Mayo medicare’s next mission

A few hundred miles south of the birthplace of medicare, what many Canadians see as one of our defining political achievements, there is small town in Minnesota where they did it much better than us. It’s an amazing story.

Tommy Douglas’s long battle to build a universal healthcare system in depression-battered Saskatchewan provoked a colossal showdown with the Canadian medical profession. They poured buckets of money into fighting medicare. Despite the CCF government’s recruitment of supportive doctors overseas to run a limping health service, neither side could prevail. Doctors refused to surrender “independent professional” status even if they were to be paid by the Crown under the new plan.

After bitter weeks of battle, Douglas’s successor accepted their demand in return for several concessions. It was a painful and fateful compromise, one that laid the seeds of much of what ails Canadian health care today.

There is a temptation to muse about missed chances — the ‘what ifs’ — at the end of any statesman’s career. Many around Douglas mused in this vein about the bitter Saskatchewan doctors’ strike of 1962. But Tommy always shook off the “what if” bemoaners. It pained him deeply, however, to see the impact doctors’ “independence” had in distorting the Canadian health-care system he had created.

Consider the foolishness of the doctors’ claim. Could a teacher or a police officer claim to be an “independent professional?” No, they are public employees, earning 100 per cent of their compensation from the taxpayer — just like doctors. This fiction, however, allows doctors to this day to be paid on an individual “fee for service” for each procedure. It leads to specialist turf wars, to stovepipes inside hospitals and to damaging competitive games.

Douglas could not have foreseen the impact on hospitals. Modern hospital governance grew up around “independent doctors” and it is a tangled web, indeed. Governments struggle to manage them: first locally, then regionally and in some foolish provinces, from a central agency. They empower hospital CEOs and boards, and then later try to constrain them, in a constantly shifting battle.

This “independence” fixation, has inevitably found its way into hospital management. Most painfully for patients, many hospitals compete over funds, hoard essential data, and poach patients, professionals and donors from each other. The more progressive hospital CEOs fight these temptations, and are good at coalition-building, but the system offers them little incentive.

There is an alternative approach. One that delivers superb patient care and hospital management. Its research, innovation and community outreach is the best. Committed to the values of its pioneering founder, who passed them to his two doctor sons, it is now widely seen as the finest hospital system in the world.

Its stunning success rests on those same principles lived today by its 64,000 employees, serving 1.3 million patients a year. Unlike most lofty mission statements, theirs are enforced. They are values we could emulate in Canada.

Patient care not only comes first, feedback on it is measured and reported daily. Specialization yes, but constant co-operation, always. Medical practice is a public service delivered by teams and every team member is a salaried employee of the non-profit foundation. Every patient is billed for their entire treatment, not by fee for procedure. Employees are assessed by their peers, their team and by patients. Diagnosis and followup are seen as just as important to good patient care, and to learning, as medical procedure.

Every patient’s data is recorded for their lifetime. It is available to them digitally, and to any doctor they approve, instantly, on their own secure mobile app. They have hundreds of research partners around the world, investing more than $700 million annually. They give back $2 billion, 20 per cent of total revenue, in financial support to uninsured families that can’t afford to pay. From a shopfront clinic in 1865, it has grown to three giant health centres and 70 smaller hospitals, plus medical schools and research centres, across the United States.

Its first modern patient record is of a Canadian from New Westminster, B.C. It serves thousands of Canadians today. Despite Douglas’s dream of the best universal health-care system in the world, his was born with a fatal flaw. A new generation of Canadian doctors — led mainly by women — has taken up the vision of a salaried, team-based system.

Maybe they will create a Canadian Mayo Clinic, in a small Canadian town, all these years later.