Essays

Essays December 2008

A Man for All Sections: Physicians, Heed Thy Hobbes

Steven Lewis

I dunno, maybe it's the season, but I feel especially moved by the plight of doctors at the bottom of the medical politics food chain. Ontario emergency room docs are just the latest in a long line of disgruntled groups crying foul over the agreement negotiated by their medical association. That agreement got the support of 79% of Ontario doctors, but most ER docs said no. Now they're mobilizing to pursue distributive justice by other means.

Unfairness in the relative income distribution of physicians is not an occasional aberration, a minor side effect of an otherwise exemplary allocation process. It is the inevitable outcome of a fierce competition within a guild that does most of its bare-knuckled work behind closed doors. Fee schedules are complex and no well-intentioned amateurs - the kinds who sit at the table on behalf of their peers - can possibly master the game with equal panache. Over time, power shifts and accretes, some groups gain the upper hand, and income disparities proliferate. There are winners and losers - all relative of course, since every full-time physician's income is at least upper-middle class.

Provincial medical associations are the certified bargaining agents for all doctors - even for doctors who choose not to join. In general, the association and the government negotiate a total amount of money for physician compensation, and most of the details get worked out by the doctors themselves. Sometimes the government targets a top-up here, a fee code adjustment there, but overall, the physician categories - called sections - duke it out for shares of the booty. The mystery is not the injustices that follow, but why habitually shafted specialties, from primary care to rheumatology to geriatrics, stay with the medical herd.

We outsiders don't really know - the doctors don't air their reasoning to outsiders - but we can speculate.

First, they are a profession, and professions love nothing more than self-regulation and self-management. They might prefer the irritations of internal decisions to the prospect of subjecting the guild to external scrutiny and meddlesome guidance. Who ya gonna trust: your peers, or the bureaucrats? We are a band of brothers (and sisters), are we not? We look after our own - imperfectly, but we get you. Stay with us, and we'll try harder for you next time.

Second, they may sense that they are absolute winners, even while they are relative losers. Medical associations are sophisticated negotiators with vast accumulations of experience and corporate memory and a history of getting what they want. Incomes rise, occasionally the government ponies up money to redress the most egregious inequities, and all groups rise, to some extent, with the tide. No zero-sum games here. Hence, even the also-rans in the section wars might be better off than they would be on their own.

Third, governments may discourage rebellion and secession. It's hard enough bargaining with one agent; the migraines multiply when going head-to-head with three or four. Divide and conquer may be theoretically tempting, but that sword could cut both ways. At least there's some devolved discipline involved in tossing the pie to the medical association and letting it play Solomon with the slices.

Still, you would think that solidarity would eventually crumble sometime, somewhere. When the offended groups are large - notably family practice - there is a lot of unexerted power. It is surely conceivable that they could do better on their own. And if the majority of physicians have a modicum of interest in overall fairness, there should be some appetite for blowing up a good deal of what is now done and starting over.

And indeed, some have tried. A few provinces have explored the notion of a relative value approach that would rewrite the fee schedule to reflect, transparently, the education, skill, complexity, and time required to perform various duties. These forays inevitably collapsed as some medical sections faced the spectre of income loss, or unaccustomed parity with their hitherto poor cousins. The message to government was clear: you can buy prosperity for the undervalued, but not at the expense of the gilded income set.

Alternate payment plans (APPs) are increasingly common, though fee-for-service still dominates. This holds some promise, especially if the new plans fall outside the overall compensation pool. If the APPs perpetuate the same distorted income patterns that fee-for-service generates, they will be a partially effective at best (though they may be highly desirable on other grounds).

The solution to all of this is about 400 years old. Thomas Hobbes (1588-1679) coined the memorable phrase bellum omnium contra omnes - the war of all against all. To Hobbes, the state of nature was just such a war, resulting in a life that is nasty, solitary, brutish, short, and poor - sort of how the Ontario ER doctors view their plight (ok, it's not quite the same as a bunch of club-wielding guys in loin cloths, but stick with the metaphor). And they're envious of family docs, for heaven's sake, who have sad tales of their own.

The interesting part is Hobbes's remedy. If the state of nature is a constant state of fear and conflict, the solution is to trade autonomy and power for security and order. Tom, Alice and Cathy, left to their own devices, will thrash each other over whatever spoils are available, and even the winners will be battered. The solution: all agree to let Daphne rule (and Hobbes gave her a swell title, Leviathan, by which he meant the state). Daphne will dispense justice; it will not be perfect, but there will be peace and order, a damn site better than the bellum omnium contra omnes.

Where does the public interest lie here? If the only consequences of the medical sections' bellum was a few thousand doctors irked by the indignity of incomes south of $200K, other matters might be more worthy of concern. But the effects are far more serious. Anticipated future income influences medical students' career choices. Increasingly they eschew the categories needed to address Canada's immense and growing chronic disease burden: family medicine, geriatrics, rheumatology, psychiatry. It's not just income signals that create these imbalances, but money matters.

It is far too much to expect medical associations to get this right on their own. So why not try the Hobbesian solution? Let someone else decide - a skilled tribunal that transparently takes into account all of the factors that should influence pay rates, including system needs. Some groups will, and should, get more and others will, and should, get less. Those that get less will still get a lot, and everyone will do fine. The state of nature in medical agreement negotiations is not a happy place. Doctors and the public deserve better. In this case, the devil we don't know will almost certainly repair the damage more effectively than the devil we do.

About the Author

Steven Lewis is a Saskatoon-based health policy consultant and part-time academic who thinks the healthcare system needs to get a lot better a lot faster.

Also by Mr. Lewis: Spare the Policy, Spoil the Profession

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