­ate care, but a 2012 study by the Dart­mouth In­sti­tute for Health Pol­icy and Clin­i­cal Prac­tice found that 30 per cent of all pro­ce­dures or­dered by physi­cians are waste­ful.

The gov­ern­ment is un­will­ing to de­cide what kind of pay cut some spe­cial­ists should get, nor will it de­cide alone which pro­ce­dures it won’t pay for any­more—and nor should it. Doc­tors need to make those calls, be­cause they are the care ex­perts. Cer­tainly no doc­tor wants bu­reau­crats mak­ing th­ese de­ci­sions for them. The U.S. tried that back in the 1990s, when in­sur­ance com­pa­nies started telling doc­tors what they could and couldn’t do for pa­tients, and it pro­voked a f lood of anger, frus­tra­tion and re­sent­ment from all in­volved.

In Al­berta, the Health Min­istry and the Al­berta Med­i­cal As­so­ci­a­tion have formed a com­mit­tee that has be­gun to tackle such spend­ing is­sues. Last month it re­duced some ra­di­ol­o­gist and oph­thal­mol­o­gist fees by more than 20 per cent. Here in On­tario, the deal the OMA and Hoskins ne­go­ti­ated this sum­mer would have com­mit­ted doc­tors to a sim­i­lar process.

In the aftermath of the deal’s fail­ure, the gov­ern­ment’s po­si­tion hasn’t changed. Health care is still bro­ken. In a writ­ten state­ment re­leased af­ter the re­sults of the vote, Hoskins said, “Go­ing for­ward, the gov­ern­ment will be guided by the need to se­cure a sta­ble and pre­dictable bud­get.” Read his lips: he is go­ing to keep cap­ping doc­tors’ pay­ments and claw­ing back their earn­ings un­til they come around.

When doc­tors ask for bind­ing ar­bi­tra­tion, they’re ab­di­cat­ing their role as stew­ards of the sys­tem. They no longer see them­selves as man­age­ment but as labour

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