Physician payment in Canada, Germany, and the United States.
The two major issues in physician payment are the mechanism and the amount of payment. In terms of the mechanism of payment, the key factors are the complexity and the predictability of the system and how, if at all, the system intrudes on professional autonomy. For the purposes of this article, professional autonomy will be divided into two components: clinical autonomy, in which a physician has the power to determine the clinical treatment of his patient, and financial autonomy, where a physician has the power to determine the dollar-value of his services.
Physician Payment--United States For the most part, U.S. physicians are paid on a fee-for-service basis. There is a small percentage of U.S. physicians who are either salaried or work under a capitated payment model. For the vast majority of physicians who are fee-for-service, billing requirements differ from payer to payer; at last count, there were 1,500 separate payers. The largest of these payers is state and federal government. Both Medicare and Medicaid reimburse doctors on the basis of a fee schedule. In the case of Medicare, these fees have been historically determined as a percentage of what doctors have charged by region; this is the so called "usual, customary, and reasonable" (UCR) formula.(1)
However, as of January 1, 1992, a resource-based relative value scale has been instituted, which pays doctors on the basis of the resources used for a particular service? In the case of Medicaid, each state has an agency that sets fees, and the formula for determining the fees differs across the states. On average, Medicaid fees are 40-50 percent below those of commercial insurers.
Each of the nongovernment payers has the right to set fees and to require that its billing forms be used. In practice, almost all of these payers use similar forms and a coding method based on uniform categories-the CPT codes and the ICD-9 classification system. Determination of fees paid do differ by payer, although the methods fall into two broad categories. For nonmanaged care payers, a variation of the "usual, customary, and reasonable" formula is used. For managed care payers (including non-staff HMOs and PPOs), fee schedules are set by the payer and, on average, are 20-30 percent below the amounts paid by nonmanaged care entities.
The managed care payers also use a reimbursement technique called a "withhold". From 5-30 percent of fees is "withheld" by the payer, and subsequent payment of this fee is based on the financial performance of the managed care firm.
U.S. physicians also bill their patients directly, and this practice accounts for up to 20 percent of their reimbursement. Direct payment is in the form of a copayment for part of the predetermined fee or is part of what is known as balance billing. Whereas 10 years ago, balance billing was widely used, today there are significant restrictions on its use. Specifically, it is not allowed in Medicaid or in any managed care model. As of January 1991, its use was restricted for Medicare patients. By 1995, a cap of 10 percent in excess of the Medicare fee will be established.
Direct billing and billing of multiple payers require that physicians have sophisticated billing procedures and personnel in their offices. On average, approximately 10-30 percent of a physicians' billings are not reimbursed and are considered bad debts. These bad debts result from patients not paying their bills and from insurance carriers' rejecting or paying less than physicians' claims. It is the prerogative of physicians to pursue this bad debt through collection agencies or formal appeals to third-party administrators.
Third-party payers extensively review physicians' claims through utilization review. As of 1990, 90 percent of payers had varying degrees of UR. These reviews take the form of prospective assessments of the necessity for elective hospital admissions, surgeries, and invasive procedures; concurrent assessment of the necessity of inpatient stays; and retrospective denials of payment for services deemed not medically necessary. Each payer has its own criteria for medical necessity, which is usually not available to physicians. Initial UR decisions are made by nurses using treatment algorithms. Although appeals are available, they are timeconsuming and frequently involve significant paperwork. Although no definitive data exist, payers expect to save about 10 percent of billed charges through utilization review.
In addition to multiple fee schedules and utilization review, there is an additional source of unpredictability involving physician payment--the volume performance standards that the Health Care Financing Administration instituted in 1991.
Applied solely to Medicare payments, the volume performance standards are a form of control on the volume of physician services. Essentially, HCFA sets a prospective target for physician expenditures for the coming fiscal year and adjusts physician payment on the basis of whether the growth target is exceeded or not. The prospective target is set by Congress with input from HCFA.(3)
In summary, American physicians face a cumbersome payment system that necessitates considerable resources for billing patients and a high degree of uncertainty about cash flow. They have varying degrees of influence in determining the worth of their services, ranging from significant in the UCR and balance billing systems to negligible in the government and managed care models. They also face a complex system of utilization review, which results in frequent questioning of their clinical judgment and requires paperwork and phone contacts. Of all the complaints about physician payment in the United States, none are louder than those about this so-called "hassle factor." Physician Payment--Canada The Canadian system of physician payment is as straightforward as the U.S. system is complex. The aggregate sum of money to be paid to physicians is decided on by each of Canada's provincial governments.(4) The funds for this payment are derived from both the federal government and the provinces through premiums and taxation. The federal government pays a fixed annual sum to each province for all of its health costs, which is determined by both historical payments and, since 1977, by the growth of the National GNP. Each province is then free to arrive at its own total health care budget, a percentage of which is applied to physician payment. Determination of this sum is through negotiations between the provincial government and the provincial medical association. Once this sum is determined, each provincial medical association determines a fee schedule for all medical procedures. Individual physicians bill the provincial government on a fee-for-service basis.
Historically, Canadian physicians have collected what they bill. There is less of a need than in the United States for doctors' offices to track bad debt. Although each province has a committee to monitor unnecessary care, it has little mandate to deny payment. There is very little of the intrusive utilization review that occurs in the United States. There is also one billing form, one fee schedule, and one billing agency per province. The simplicity of the Canadian billing system is reflected in physician office overhead costs, which are 70 percent of those in the United States.(5)
Significant changes in the Canadian physician payment system have occurred since 1984.(6) The Canadian Health Act, passed in that year, effectively outlawed the practice of balance billing. In addition, the predictabilty of physician payment has decreased markedly since the institution of expenditure caps in 1985. Five of Canada's 10 provinces have adopted annual ceilings on aggregate physician payment, such that, if the ceiling is exceeded, fees for subsequent services are discounted. The ceiling is examined quarterly. Because fees are set prospectively, this system is really a control on volume of physician services. Because the cap is aggregate, a given physician's fee can be lowered because of the behavior of all physicians in the province.7
From the perspective of a U.S. physician, the obvious advantages of the Canadian payment system are its administrative simplicity and the lack of an aggressive utilization review system.s With respect to clinical autonomy, the Canadian physician has reason to be more satisfied than the U.S. physician. The physician can establish a relationship with the patient and make professional decisions without being second guessed. However, another aspect of clinical autonomy is the doctor's ability to actually get his treatment plan initiated. The rationing though queuing that exists in Canada is an impediment to physician autonomy.
In terms of financial autonomy, the U.S. physician would probably look less favorably on the Canadian model. While the unpredictability of reimbursement seems equal in the two countries, although for different reasons (bad debts vs. volume control), the power to influence fee determination is far different. Although Canadian physicians negotiate with the provinces about their share of the "pie," it is a pie whose size has been determined without their say.(9) In addition, they have no freedom to balance bill. This most resembles the role of the U.S. physician in government and managed care programs.(10) However, the U.S. physician has considerable more power and autonomy in the sphere of "commercial" insurers, where their fees are largely market-based. This is still the case for a substantial percentage of physician income in the United States.
Physician payment in Germany depends on whether a doctor is hospital-based or community-based and on whether a citizen is covered by a sickness fund or by private insurance.(11) Hospital-based physicians are paid a salary based on specialty and seniority; funds come from per diem hospital payments negotiated between hospitals and sickness funds.
Community-based ambulatory care physicians are paid on a fee-for-service basis. Their payments are based on fee schedules, which are different in sickness funds and private insurers. The sickness funds dominate the market, covering 88 percent of the population. There where 1,147 such funds in 1991, some of which were local, some national, and some based in private industry. These funds project the annual health care costs for their members and take the needed money from employers and employees. The sickness funds then negotiate with regional medical associations to determine the percentage of annual funds that will be used to pay for ambulatory care. This lump sum is turned over to the medical associations, which determine fee schedules for each service. Doctors bill the medical association quarterly and payment follows.
In 1987, sickness funds initiated a revision of physician payment in which the fee paid to primary care doctors was increased relative to that paid to specialists.(12) Physicians' role in fee determination is actually at two levels--as one of many representatives on the Concerted Action Conference for Health, which recommends funding levels to sickness funds, and at formal negotiations of regional medical associations with contracting sickness funds.
There are 42 private commercial insurers that cover 12 percent of the population. These companies have their own fee schedules, which are often twice the rate negotiated by the sickness funds. An additional feature of private insurers is that doctors collect copayments directly from patients; this does not happen with the sickness funds. It is not clear from the available literature if each of these insurers has its own forms and codes, although this seems unlikely. It does seem likely that they also contract with regional medical associations, in which case physicians would still have only one billing source. Fees are determined by negotiation between the medical association and private insurers.
Although German physicians have only one party to bill, and likely use just one set of forms or codes, their reimbursement is subject to expenditure targets, which has been national policy since 1977. This leads to a degree of unpredictability in cash flow. Each regional medical association is given a fixed sum of money annually for ambulatory care services, and it is considered a zero-sum pool. Expenditures are evaluated quarterly, and subsequent reimbursements are adjusted in proportion to financial performance. Thus, German physicians' reimbursement depends on the volume performance of their entire regional association.
In 1989, the Health Care Reform Act was passed, which mandated utilization review.(13) Review is done by the regional medical associations in a strictly retrospective manner. Each quarter, the clinical practices of 2 percent of the associations' physicians are reviewed; about 7-10 percent of the physicians are contacted each quarter. Although only 2 percent of claims are actually denied, it is clear that the medical association's are engaged in "economic monitoring," which implies a set of utilization standards.
The German physician payment system shares with the Canadian model administrative simplicity (for the doctor), but seems to also share the negative aspects of the Canadian and U.S. systems. As in Canada, German physicians have limited financial autonomy. Not only are their reimbursements unpredictable because of volume constraints, but their power in determining the worth of their services is limited. Both in the Concerted Action Conference and in their regional medical associations, their role is one of suggestion and negotiation. Only in the minority of their income that derives from the private insurers do they have the financial autonomy that accounts for the majority of U.S. physician income.
As with U.S. doctors, German physicians' clinical autonomy is compromised by the utilization review mandated by the Reform Act of 1989. However, the fact that review is strictly retrospective, that only 2 percent of claims are reviewed and rejected, and that only 10 percent of physicians are actually contacted makes the intrusion far less in Germany than in the United States.
The three aspects of physician income that will be compared here are actual income levels, relative values of these incomes, and trends in income growth. The values are expressed in U.S. dollars and represent net income, i.e., after overhead but before taxes.
Table 1, right, compares average income for all physicians in the three countries in 1986. Whereas all physicians' incomes are averaged for the United States and Canada, the figures used for Germany represent ambulatory doctors only. Although no data were available for the incomes of hospital-based physicians, their salaries are known to be below those of their office-based counterparts.
The data become more revealing if primary care physician incomes are compared with those of specialists (see table 2, right).(13) It is notable that there is a striking similarity in the wages of primary care doctors among the three countries despite the distinct differences in the payment systems. However, it is equally notable that specialty physicians in the United States have incomes significantly above those of their primary care counterparts. Although the primary care/specialty ratio is .73 and .74 in Germany and Canada, respectively, it is .62 in the United States.
These net incomes are more meaningful when they are viewed in relation to nonphysician incomes (table 3, right). This ratio tends to mute the differences in the standards of living among the three countries.(16) Again, despite the marked differences in the payment systems of the three countries, physicians seem to be equally highly paid relative to nonphysicians. The equality would break down, however, if the ratios were calculated for specialty physicians. Particularly in the United States, specialists have relative incomes significantly greater than all other physicians.
The one area in which the centralized, budgeted payment systems of Canada and Germany seem to be most in contrast to the decentralized model in the United States is in the trend of physicians' income. Table 4, above, compares "real" physician income increases (actual fee increases/CPI) in the three countries. The dramatic difference in inflationadjusted fee increases over the decades studied indicates that doctors' incomes are more easily controlled in a centralized health care system. It also makes it predictable that the greatest resistance to centralization of physician payment in the United States comes from the specialty societies.
It was expected that the centralized systems in Canada and Germany would provide more administrative simplicity, and, indeed, this is the case. It was also predicted that physician fee trends would be more affected in the more centralized models, and table 4 illustrates the dramatic differences among the countries. In terms of financial autonomy, U.S. doctors fare better than their foreign counterparts, at least in the sphere of commercial insurers, and this was the presumed outcome.
Somewhat unexpected was the finding that there is equal unpredictability among the countries with respect to physician income projections. While this was expected in the United States because of the complexity and the extensive utilization review in doctor payment, its presence in the other two countries, though largely due to volume targets, was a surprising finding.
The issue of clinical autonomy yielded unexpected findings as well. It is well-known that American physicians have significant intrusions into their autonomy through extensive third-party utilization review. This has been a source of significant dissatisfaction in the United States. A recent survey indicated that 40 percent of doctors would seriously consider making a different career choice if they had the opportunity. In addition, medical school applicants have decreased by 10-15 percent in the past decade.
It has been an argument of proponents of more centralized health care systems that clinical autonomy is preserved. However, a close examination of the recent changes in the Canadian and German models call this statement into question. The 1989 Health Care Reform Act in Germany has resulted in a system of utilization review that resembles the U.S. model. Although their review practices are not nearly as extensive as those in the United States, German doctors have voiced their dissatisfaction. According to Iglehart, German physicians often feel an antipathy toward their regional associations that is similar to the attitude many American doctors have toward third-party payers.(11)
In Canada, health policy analysts have pointed to the lack of an extensive utilization review network to determine that Canadian physicians have suffered no erosion of their clinical autonomy. However, because clinical autonomy is defined as a physician's power to determine the treatment of his or her patients, restrictions on access to prescribed interventions can be seen as an impediment to this power. If a physician determines that a particular course of action is medically necessary but cannot obtain the needed treatment because of unavailability (e.g., MRI scans, coronary bypass surgery), it is arguable that autonomy has been compromised.
Canadian physicians seem increasingly unhappy about their dwindling professional autonomy.(17) In 1987, a strike by Ontario physicians protested their lack of financial autonomy (in that case, the ban on balance billing). A survey in 1989 found 94 percent of Ontario physicians disapproving of the way in which the provincial government was handling the medical system.(15)
Despite dissatisfaction in all these countries, three paradoxes emerge. The first is that, despite growing UR and shrinking salaries, German physicians "remain in general very supportive of the German Health System."(11) The second is that, despite their voiced dissatisfaction, less than one percent of Canadian physicians have moved their practices to the United States, and their profession has grown relative to the overall population over the past 15 years. Third, even in the United States, applicants for medical school increased in 1991 after the aforementioned 10-year slide.(3) In all three countries, despite the voiced dissatisfaction, there is no evidence of a decrease in quality of care, as measured by infant mortality or average length of life.
What, then are the lessons learned from Canada and Germany? How does the United States look at the unexpected findings and paradoxes detailed above and apply them to its own system reform? Part of the answer lies in the nature of dissatisfaction. It is conceivable that German doctors are the least dissatisfied because their system has been in effect the longest. Because dissatisfaction is often the product of disparities between expectation and reality, it may be that physician dissatisfaction in Canada and the United States has most to do with the fact that these professions are in the early decades of profound changes. It may be that physicians are more upset with the process of change than with the changes themselves.
If we look at Canada and the United States, how do we explain the growth in the number of doctors at a time of such dissatisfaction? The answer lies in the fact that physician payment and professional autonomy are only two aspects of why people choose medicine as a career. Surveys have shown that a propensity for altruism and enjoyment of intellectual challenge are important determinants of a person's decision to become a doctor. Despite the general waning of public respect for doctors, surveys continue to indicate that individual patients are still quite content with their physicians. No matter whether payment is centralized or decisions are second-guessed, the unique satisfaction of the doctor-patient relationship exists in all health care delivery systems.
Because Canada and Germany have controlled physician fees far better than has the United States, while maintaining a growing rank of competent physicians, the United States has much to learn from these countries. What both Canada and Germany do is to ensure physician involvement (through medical associations) while avoiding physician control. Physicians' incomes remain high, but their growth is constrained. In both countries, there is a consensus among the nonphysician population about access and cost containment; physicians are thus allowed to participate and complain, but not to dictate. These two countries have found a workable solution by encouraging physicians to do "good" while controlling their efforts to do increasingly "well."
1. Glaser, W. "The Politics of Paying American Physicians." Health Affairs 8(3):129-46, Fall 1989.
2. Ginsburg, P., and Lee, P. "Defending U.S. Physician Payment Reform." Health Affairs 8(4):67-71, Winter 1989.
3. Iglehart, J. "The American Health Care System." New England Journal of Medicine 326(14):962-7, April 2, 1992; 326(25):171520, June 18, 1992; 327(10):742-7, Sept. 3, 1992; 327(20):1467-72, Nopv. 12, 1992.
4. Iglehart, J. "Canada's Health Care System." New England Journal of Medicine, Part 1, 315(3):202-8, July 17, 1986, and Part 2, 315(12):778-84, Sept. 18, 1986.
5. Fuchs, V., and Hahn, J. "How Does Canada Do It? A Comparison of Expenditures for Physicians' Services in the United States and Canada." New England Journal of Medicine 323(13):884-90, Sept. 27, 1990.
6. Evans, R., and others. "Controlling Health Expenditures: The Canadian Reality." New England Journal of Medicine 320(9):571-7, March 2, 1989.
7. Barer, M. "Controlling Medical Care Costs in Canada." JAMA 265(18):2393-4, May 8, 1991.
8. Griffin, G. "Canada's HealthCare Billing Is a Snap." Postgraduate Medicine 91(4):29-35, March 1992.
9. Lomas, J., and others. "Paying Physicians in Canada: Minding our Ps and Qs." Health Affairs 8(1):80-102, Spring 1989.
10. Hughes, J. "How Well Has Canada Contained the Costs of Doctoring." JAMA 265(18):2347-51, May 8, 1991.
11. Iglehart, J. "Germany's Health Care System, Parts 1 and 2." New England Journal of Medicine 324(7):503-8, Feb. 14, 1991, and 324(24):1750-6, June 13, 1991.
12. Brenner, G., and Rublee, D. "The 1987 Revision of Physician Fees in Germany." Health Affairs 10(3):147-56, Fall 1991.
13. Schneider, M. "Health Care Cost Containment in the Federal Republic of Germany." Health Care Financing Review 11(3):87-101, Spring 1991.
14. "Doctor's Earnings on Rise Again." Medical Economics 64(18):212, Sept. 7, 1987.
15. Iglehart, J. "Canada's Health Care System Faces Its Problems." New England Journal of Medicine 322(8):562-8, Feb. 22, 1990.
16. Ellis, R. Presentation on International Comparison of Health Care Financing and Delivery Systems, Feb. 27, 1992.
17. Overmyer, R. "What Canadians and Their Physicians Like and Dislike About Their Health Care System." Physician's Management 32(8):54-74, Aug. 1992.
Summary of Previous Scenario
Dr. Storr, Medical Director of Arno Hospital, had first been alerted six months earlier to potential problems in the performance of Dr. Lakin, one of the hospital's top surgeons, by the medical records department. Dr. Lakin's postoperative notes had been garbled. He had corrected the deficiencies, but he had seemed confused and defensive about the episode. On another occasion, he had violated asepsis in a procedure. Recently, the incidents had increased in number and intensity. Dr. Storr decided to talk to Dr. Lakin to get to the bottom of the problem, but the encounter had been frustrating. Dr. Lakin had seemed confused and embarrassed talking to Dr. Storr, and no resolution had been possible. Dr. Storr knew no more than he did when the conversation began-only that Dr. Lakin's behavior was not normal and was not acceptable. What, he thought, should be his next step?
Dr. Lakin apparently has one of two problems. He may be using drugs and/or controlled substances, or he may have developed a neurological or psychological problem. Given the information available, I tend to suspect the latter and will spend the bulk of this review addressing the potential medical problem. If a substance abuse etiology were suspected, a discreet phone call to the impaired physician section of the state's department of professional regulations would result in a confidential investigation without the origin of the complaint being revealed. If such a problem was confirmed in Florida, Dr. Lakin would be placed in a program to help him toward recovery and protect his medical license.
I would call Dr. Lakin into my office and preface my comments with a statement that he is an asset to the hospital, not only because of his strong financial support of the institution, but also because of his reputation as a premier surgeon. The purpose of the prefacing remarks would be to diminish or eliminate any possible belief that he is the victim of a "witch hunt."
I would then speak to him on a personal level, reviewing the events described in the scenario in light of their clinical significance to underscore the fact that there appears to be a medical problem. I would explain my concerns. First, an adverse verdict and award from a lawsuit could have negative effects on the institution's reputation and financial well-being. We must ensure that Dr. Lakin continues to provide a level of care at or above the "community standard" and that his patients are protected from any ill effects of a disease process that impairs him.
Another concern is Dr. Lakin himself. The hospital has a duty to him and a concern for his health. His current actions may result in his having to endure the hardship of a lawsuit, perhaps tarnishing an otherwise unblemished career. Moreover, Dr. Lakin may have a condition that, left untreated, may severely affect his health.
Ideally, this conversation would be sufficient to persuade Dr. Lakin to pursue a thorough medical evaluation, with results reported to the hospital. If the physical examination fails to reveal any organic etiology for Dr. Lakin's behavior, supratentorial problems must also be considered. I would then encourage Dr. Lakin to seek psychiatric consultation. If Dr. Lakin does not agree with this plan, there would be no alternative to referring the matter to the executive committee for further action.
It is important that documentation regarding discussions with Dr. Lakin be filed and maintained in the proper location (e.g., quality assurance) in order that it remain protected from legal discovery through the peer review process.--Faustino Gonzalez, MD, Chairman of Medical Evaluation Committee, and Bradley S. Feuer, DO, JD, FCLM, Director of Medical and Academy Affairs, Palm Beaches Medical Center, West Palm Beach, Fla.
If Dr. Lakin were an airline pilot instead of a surgeon, there would be no management dilemma. He would be ordered by his supervisor to undergo a complete physical examination before he could resume his professional duties. The differential diagnosis is serious and threatens Dr. Lakin's life as well as those of his patients. If the hospital bylaws do not empower Dr. Storr or the quality assurance director to order an evaluation, such a bylaw should be proposed.
The risk is sufficiently acute, however, that Dr. Storr should not wait for an official mechanism if none is in place. The intervention technique for substance abuse (even if that is not the problem) is probably the best hope for a positive outcome. This would entail a confidential planning meeting of key people in Dr. Lakin's life--the medical director, the chair of surgery, perhaps key O.R. personnel who know him well and observed the incidents, and possibly family members. They would rehearse the messages they would give at a subsequent group meeting with Dr. Lakin:
* Review of his strengths and contributions and their affection and concern for him.
* Review of the behaviors that caused concern.
* Explicit actions that are required (i.e., a thorough
* Explicit consequences if he is noncompliant (probably suspension of surgical privileges).
If Dr. Lakin hears the concern and the respect, the meeting can succeed. If he retreats into defensiveness and denial, the situation becomes potentially litigious. Better, however, to argue that case in court than a malpractice suit if he is allowed to continue and an adverse patient event ensues.--David M. Baughan, MD, Associate Clinical Professor, Division of Family Medicine, School of Medicine, University of California, San Diego, Calif.
In all likelihood, Dr. Lakin has developed an organic brain syndrome and needs a thorough neurologic and neuropsychological evaluation. Dr. Storr should present the problem to the executive committee of the medical staff without Dr. Lakin's being present and seek the executive committee's approval to grant Dr. Lakin a compulsory "sick leave" and suspend his privileges until he is pronounced by a neurological specialist to be fully fit to return to work. Armed with this mandate, Dr. Storr should approach Dr. Lakin and inform him of the necessity to undergo a complete neurologic and neuropsychologic evaluation. Chances are this would document the problem and may reveal the cause.--Mahendr S. Kochar, MD, MS, MBA, Executive Director, Medical College of Wisconsin Affiliated Hospitals, Inc., Milwaukee.
The first consideration is whether Dr. Lakin is a danger to himself, his patients, or others. The answer will determine how fast or extensive the corrective action should be. Because Dr. Lakin did not respond to an informal, collegial approach, he should be requested to appear in front of a formal peer review body of the medical staff (physician aid committee, medical executive committee, or a special ad hoc committee appointed by the medical executive committee). The least damaging approach would be to give Dr. Lakin a final warning, listing a number of events that would result in immediate suspension of privileges.
In the meantime, the medical community should be educated on aberrant behavior and be encouraged to report such behavior to administration or to the medical staff office. A track record or file must be maintained to provide objective evidence to support the decisions of the peer review body.--William J. Mandell, DO, JD, Simi Doctors Medical Clinic, Inc., Simi Valley, Calif.
Dr. Lakin, as a surgeon, is in a particularly sensitive position. It would appear that his judgment and performance in the operating room have shown considerable breaks with routine. Dr. Lakin and his patients, as well as the hospital, are at considerable risk. Dr. Storr, as medical director, is obligated to pursue this matter vigorously. I would be extremely concerned that Dr. Lakin is medically ill. The very first step Dr. Storr should pursue is to have Dr. Lakin submit to a neurologic examination. The episodes described are suggestive of possible embolic phenomena to the brain or an intracranial mass lesion. A neurologic examination will give Drs. Lakin and Storr an excellent starting point as they resolve this dilemma. John C. Alexander Jr., MD, Division of Cardiovascular and Thoracic Surgery, Evanston Hospital, Evanston, Ill.
Dr. Storr's approach to dealing with this situation will depend a great deal on his experience and comfort in dealing with impaired physicians. Based on the scenario, I presume that Dr. Storr is not experienced in identifying and dealing with impaired physicians. Therefore my recommendation would be for Dr. Storr to access the support and resources of the medical staffs "physician well-being committee" if such a committee exists and if not, to contact his state impaired physicians committee and seek its guidance and assistance in confirming the suspicion that Dr. Lakin may be impaired and arranging and coordinating an intervention that would result in a timely and comprehensive evaluation.
Most, if not all, states have an impaired physician program that is an effective resource for investigating and dealing with suspected impairment. Physician executives, and all physicians for that matter, should become familiar with the symptoms of impairment and with the resources available within their hospitals, communities, and states to address the problem.--Daniel J. David, MD, Associate Professor/Program Director, Johnson City Family Practice Program, Johnson City, Tenn.
As the new medical director of a large staff-model HMO, Dr. Herm made a decision to remove treatment for substance abuse from the HMOs mental health department and to establish a new department for substance abuse. A young physician trained in this discipline was hired, and he was allowed to take the lead in hiring staff and developing the department. After a year, the department exceeded the HMO's expectations in the improvement of inpatient bed day use, accessibility for ambulatory care, and patient satisfaction. The HMO was very pleased with the new department and its staff and with staff members' performance and eagerness to help others understand substance abuse and its management.
The department director and his assistant have now approached Dr. Herm with a request that benefits be changed to include residential treatment or, short of a formal benefit change, that such treatment be allowed under a utilization interpretation. They cited a few patients who would be suitable for this kind of management and stated their conviction that the HMO could save even more money with such a benefit.
Dr. Herm is favorably impressed with their eagerness and the thoughtful consideration behind their proposal. He is not surprised that they have come to him with a proposal to improve services. Their track record has been one of doing everything possible to help patients, improve care, and conserve resources.
Dr. Herm's has some reservations about the move, however. His experience has shown that changing benefits or services to save money too often has the opposite effect. He is not in favor of substituting utilization decisions for formal benefit redesign. And he strongly suspects that the proposal would fail to produce the savings that the department predicts. But he doesn't want to dampen the department's enthusiasm. How can he handle their request to best serve the HMO?
The following additional sources of information on the Canadian health care system were obtained through a computerized search of databases. Copies of most articles are available from the American College of Physician Executives for a nominal charge. For further information on citations, contact Gwen Zins, Director of Information Services, at College headquarters, 813/2872000.
Danzon, P. "Hidden Overhead Costs: Is Canada's System Really Less Expensive?" Health Affairs 11(1):21-43, Spring 1992.
Evans, R. and others. "Controlling Health Expenditures- the Canadian Reality." New England Journal of Medicine 320(9):571-7, March 2, 1989.
Honaker. C. "Canada: Model for Total Care?" Group Practice Journal 38(6):20-2,24-30,41, Nov.-Dec. 1989.
Mann, W. "Universal Healthcare Coverage, Canadian Style." Administrative Radiology 11(4):213,25. April 1992.
Muldoon, J., and Stoddart, G. "Publicly Financed Competition in Health Care Delivery: A Canadian Simulation Model." Journal of Health Economics 8(3)313-38, Dec. 1989.
Orford. R. "Reflections on the Canadian and American Health-Care Systems." Mayo Clinic Proceedings 66(2):203-6, Feb. 1991
Rakich, J., and Becket, E. "United States Physician Payment Reform: Background and Comparison with the Canadian Model." Health Care Management Review 17(1):9-19, Winter 1992.
Roehrig, C. "An Insider's Look at the Canadian Health System." Internist 31(2):16-9, Feb. 1990.
Sheils, J. and others. "O Canada: Do We Expect Too Much from Its Health System?" Health Affairs 11(1):7-20, Spring 1992.
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|Author:||Galvin, Robert S.|
|Date:||May 1, 1993|
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