David R. Henderson  

Canada's Single Payer/Single Problem

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Have you seen this sign in your doctor's office? It reads, "One problem per visit, please." An editorial in the Canadian Medical Association Journal says this sign is popping up in the offices of some family physicians.
This is from W. Gifford-Jones, M.D., "It's only one problem, but it's a big one," Winnipeg Free Press, January 17, 2009.

I was in Winnipeg last week to interview my first mentor, Clancy Smith. He mentioned that it is increasingly common for doctors to have signs in their waiting room telling patients that they are allowed to mention only one ailment per visit. Clancy said that he had heard of one sign that told patients that if they mentioned more than one, the appointment would be ended immediately. I told my wife about it, who found the link above.

Why does this happen? The government has a fee schedule that pays doctors for specific problems handled. I'm guessing that if they have a patient for an appointment, the doctor can name only one problem on the form that generates the payment.

For my chapter on Canada's rationing by waiting, see David R. Henderson, "The Inefficiency of Health Care Rationing--and a Solution," in Steven Globerman, ed., Reducing Waiting Times for Health Care: What Canada Can Learn from Theory and International Experience.

UPDATE: A message from a doctor friend causes me to think that I didn't make my point clearly. My point is that doctors can charge for only one thing and, therefore, want the patient to make multiple appointments to maximize charges.



COMMENTS (19 to date)
vikingvista writes:

"I'm guessing that if they have a patient for an appointment, the doctor can name only one problem on the form that generates the payment."

Then the physcians probably also can't bill differently for different problems, or there would be an incentive to hear a litany of problems so that the best paying one could be selected for billing.

Arthur_500 writes:

Medicine is complex and all too often multiple ailments may point to a different medical issue. If I treat the headache but ignore the leg pain I may not realize that the person has a serious blood clot that is threatening their life.

Our ObamaCare seeks to get better results from our medical community but they retain the same system of pay for service. Many services are paid for unnecessarily.

Years ago I worked for a hospital and my department was the only one actually making money. At a staff meeting the department heads (doctors) were told to bring in the money. I visited a physician about my bad knees and was told an operation could fix my problems. Being needle averse I looked at another location for a second opinion. Even though the results showed that an operation was not necessary the Insurance company would not pay for that second opinion because those services had already been performed.

Profit needs to be balanced with need. If I need a car I purchase what I want and am willing to pay for. The dealer must try to meet my desires with his profits. Why is this different with medicine? The answer is that someone else is paying the bill so I have little stake in the situation (other than health). When we have to participate in the entire process only then will we see adjustment in the cost, service, fee structure.

No, I don't see this happening through ObamaCare. I see this happening through individual physicians meeting with patients on their own dime.

Rusty writes:

I love your posts but think this one may be a bit off because I have seen this in the US.

I've lived in two US states in the past five years. I have seen these signs in Dr offices in both states.

My guess is that we see it both in Canada and the US for similar reasons. My thought was always that insurance companies bargained low enough prices that the doctors try to make up for it by forcing more visits or reducing the time for a single visit.

sam writes:

The problem is inherent to any system in which the payer and the customer are different.

When the customer pays, the customer and service provider have an incentive to balance cost and service with each other.

In this case:

The customer has no incentive to reduce costs.

The payer has no incentive to improve service.

The service provider has bureaucratic incentives orthogonal to both customer and payer.

There is none of the feedback that causes capitalism to be self-correcting.

Such a system may succeed initially because the people who make up the customer, service provider, and payer groups are part of a capitalist culture that instinctively values the provision of effective and efficient service. Their morals and culture will lead them on, for a while.

Eventually they start pretending to pay us, and we begin to pretend to work.

vikingvista writes:

Arthur_500,

"No, I don't see this happening through ObamaCare. I see this happening through individual physicians meeting with patients on their own dime."

ObamaCare is designed to even further remove patients from direct health care price signals. Of the central problems plaguing US healthcare, ObamaCare correctly identifies nearly all of them--and intentionally makes them worse. Expect future health care legislation, regardless of legislating party, to continue on that central planning track, since a public servant isn't seen as helping if he isn't taking control of the problem.

Avoiding 3rd party financing seems to avoid most of these perverse incentives, and probably one day you will for that reason see an explosion of cash services for routine office visits and minor elective surgeries (already uncommonly available)--at least until our public servants start ordering us not to do that.

Unfortunately, some unexpected procedures though cheaply insurable are beyond most people's ability to immediately pay cash. Since the land-of-the-free prevents Americans from contracting with unlicensed overseas insurance companies, a great many of such procedures will probably be the venue of a growing overseas medical tourism industry.

Of course as expected, those too poor to travel, too poor to possess any significant cash, or simply too poor after paying health care taxes to do much of anything, will be relegated to the government-designed system that everyone who can pays extra to avoid.

David R. Henderson writes:

@Rusty,
I love your posts
Thanks.
but think this one may be a bit off because I have seen this in the US.
Interesting.
I've lived in two US states in the past five years. I have seen these signs in Dr offices in both states.
Which two?
My guess is that we see it both in Canada and the US for similar reasons. My thought was always that insurance companies bargained low enough prices that the doctors try to make up for it by forcing more visits or reducing the time for a single visit.
You may well be right. I live in California and have never seen such a sign. However, one of the reasons I dropped my former doctor is that he charged me about $150 just to talk for 5 minutes before he renewed all my meds that we both knew in advance needed renewing. My current doctor is not that way.

RPLong writes:

I lived in Canada for 9 years. Mine is just the experience of one human being, but here it is, for what it's worth:

"I have a cold, and also can you take care of this wart on my foot and write me a referral to see an allergist?"
In Canada, the wait times at clinics and doctor's offices can be in the 4-hour range. Americans can let that sink in for a little while. I have waited as long as 3 hours for a scheduled appointment. The waiting list is not just a mild inconvenience, it is a major disincentive to show up at all.

Consequently, people might not make it into the doctor's office until they have multiple issues. I certainly didn't.

But now Canadian doctors are faced with a barrage of conditions-per-patient rather than a barrage of patients.

In short, they still haven't fixed the core under-supply problem faced by every health care system in the world.

mucgoo writes:

For the UK what RPLong said.
A pre-booked appointment will often not be available for a week and the doctor might be running late due to multiple issue patient causing an overrun of each slot. Longer if you can't go during normal business hours. If your lucky there's a cancelled appointment.
Something urgent like a severe cut I'd get prompt initial treatment but I'd expect to wait several hours for it to be cleaned up and assessed for stitches.

Hazel Meade writes:

I've never seen a one-issue-per-visit sign in any of my appointment, although at in-network offices, sometimes wait times can be long, even for scheduled appointments. Not 4 hours long, but even an hour is an inconvenience when you are taking time out in the middle of a workday to hit the doctor's office.

I have to imagine that for Canadians going to the doctor means taking the whole day off of work.

Hazel Meade writes:

Also, waiting three weeks for a scheduled appointment is not at all untypical for in-network clinics.

John Goodman writes:

Rusty is correct. We do have the same problem in this country, although not as bad.

Medicare will pay for a doctor to deal with a second and third problem, but not as much as it will pay if the problems are dealt with on separate visits. Hence doctors have financial incentives to impose a one-problem-one-visit rule.

Ton West writes:

As a Canadian, I haven't seen such a sign, nor do I think they're common, but in any system, I'd expect at least a few participants to optimize the system.

As for wait times for appointments, with the same doctor, I've had waits from 0 minutes to at worst 2.5 hours. It's the cost of having a doctor that takes the appropriate amount of time for each patient, regardless of how long your appointment was (which for GPs, is usually a standard 20 minutes).

And of course, Canada optimizes for lower cost. If you're paying near twice as much per capita for slightly better outcomes, I'd hope that at the very least, patients are much less inconvenienced.

And, of course, for the Canadian system, you don't have the choice to pay for ratio of doctor vs. patient waiting time to be more even.

Rusty writes:

I saw these signs in Utah and Iowa. They were in large offices with lots of doctors. The individual doctors that I saw didn't enforce it.

Mark V Anderson writes:

This is definitely a US issue also. My doctor once told me he couldn't help me with something other than what my appointment was for, because the insurance company would get mad. I wish I could remember what the particulars were. I think it had to do with a follow-up on a surgery or something that was already covered by a previous payment.

I am in Minnesota, although I'm not sure if the state matters.

Hopaulius writes:

This past winter I had a scheduled physical with my small town US doctor. He found a suspicious mole and told me that in times past he would have just removed it and sent it for biopsy. Now, due to changes in the law under Obamacare, he cannot bill for any procedure not covered by the scheduled appointment. So I made the second appointment, he removed the mole, and it turned out to be cancerous. The mole removal also removed the cancer. I don't know whether he would have been reimbursed if I had suffered a heart attack during the physical. Probably not.

RebeccaJ. writes:

I have seen that at two different doctors' offices here in Illinois. What's more, at my well-patient visit last year, the doctor did not allow me to bring up a problem that I wanted to talk to him about. He said I needed to make another appointment to talk about it. I thought it particular irksome that after he said that and I shut up, he asked me whether I had any other questions as he led me out the door.

I agree with you. I think it has to do with the way they have to code for their insurance reimbursements. But it's a terrible waste of my time. I didn't bother to make that second appointment.

Thomas Boyle writes:

I too have seen this happen in the US, both with a general practitioner, and a dermatologist.

One doctor dithered for a bit, then decided to deal with two issues in one visit. From his dithering, I deduced that he was trying to decide if he could get away with billing for two separate visits on the same day. But, perhaps it was something else.

Pierre writes:

One problem per visit, and, if you're in B.C., there is a government mandated maximum number of patients that can be seen per day. I haven't personally seen the one problem per visit sign, or had any problems with my family doctor along those lines, but I have tried to go to a clinic and found it closed because the clinic had served "too many" people that day.

Pierre

Peter Drake writes:

It's not easy creating a system with separate payee and consumer. My experience of the Canadian system is that there is generally less paperwork, but there are wrinkles that can incentivize inefficiency.

My doctor works under a program where the entire practice (12+ doctors) is paid a base rate per patient (based on health profile). As long as she isn't running late on her appointments she is happy to deal with secondary issues. In healthcare the earlier that problems are identified the better the outcomes, generally.

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