Unintended Consequence

The Gatekeeper Theory arose out of an economic discussion and was intended, or so we were told, to address an economic problem. The problem just happened to be one of how to pay for the delivery of healthcare. That it was so carefully couched in the language of economics allowed the theory to be decoupled from the impact it would have on care delivery. The decoupling was artificial; you can’t change the economics of care delivery without affecting the delivery of care.

Battles over billing number restrictions were fought in court back in the nineteen-eighties. For the most part, the fight was taken up by medical students, interns and residents, medical learners in training. The Professional Association of Interns and Residents of BC, supported by the Canadian Association of Interns and Residents (now called Resident Doctors of Canada, since we don’t have interns in medical education anymore) and the other similar provincial organizations, took the provincial government to court to overturn billing number restrictions. They were, after all, the ones most immediately affected; patients wouldn’t feel the impact until much later.

Eventually, restrictions in billing numbers were either eliminated by the courts or modified to the point they lost much of their teeth. Governments stopped being so transparent in their desire deal with what I once heard the CEO of a local regional health authority refer to over lunch as “the doctor problem” (she wasn’t speaking to me).

At some point I began to wonder if the days of antipathy towards Family Doctors might have finally been flushed by those making decisions. I was at a meeting with representatives of the provincial Department of Health about ten years ago. I mentioned the name of one of the economists who was a proponent of the Gatekeeper Theory to see what the reaction would be. The departmental types were effusive with their praise for the wonderful work of this economist and how much they were indebted to his many writings in the work they were doing.

If the overt governmental manifestations of The Gatekeeper Theory are no longer readily apparent, their consequences are still manifesting. I am being charitable in referring to them as unintended. Like a tide ebbing to reveal a forgotten shipwreck in the mud, the passage of time has revealed the wreckage that getting rid of Family Doctors would have on the health of Canadians.

It shouldn’t have been that difficult to anticipate what would happen but let’s walk through it anyway. To decrease spending, access to care was to be throttled by literally giving people with health issues no one to see. No visit to the doctor, no testing, no consultations, no therapeutics. No fiscal expenditure. Economic Nirvana.

For the patient with the problem that they want to bring to the attention of a Family Doctor in the hope of some relief, however, Nirvana is not even on the horizon. It turns out that the way to achieve fiscal restraint was to dissociate the patient from care, to the extent possible. The greater the dissociation, the greater the health of the public purse at the expense of the health of the actual public. From a health economics perspective, the best patient was the one who died at home without ever being able to obtain any care at all.

Distilling over forty years of policy into a couple of paragraphs may be a little jarring, but please take a moment to consider; increase utilization of the Healthcare System caused increased health service expenditure. The way chosen to address this increasing government spending was by limiting access to providers and services. Persistence in this approach would inevitably lead to segments of the population without a Family Doctor and increasingly long waiting lines to obtain any kind of care at all.

Sound familiar?

Over the years, I have been involved in initiatives intended to deliver better care to patients. The real Gatekeepers to care are not the Family Doctors but the politicians and Departmental officials that decide which are funded and not. In a world where care comes first and expense is a secondary consideration, the conversation would follow that pattern. Instead, in my experience, every initiative is met with the same first question; how much is this going cost? It may seem exaggeration to maintain that, from the point of view of Provincial Governments and Departments of Health, cost trumps care. I wish it was easier to dismiss that perspective.

For example, I was involved in a research project that showed a different approach to consultation could save “The Government” money on patient transport. All we needed the Department to do was to agree to pay the doctors involved in providing the money-saving care. We were flabbergasted when we met with officials in the Division of the Department that paid doctors to find they opposed the service since, even though it saved The Government more money that it would cost to pay the doctors, the savings did not come from their Division of the Department. They opposed the service because it would require them to pay the doctors more money, which would require them to ask for an increase in their Divisional Budget, reflect poorly on them. When we pointed out the overall savings the program would accrue, we were told savings would be achieved by another Division of the Department, making that Division look good. The impact on the patients was never part of the discussion.

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?

Since we are talking about how money gets spent, let’s spend a little time on how doctors are – and are not – paid for services rendered.