Insights July 2014

Ontario Spent $110 Million to Get Doctors to Increase Cancer Screening Rates. It Didn’t Work. That’s Good News

Steven Lewis

No, wasting money is not good news, but it’s hardly a new catastrophe. We waste millions of dollars every day in healthcare – Canada is a long-standing high-performer in the Choosing Unwisely campaign. The good news is that yet another pay-them-and-they-will-do-your-bidding experiment has failed. It will be bad news if yet again, governments and their medical association tango partners repeat the experiment. These negative results have been replicated quite enough. It’s time to call a halt to this particular innovation.

Briefly: From 2006-07 to 2009-10, the Ontario government gave family doctors $110 million to boost screening rates for cervical, breast, and colorectal cancer. Never mind that there is a lot of over-screening for cervical cancer (many women get a Pap test more frequently than the recommended every 3rd year) as well as under-screening. Never mind that the evidence for universal breast cancer screening grows shakier by the year. Take it at face value: spending designed to achieve specified effects.

It flopped. Family physician Tara Kinan and colleagues have just published a study that shows no impact. Why should we be happy? Not because it makes the Ontario government look bad. Not because it’s good that doctors fail. The good news is that the study shows, yet again, that few doctors are cynical, practice-to-the-test mercenaries whose only motivation to improve is the prospect of scoring bonuses on top of their already-substantial regular pay. The results suggest that the typical Ontario family doctor in essence said: screw you. I’m not rearranging my priorities and my focus just because the OMA negotiated a windfall. Sure, I’ll take a few thousand bucks for meeting targets I had already met prior to the scheme. But don’t think for a moment that your P4P scheme owns me. If you think my behaviour and motivation are explained entirely by money, you don’t get me.  

It’s not the first study documenting the intellectual poverty of policies that owe their theory of human action to Pavlov. BC seems to have blown a billion (not a typo) over the past decade on a similar approach to improve primary care. The message is clear. Quit treating physicians as if they’re crack whores.

What, you’re offended by the analogy? A crack whore is an addict whose behaviour can be entirely explained by the prospect of getting a crack fix. That behaviour is a purely extrinsic motivation – no one chooses, in the full sense of the term, to become a crack whore, and the unfortunate addict would choose another line of work if liberated from the addiction. (OMA negotiator?) When the government and the medical association decide that the way to get doctors to screen more often is to give them money, they are pursuing exactly the same logic. Don’t assume they share your goals or aspire on their own to do better. Rather, assume you have to show them the money before they will up their game. Yes, the addictive substance is different and so is the behaviour for which it is exchanged. The presumed mechanism of action is identical.

If these reductive public policy fiascos were merely wasteful and insulting, it would be bad enough. But as they become increasingly standard practices, over time they could do serious damage. It is possible to addict good people and spoil nice children. It is possible to erode altruism and devotion to excellence through policies that assume neither exists. Appealing to and rewarding what’s worst in us will often bring out what’s worst in us. Cynical target-chasing can, if you work at it, become the new normal.

Thank you, family doctors of Ontario, for not responding to the cynical carrot. And thank you in advance, OMA and Government of Ontario, for stopping the madness. Fool yourselves once with simple-minded economics, something learned. Fool yourselves again and again, shame on you. 

About the Author(s)

Steven Lewis is President of Access Consulting Ltd., Saskatoon SK  S7K 0C2.


Monique Moreau wrote:

Posted 2014/07/24 at 10:48 AM EDT

I agree with Stephen Lewis on this topic for a different reason. The screening programs are being shown to do more harm than good. We are not saving lives or preventing cancers. We are creating more chronic diseased people who still get the cancers and die from them slowly over many years, where there lives are dominated by having cancer, thinking they have beat it, and waiting for it to come back. Primary care focus should be on changing lifestyles that lead to increased risk for cancer. Screening to find it early is ineffective at best. I agree; let's stop the madness.


Alex Franklin wrote:

Posted 2014/07/24 at 11:17 AM EDT

As physician for 55y the great advance in medicine is early detection & prevention through screening. Early diagnosis & treatment can prolong life. Adjunct Sask.U.Prof.Steven Lewis MA is needlessly offensive to MDs. Business may be low for his Access Consulting Ltd.


Katie Dainty wrote:

Posted 2014/07/29 at 02:10 PM EDT

Sadly, we will never know if Steven Lewis' personal opinion of why physicians didn't change their practice is accurate or not (likely not) because in addition to wasting money, the health system wastes precious opportunities to do proper evaluations of WHY things don't work in order to learn valuable lessons about what exactly not to do next. The quantitative research showing that it didn't work is important but understanding why didn't work would be much more useful moving forward.

Katie N. Dainty, PhD
Qualitative Scientist
Li Ka Shing Knowledge Institute at St. Michael's Hospital
Assistant Professor, IHPME, University of Toronto


Elizabeth EB wrote:

Posted 2014/04/10 at 03:54 AM EDT

This is good news, I've always resented the way these programs interfere with the doctor/patient relationship. All cancer screening is supposed to be elective and legally and ethically requires informed consent, but it seems many view screening as mandatory for women. Try declining a pap test and see if your decision is respected.
The fact is many women do not consent to cancer screening at all, they are coerced into cancer screening, no pap test = no Pill. (and in the US and Canada they might also, tack on an unnecessary pelvic and breast exam, neither exam is recommended here in Australia, at any age, both of these routine exams were thankfully, ditched long ago)

Cancer screening has nothing to do with the Pill, the only clinical requirement is your medical history and a blood pressure test. Yet every day women are denied the Pill or non-emergency medical care if they choose not to screen, to exercise their legal right.
Our doctors here in Australia receive target payments for pap testing, but this potential conflict of interest is never mentioned to women. Also, our program seriously over-screens which does not benefit women, but leads to huge referral rates for excess biopsies and potentially harmful over-treatment. The lifetime risk of referral here is a huge and hidden 77% to screen for a cancer that carries a lifetime risk of just 0.65%

I've always watched the Finns and Dutch, both have managed to put women and the evidence first. Since the 1960s the Finns have offered 7 pap tests, 5 yearly from 30 to 60, they have the lowest rates of cc in the world and refer FAR fewer women for colposcopy/biopsy etc.
So this is not new evidence. Here women are still being urged to have 26 or more pap tests, and scolded if they don't.
The Dutch will scrap population pap testing and their new program will offer 5 HPV primary tests or self-testing at ages 30,35,40,50 and 60 and ONLY the roughly 5% who are HPV+ will be offered a 5 yearly pap test. MOST women are having unnecessary pap testing.

I declined pap testing decades ago, I'm not prepared to accept much risk at all to screen for a rare event, I now understand I'd be HPV- and cannot benefit.
I rejected breast screening when I turned 50, the Nordic Cochrane Institute summary helped me make an informed decision. The NCI is an independent, not for profit, medical research group.
In my opinion, cancer screening for women is viewed as a lucrative game, tell women any old rubbish and devise ways to "capture" them, it should be a scandal.
Needless to say, I'd urge women to do their research and make informed decisions, never rely on the official discourse and doctor-shop, find someone ethical and competent.
I think non-evidence based screening that ignores consent/informed consent is one of the greatest threats to our health, lives and quality of life.


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