Insights (Essays) August 2010

CMA Emerges Dazed from Cave, Writes Report

Steven Lewis

Remember the news stories from the sixties and seventies about Japanese soldiers emerging from island caves in full battle regalia, unaware that WW2 ended in 1945?  For them, time had stopped.  They were still at war and girded for combat.  It appears they had some company:  the authors of the recently released Canadian Medical Association report, Health Care Transformation in Canada. 

What a strange, atavistic confection, and what a missed opportunity.  I had high hopes for the report – an updated perspective, some serious self-reflection.  Surely it wouldn’t recycle hoary old solutions and beguile us with policy legerdemain. 

Surely it did.  It is a remarkable document on many levels, both for what’s in it and what isn’t.  Solutions based on unstated premises.  More doctors, more services, more of everything – except restraint.  Don’t take my word for it - read it for yourself.  Here’s a sampler of the report’s proposals:

  • More physician extenders (their term) but not a single reference to nurse practitioners.  Handmaidens good; competitors with proven track records bad.  NPs are the loved that dare not speak their name.  Physicians fought them off in the 1970s and 1980s, and they’re fighting them off again.  No surrender!
  • Increased medical school enrolment and expanded residencies.  Wake up, Rip Van Winkle:   medical school enrolments rose by 70% between 1999 and 2009, and residencies by even more.  International medical graduates have easier paths to licensure.  We’re just beginning to see the bubble of new entrants to the workforce.  Old docs aren’t retiring as fast as predicted.  Ontario has rostered huge numbers of new patients in Family Health Teams with modest increases in supply.  Can you spell g-l-u-t?  Wait for it.
  • Thousands of new nursing home beds, assuming current rates of institutionalization will be the norm for the future seniors population.  Memo to CMA:  look around you.  The middle class have abandoned nursing homes for private sector assisted living facilities that have left the medical model behind.  Why not freeze bed numbers (like Denmark did by law 20 years ago) and pursue the alternatives that people actually want?
  • Tax-deductible long-term care insurance, which manages to be both regressive and witless at the same time.  Is the CMA advocating full privatization of long term care?  Does it really want insurance to be cheaper for the rich than for the poor – the inevitable result of making it tax deductible?  More perversely, insuring a certain form of care creates an incentive to use it.  Which is exactly the opposite of what we should be doing.
  • Pay for performance, oblivious to (or maybe fully aware of, come to think of it) the UK experience that hugely inflates doctors’ pay for performing to a level the public should expect routinely.  P4P isn’t bad in theory, but too often it becomes a boondoggle because the targets have to be simple, measurable, and achievable in the short run.  In other words, no-brainers, which is why British GPs score 96% of the available bonus money.

If what’s on the page is otherworldly, the omissions and subtexts are just as telling.  For instance:

  • Twice citing a report that ranks Canada 30th out of 30 on value-for-money, the CMA still calls for more money.  And it is utterly silent on doctors’ contribution to the inefficiency even though they drive two-thirds of the costs.  There is no commitment to reduce variations in practice, and no soul-searching about the over-medicalization of modern life. 
  • Applause for Quebec’s regressive and inflationary policy shift (sequestered health saving accounts, “pre-funding” certain types of expenditures, utilization-based tax surcharges) guaranteed to feed the beast and exempt health care from competing with other public goods.
  • In calling for expanded pharmacare (a good idea), not one word about shoddy prescribing patterns, doctors’ penchant for getting their “education” from drug companies, the fee-for-service incentive to write a scrip and terminate the visit.

Here is a suggested preamble for every CMA report on the future of the healthcare system:

Canada, we’re in a mess, and we doctors are at the centre of it.  We’re the most powerful actors in the system.  The system allows us to churn patients, mindlessly order CT scans, chop up consultations with complex patients into repeat fee-generating visits, saturate the cities, and ignore the rural and remote areas with virtual impunity.  And some of us do.  We drive most of the costs and bear none of the financial risks.  We’re not responsible for all of the system’s problems, but not much goes on without our say-so.  We do some things well and some things badly.  We are fully implicated in both the successes and failures. 

We must change, and we will change.  We will no longer cry for more without delivering better quality, becoming good stewards of resources, and calling each other out when needed.  We will humbly acknowledge and learn from our imperfections and board the quality improvement train en masse.  We will use electronic health records and welcome objective, publicly reported analysis of our performance to help us get better at what we do.  We will get off the treadmill that ties our incomes to doing more and often doing it badly, because at times we need to do less, and do it differently.  We will cease hoarding practice turf and support efforts to make the division of labour more efficient.  Only after we clean up our own house will we ask others to clean up theirs.   

No such luck.  Nothing sticks to this guild in this guild’s world-view.  The CMA is quick to lecture governments and the rest of us about what we need to do while spouting pious platitudes that exempt doctors from having to do anything.  The report’s authors include incoming CMA President Jeff Turnbull, a progressive keenly aware of the non-medical determinants of health and sharing none of the privatizing ambitions of his predecessors Day and Ouellet.  Their fingerprints are all over this report; if Turnbull wants to make his mark, he would do well to hide it under a bushel. 

About the Author

Steven Lewis, President Access Consulting Ltd., Saskatoon & Adjunct Professor of Health Policy, University of Calgary and Simon Fraser University Email:



Marian McGee wrote:

Posted 2010/08/24 at 01:35 PM EDT

I appreciate the succinct commentary by Stephen Lewis. His observations are, in my opinion, absolutely correct.
How are we going to get the public to see and act on his words? That is the only way change will come about--change that is sorely needed. I suggest 'organized' medicine is exacerbating our 'disorganized' health care system.


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