eric hoskins has a master plan
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