The Gatekeeper Theory

It was known by some as the Gatekeeper Theory of Health Economics. Whatever it was called, it was an effort to keep economic expenditure under control, not to improve the quality of healthcare provided.

The theory went something like this; healthcare expenditure was driven by patients making use of the healthcare system. The more care they sought, the more money had to be spent by government to cover the expenses incurred. The way then to cap healthcare expenditure was to limit patient access. Since the first step in this process was seeing a Family Doctor, Family Doctors became the Gatekeepers to Healthcare, or, put another way, the enemy of the public purse.

The theory developed; it was, after all, doctors that saw these patients when they needed care. That cost money. The doctors usually ordered tests, like labs or x-rays. These also cost money. They might want to consult their specialist colleagues; more money. Those specialist usually ordered more tests, more referrals. Some patients got admitted to hospital for more intensive testing, monitoring, treatments, operations; all very expensive … oh, the humanity!

Politically, telling patients they couldn’t use the healthcare system was suicide. What politician was going to tell the public that, the good news is, you don’t have to pay for healthcare. The other news is we don’t want you to take advantage of not having to pay. That’s not the kind of message that gets a politician reelected (which is the whole point of being a politician). How to limit patient opportunity to take advantage of healthcare without getting yourself fired from your political position?

The theory matured; if a method could be put in place that kept the patients from seeing the doctors, healthcare expenditure problem solved! But how to accomplish this. The politicians couldn’t tell the patients not to go to see the doctor, or the doctor to not see the patient for fear of political fallout. Perhaps the solution was to find a way to prevent doctor seeing patient … by not having a doctor available to see the patient. If the patient has no doctor to see, the doctor doesn’t get paid, tests don’t get ordered, consultation never happens, money doesn’t get spent. Now, they were on to something.

This was how the Canadian public found itself in the nineteen-eighties being told that there was doctor surplus. “We” have too many doctors, the politicians told the public, and it was the “oversupply” that was causing the blooming healthcare costs that “threatened” the Canadian Healthcare System. The doctors were the problem and, in order to solve that problem, politicians were going to do … something.

Getting rid of doctors already in practice was not going to work. While most patients may not worry if the doctor they don’t see down the road goes away, surveys consistent showed that patients were very loyal to their doctor. The politicians risked voter ire if they cut the cord between already practicing doctors and their patients. That water was already under the bridge. The best alternative was to dam the river above the bridge; pinch the supply of new doctors at every entry point.

So in the nineteen-eighties, governments across the country, of all political stripes, started announcing that the surplus of doctors was so severe and costing our Healthcare System so much, medical school enrolment had to be decreased. We must limit the seats in medial school to the minimum required, for the good of our overall Healthcare System.

Why can’t you find a family doctor today? One reason is government design; they put measures in place forty years ago to limit the supply of doctors entering and graduating medical school. They created this problem through deliberate action. This was not a mistake. It is a consequence of decisions made by government actors, by design. Pause on that for a moment.

The other thing they did was make it as difficult as possible for new Family Doctors to set up shop. There was no master plan for where doctors practice (still isn’t). They would finish their training and then find a place to hang their shingle. Many factors went into that decision, most of them where the newly minted doctor felt their training and services would be mutually beneficial; they would do the work for which they were trained, the public in their practice area would get the benefit of that training.

Again, governments were forced to come up with other explanations for limiting where new Family Doctors set up shop. Governments started talking about the deficiency of doctors in rural areas. “Too many” doctors, the argument went, were setting opening their practice in urban areas and “not enough” in rural areas. The only solution, they told the public, was to limit billing numbers where government decided there were “too many” doctors.

Brief aside; we will cover this more later, but a billing number is required by fee for service family doctors to submit their bills for government payment. No billing number, government won’t pay for services rendered. Hard stop. No discussion. In the Canadian Healthcare System, unless you practice a very niche area of specialty that allows you to opt out of the public system altogether (you were either in or out of the public system those days, there was no in between), no billing number meant no practice.

It is worth noting that the phrases “too many” and “not enough” are not statistical terms; they are judgement statements. Who determines what “too many” or “not enough” mean? How does one measure that? In two words, the government, and they did. And they sold it to the public, who, at that time, weren’t having that much trouble finding a practitioner to take care of them, so what’s the bother?

Review time; if you view the actions of government over the last forty years through the lens that they really were trying to recruit and retain family doctors to care for the Canadian population, what kind of a job have they done? If, however, you view their actions through the lens that they were, all this time, trying to discourage and frustrate family doctors, hoping they would retire from the field, what kind of a job have they done?