ER closures due to uneven fee schedules

News articles about ER closures always place the cause of the disruption as “a doctor shortage”.

In January 26, 2017, Cumberland News Now quoted Dr. Bill Lowe, head of family medicine for the Nova Scotia Health Authority’s northern zone that the ER closures at All Saints was due to “an inability to find sufficient locum physicians to fill all the shifts.”

March 30, MBS Radio reported, “The South Cumberland ER in Parrsboro will be closed Saturday from 8:30am-8:30pm. It’s due to a doctor shortage.”

On April 20, MBS reported, “The South Cumberland ER in Parrsboro will have several day closures next week and weekend. It’ll be closed Monday, Wednesday, Thursday, Friday, Saturday and Sunday from 8:30am-8:30pm due to a doctor shortage.”

Cumberland News Now reported on April 26 that the Pugwash ER would be closed for four hours “because there is no physician to provide the necessary medical coverage.”

On May 17, CKDH radio reported another ER closure for Pugwash “due to a doctor shortage.”

In total Cumberland County ERs had 65 closures in 71 days.

What is left out of the announcements about these doctor shortages is that there are no doctors available to work for the fee schedule offered. The fees paid to rural ER doctors are so low that it doesn’t make economic sense for physicians to leave their offices to staff ERs. To do so is an act of fiscal charity.

Left unsaid is that our universal health care system has a tiered, geography-based fee schedule. The Nova Scotia Health Authority, like its predecessor authorities, believes that rural health can be provided for less money than urban health. So the fees paid to doctors working in rural ERs is less than that paid to doctors working in city ERs.

I’ve written about this before (https://wordpress.com/post/helphealthcare.wordpress.com/1162).

In setting the fee schedules there is a lop-sided valuation of responsibilities. Health executives, whose pay is not based on geographic determinants, have decided that rural ERs are less challenging situations, so those doctors are paid $75 an hour less than a doctor in a Halifax-based ER.

It’s a curious distinction. It implies an official policy that says city people are sicker than rural residents. The subtext is that rural lives don’t matter (as much).

How is it that we believe a uniform rate of pay for teachers is necessary to achieve a universal level of education for all students in the province, but we use geography to devalue a physician’s contribution to patient health? MLAs, Cabinet Ministers, civil servants, health executives have one pay scale, regardless if they represent and/or work in a rural or urban riding or setting. There is no distinction made based on geography. So why is it okay to play with health care dollars in this manner?

We can hire all kinds of recruiters to try to attract doctors to the province, but if we don’t pay them competitively, we will continue to have ER closures. Of course, those closures don’t happen in the city because of the pay rate provided to ER doctors. As I previously wrote a county warden felt it unfair to place rural doctors at the bottom of the pay pile because they (the rural doctor) had the greater responsibility for the patient.

In a city ER, the doctor has a wider array of support services and specialists to call on. A city ER can “process” a patient more quickly. In a rural setting, the ER doctor has fewer on-site resources, so is more involved in stabilizing the patient then determining if that patient can return home, must stay on-site for treatment or should be transferred to the city.

I also suggest that rural doctors are often dealing with a bloodier type of medicine given rural occupations in farming, fishing and forestry. Not as many city residents are working with heavy equipment, large animals or sharp instruments in all types of weather.

The growth in ER closures is the canary in the mineshaft for the problems in health care. In the past, physicians spoke about problems with the system and management. Now their complaints are management and money.

When it comes to management physicians feel undervalued, stressed and abused. The NSHA speaks of “consultations”, but that is, to quote many physicians, “corporate bullshit”. There are meetings, but the conversation is one sided. Management isn’t listening. The acrimony is so great I’ve heard of physicians telling NSHA executives to “shut up” so they – the physicians – could speak. It doesn’t happen. But the NSHA, coddled by an out-of-touch board, pretends to have dialogue and “consultations” with doctors. And nurses.

On the topic of money, family physicians are stressed. The current fee schedule doesn’t cover basic services like renewing prescriptions, so doctors have to add a billable service to an office visit. Another ridiculous situation is that for a face-to-face appointment a doctor is paid half of what the Province pays for a call to the 8-1-1 service, which is not answered by a doctor.

A doctor’s appointment used to be for whatever medical issues a patient had. Now, patients are actively discouraged from arriving with a list of ailments. Most doctor’s office walls and websites contain notices to confine yourself to one or two issues. A basic patient appointment generates a billable fee of less than $31.

So, to cover their costs, doctors are forced into a type of production-line-like appointment schedule. Where once doctors saw patients for all their medical concerns, time management has become an economic necessity. Doctors were scheduling appointments in 15-minute increments. Recently, I have seen appointments scheduled in 12-minute increments. That allows a doctor to see an additional 8 patients per eight-hour day, so 40 patients a day instead of 32.

Given the costs of operating a practice – rent, utilities, supplies, office staff, technology, equipment, etc. – doctors have to think as much about the economics of a practice as the medicine. The public has the impression that doctors roll in money. The dirty little secret in Nova Scotia is that the family practice income is shit. I recently heard of a family physician whose taxable income was $60,000! A lot of family physicians are earning in the $98-to-$144,000 range. That can seem like a comfortable income when compared to what others earn in Nova Scotia, but doctors deal in life and death. They spent years studying to achieve their qualifications to practice. We pay others comparable amounts – or more – for duties and services with substantially less stress and responsibility.

If we want to solve the doctor shortages – whether in ERs or private practice – we need to pay physicians better. We also have to lighten up on this death-grip idea that a collaborative care practice is the super solution to health care delivery. It is viewed as a questionable option. More on that next week.

 

 

 

 

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Death while under Protection

Saturday evening a resident in a long-term care facility was found unconscious on the floor of the washroom in their room. It’s unclear if the individual had a heart attack or fell and hit their head. They were unconscious, but breathing on their own.

Their care-giver found them, called the RN on duty, who assessed the person and situation and called 9-1-1. Someone stayed with the resident the whole time. Paramedics arrived within 10 minutes. Just at their point of arrival did the resident stop breathing. There is some question about whether CPR could have helped. None was administered. The caregiver maintains the person had only just stopped breathing, the paramedics decided it was too late to do anything.

Having declared the resident deceased, the paramedics helped move the person from the floor to their bed. The question becomes what next?

This resident was under the direction of Adult Protection Services of the Department of Health and Wellness, with final instructions sealed and held by the Public Trustee.

Staff at the care facility had no instructions about who to contact to inform about the death. Are there family to inform? Is the deceased to be buried, cremated or are they an organ donor? Where organ donation is a factor speed is of the essence. Those details were under seal with the Public Trustee.

This is an example where the health care system is designed for the convenience of the executives rather than the patients and front line workers. The Public Trustee’s office is open Monday to Friday. It’s either from 8:30 am to 4:30 pm or 9 am to 5 pm. Specific hours aren’t listed on the Department of Health’s website. And the 211 Service says “the site” hours are 8:30 am to 4:30 pm. I’m unsure if that’s their (the 211-service’s) site or Dept. of Health’s site:

http://ns.211.ca/service/10060203_6030784/adult_protection_services

Nonetheless, the information available is fairly ambiguous. It seems to be a wait-until-the-office-opens situation. Meanwhile, a person’s remains are in limbo. Does Halifax expect long-term care facilities to keep deceased residents around, in this case for 37 hours, until someone comes in to an office? And if that person had agreed to organ donation, would all of those transplantable parts no longer be suitable for surgery?

This is one of the many gaps created in a health care system which relies on top-down ideas. No one seems to have considered the details and procedures for death outside office hours.

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Oh good grief!

Oh good grief.

Jean Laroche of the CBC reports that a facility for those with mental health issues, Simpson Landing, sits half-empty. Simpson Landing has an abundance of beds, yet we keep hearing of a “quiet crisis” in the delivery of mental health care.

http://www.cbc.ca/news/canada/nova-scotia/simpson-landing-mental-health-nova-scotia-hospital-1.4157233

We hear that people suffering mental health emergencies have gone to ERs and been turned away. More than once there have been stories of a refusal to admit a person into care or someone being released against family wishes – the implication is that there is no room for them. And while some people struggle for help, we have 20 beds sitting empty!

http://atlantic.ctvnews.ca/n-s-woman-struggling-to-find-mental-health-services-for-friend-in-need-1.2865967

Now that this has been made public, the Nova Scotia Health Authority (NSHA) have resorted to the classic response: “The health authority said it was looking at other uses for the vacant part of Simpson Landing, but refused to discuss any or talk about a timeline.”

Of course, further use of a medical facility and a timeline for use are state secrets.

Former NDP cabinet minister Graham Steele has told us that politicians and organizations love to say something is being “studied”. Study sounds like something is being done, when the real purpose of any study is to give cover for inaction. A government may engage in studies to wait out the next election. With senior bureaucrats, like those at NSHA, one assumes study helps them wait out their impending retirement (3-4 years based on age).

Simpson Landing is another in the long list of health care project cock-ups. It was five years late opening and 48 percent over budget.

When it opened then health minister Dave Wilson said the delays and costs were due to a change in location (it was moved closer to the street) and the cost of demolishing another building on the site. Why weren’t demolition costs factored in to the original budget? And in the original planning process why wasn’t location better considered? Any homeowner knows that mid-project changes turn into a money pit, so who authorized the location change? And why wasn’t better planning in evidence?

http://www.cbc.ca/news/canada/nova-scotia/simpson-landing-opens-in-dartmouth-after-5-year-delay-1.1246815

This project would have been approved in the same time frame as the new Truro hospital, which was two years late opening and 80 percent over budget. Nova Scotia has over 200 years of government projects not coming in on time and on budget, yet, those responsible constantly feign surprise. And with health care we not only can’t project costs and delivery time, we can’t project need.

So what else can’t health executives manage?

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Complaining for care

The Globe and Mail’s health reporter, Andre Picard, has been in Halifax this week attending a conference. Picard is the author of a new book, Matters of Life and Death, Public Health Issues in Canada.

One a radio phone-in he was asked what we, the public, can do to improve health care. Picard’s suggestion was to complain more. He said Canadians have been too complacent and too accepting of the status quo.

Not surprisingly, I agree.

I know it goes against the grain to criticize and complain, but being polite and respectful hasn’t worked.

I am old enough to remember when AIDS was first identified. Initially there was a lot of ignorance and prejudice around the illness. As generations were decimated by AIDS, activists, like Larry Kramer, stopped being polite. Polite hadn’t worked. They adopted an in-your-face position. At first I was uncomfortable with what I thought was unnecessary rudeness.

As I faced our health care system and learned of the shared experiences of others, I understood the frustration, anger and disappointment of those early AIDS activists. Their campaign was simple: Silence = Death.

We have grown up with the concept that the squeaky wheel gets the oil, so why are we afraid to complain about the lack of progress in solving problems in health care? We shouldn’t pretend things are great when for many they obviously aren’t.

The election is over. That doesn’t mean that citizens should put their concerns on hold for four years. Feet to fire is the only way to get change. It’s our duty to ourselves, those we love and the system.

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Forget refreshed, go with ministerial experience

A post-election comment suggests the Premier name a new health minister because given the mood in the province “it would be difficult to move things forward. A fresh face” and a new deputy health minister “could mark a refreshed approach to the problems in our system.”

That, I believe, is a simplistic, unrealistic solution. The problems in the system existed long before the 2013 election. It is the constant shuffling of health ministers that allowed the systematic problems to continue and thrive.

As I have repeatedly said: we change governments, we change health ministers, we reorganize the system, we reorganize individual work flows, we change how front-line health care is delivered and whether the government is red, blue or orange, the problems persist. What doesn’t change are the health executives. Does no one see a cause and effect connection?

Constantly changing health ministers allows the health executives to have the upper-hand when this “refreshed approach to problems” are presented. The people who have done well and are most comfortable within the system are hardly likely to change it.

Health ministers – and premiers – don’t oversee the day-to-day delivery of health care. That’s the responsibility of health executives.

No health minister advocates for under-staffing or throwing up roadblocks to doctors who want to practice in the province. Health ministers are politicians. Their lives would be easy if everyone had a doctor, there were no nurse shortages and buildings weren’t disintegrating.

So the problem has to be the tightly micro-managed way the Nova Scotia Health Authority (NSHA) has chosen to operate.

The heads of the NSHA aren’t particularly responsive. For example, in October 2009 I had a meeting with Dr. Lynne Harrigan, who was then vice president of medicine for the Annapolis Valley District Health Authority, now vice president of medicine for the NSHA. At the meeting Dr. Harrigan told me that when the Valley Regional Hospital opened there had been “a double cross in the local medical community” which left most Valley doctors without hospital privileges. Without privileges doctors couldn’t see any hospitalized patients. Doctors were informed, via letter, when one of their patients was admitted to hospital. Eventually, after the patient was released or died, another letter would be sent to the physician noting the discharge/death. Doctors were not necessarily consulted or informed of the care and status of their patients while in hospital.

That “double cross” (her words) happened 15 years previously. This is eight years later and the situation was never rectified. If health executives were genuine in their desire to work with the physician community that would have been one step. We should judge people not just by their words, but their actions.

We are told that doctors don’t want to have solo or rural practices. There has been an argument, advanced by the NSHA, against old-style practices. While most new doctors want a better work-life balance there is currently is no accommodation for medical mavericks who are prepared to go it alone or work in a smaller medical partnership than what Doctors Nova Scotia describe as the “aspirational collaborative care practice model” that the NSHA is set on establishing.

Even on a fee-for-service basis, where the doctor assumes the risk of establishing their practice in under-serviced areas – assuming any physician wants to go to such a place – the NSHA prevents it. Technically, they don’t. They don’t say a doctor can’t open in a Wedgeport, however, they won’t “credential” the physician. This is a clever way to control where and how doctors practice. NSHA have seen other provinces lose court cases over limiting where physicians practice. So the NSHA doesn’t say you can’t practice here, instead it withholds these credentials, which means a doctor can’t order lab tests, can’t access diagnostic imaging or write prescriptions. In essence, without these no medical doctor can make a living. (A psychiatrist can.) This is the impediment to practice and it could be changed instantly on Janet Knox’s or Lynne Harrigan’s say so. It does not require NSHA board approval, a change in legislation or consultation with the College of Physicians and Surgeons.

One Nova Scotian physician told me the idea that no one wants a solo practice “is a lie”. A medical student has written this site to say that the idea of solo practice isn’t even mentioned in medical school. Those are two issues to be addressed.

It all comes down to whose definition of collaboration you use. A little respect wouldn’t be amiss.

I’m told of a fall meeting called by the NSHA where a group of doctors were told, “you people are fat cats who think you know it all. You’re a bunch of elitists who are out of touch.”

Another comment was that a particular senior NSHA manager is “somebody who could make peaceful monks want to hurt each other. He’s got this way of communicating that gets everybody on edge.” At a meeting attended by 100 physicians, a doctor in attendance said, “We were appalled at the way we were spoken to. We were first told this was to be an ‘engagement meeting’ where we were going to develop community-based solutions in collaborative care. Essentially, he (the NSHA manager) put up a list and said this, this and this is going to happen. Take a look at the document given to you.” The engagement was another top-down edict from NSHA to doctors. It was to give cover for decisions made by those who don’t engage with front-line care.

We shouldn’t be surprised by this one-sidedness. In 2011 the IWK stupidly posted on their website that they no longer were recording complaints as criticism, but instead would consider it “feedback”. I wrote about it here:

https://helphealthcare.wordpress.com/2011/11/14/why-save-our-secret-system/

Last year a doctor told me of a “consultation” between the NSHA VP and a group of Halifax specialists. This was also supposed to be an opportunity for doctors to speak about their challenges and share ideas. Instead, it was yet another top-down presentation by the NSHA. Doctors were not given an opportunity to speak. It was such a waste of time that one frustrated physician told the NSHA VP to “shut up” and let them speak.

No doubt such events are considered “consultations” by the NSHA executives.

A long-serving health minister is the best hope we have to break through corporate complacency for better care. And happier working conditions for those in the health care system. A long-serving minister will be the bullshit detector. Be angry. But be angry at and disappointed with the right people. Otherwise, no meaningful change will ever come.

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A radical idea for meaningful change in health care: consistency

The final week of the Nova Scotia provincial election has taken on American overtones. The leaders of the Progressive Conservative and New Democratic Parties are pushing Liberal leader, Premier Stephen McNeil, to say that health care is in a crises.

In a leaders’ debate the Liberal leader said health care has challenges. The PCs and NDP have formed a united front to get the Premier say health care is in crises. Then what? Does that change anything? Does it impact their platforms and plans? Beyond throwing money towards health care, have they real measurable plans to improve the delivery of care? We’ve had decades of simplistic solutions, like tossing more money at health care, that haven’t resulted in better outcomes for patients.

Focusing on a phrase is what happened in the U.S. presidential campaign. Donald Trump focused his election campaign about the refusal of then President Obama and candidate Hilary Clinton’s to mouth the phrase “radical Islamic terrorism”. Saying the phrase doesn’t stop terror attacks.

Focusing on a phrase instead of a plan is what drags our provincial election to the level of what we saw in the United States. Do we want that?

I’ve long been critical of our health care system. And my frustration began long before this government was formed. I started this blog as far away from an election cycle as possible because I wanted us to have a substantive, sustained discussion about the problems, issues and concerns around the delivery of quality health care in Nova Scotia and hopefully share actionable ideas to improve it. I did that because the traditional election conversation about health care is to see who is prepared to toss the most money at it.

Study after study has said that more money isn’t a panacea for better health care. More money means solutions are more expensive.

Public memory is short. Our hospitals have been falling apart for decades. During 2009-11, I was told of 37 doctors who quit their practices in two communities. These weren’t retirements, they were physicians fed up with their working conditions. Later I met mayors and wardens who appealed to their local health authorities (under the nine-authority system) and the Department of Health to fix their hospitals and hire more doctors and nurses. Before the last provincial election a Valley mayor told me he was so fed up he refused to speak to the president of his local health authority.  In 2012 I attended a meeting in Berwick where an Annapolis Valley District Health Authority board member told those complaining about care they “didn’t know what they were talking about.” The idea that local decision makers are more responsive is fantasy. At least as it was managed in this province.

In thinking about how to help health care, I realized the problem is two-fold.

First, it’s the executives who, whether they sit in communities around the province or a health headquarters in Halifax, are too embedded in old thinking. We built a new system around cooperation, coordination and collaboration, but put it in the hands of people who have a history of being unresponsive. They drape themselves in a pretense of consultaion, but as doctors, nurses, surgeons and others have told me, meetings are called not to listen to concerns and ideas, but present top-down measures from people who haven’t been on the front lines in decades. These executives don’t recognize that change and innovation are about action, not simply peppering conversation and memos with the management catch phases du jour. Health executives have not shown themselves to be innovative or collaborative.

The second problem is the revolving door of health ministers. In the last 14 years we have had eight ministers of health and/or health promotion. Some have been responsible for multiple ministries at the same time. Here’s the list:

Rodney MacDonald – Minister of Health Promotion (2003)

Barry Barnet – Health Promotion and Protection, African Nova Scotian Affairs and  Communications Nova Scotia (2006)

Chris d’Entremont – Minister of Health and Acadian Affairs (2006)

Pat Dunn – Health Promotion (2009)

Karen Casey – Minister of Health (2009)

Maureen MacDonald – Minister of Health (2009)

David Wilson – Minister of Health (2012)

Leo Glavine Minister of Health 2013 to present.

Health is the biggest single file the government has. It deserves a minister’s full attention not just photo ops. As President Donald Trump learned, “It’s an unbelievably complex subject. Nobody knew health care could be so complicated.” Certainly the solutions presented in this provincial election seem pretty simplistic.

In Nova Scotia the average term of a Minister of Health is 21 months. The issue is this: when a new minister comes in it takes at least a year to come to grips with the file. Then, when they have begun to grasp the basics of it they focus on a pet project. That announced, there’s a cabinet shuffle and a new minister takes over. The cycle starts again and about the time the new minister understands the file we’re in an election campaign. More promises, more dashed dreams.

The other problem is that each new minister is advised by the same bureaucrats and health executives as his political opponents. Whatever party is in power, the status quo remains because the advice comes from the same people. Many years ago a senior bureaucrat in Newfoundland told me they had three people in their department whose job it was to talk the minister out of things. No doubt each health minister is surrounded by multiple advisors explaining why something can’t be done. Based on that we delude ourselves when we think we’re voting for change.

Perhaps the best thing we could do to help health care is to vote for consistency. The current Minister of Health, Leo Glavine, has been minister for the entire duration of this government. That hasn’t happened in Nova Scotia in over 40 years. Before he was minister he was health critic. No one has a better grasp of the file than him.

Glavine is not a flashy personality, so the public probably isn’t aware of all the heavy lifting done in health care in the last three-and-a-half years. There was the merging of the health silos to create better cooperation and use of resources and people and work done to prepare for a reorganization and replacement of the VG. Instead of a focus on the next election, health planning has been done for what’s best now and in the long term, so that in 10 years we won’t still be complaining about the same things we complain about now and complained about in the year 2000.

The radical idea to better health might be keeping a Minister of Health in place for eight years instead of 21 months. A long-term minister would have the confidence to take the lead in health care change and not have to rely on guidance by vested interests.

Other voices:

http://thechronicleherald.ca/opinion/1470085-surette-best-bet-to-keep-mcneil

http://thechronicleherald.ca/novascotia/1469887-opinion-weighing-in-on-the-ndp-platform

http://thechronicleherald.ca/nsvotes/1468968-black-economic-development-is-tory-plan’s-linchpin

http://thechronicleherald.ca/novascotia/1471488-black-liberal-platform-just-a-reprise-of-the-budget

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What cost comfort?

This week the leader of the Nova Scotia New Democratic Party, Gary Burrill, called on Premier Stephen McNeil to apologize for the $250,000 purchase of furniture for the Nova Scotia Health Authority’s executive offices.

I understand the outrage, but it’s directed to the wrong person. The Premier didn’t spend this money, the health authority did. They took it from the money the province provides for the administration and delivery of health care. The person responsible for this expenditure is NSHA President and CEO Janet Knox. Public anger and frustration should be directed to her. It was her decision.

To blame the Premier is playing politics with health care. When the NDP formed a government, they didn’t apologize for the 30 percent one-year jump in the number of executives earning over $100,000 (that was in fiscal 2012), so its disingenuous to now be outraged by this $250,000.

Put blame were it is due.

Knox is not a budget hawk. She has a history of administrative extravagance. When she was president of the Annapolis Valley District Health Authority (AVDHA) in Kentville administrative costs were 60 percent above the national average. In an attempt at belt-tightening, AVDHA under Knox, reduced access to x-rays in clinics in Wolfville and Berwick; cut 2.5 ER nurse positions; and reduced two more nurse positions in other departments. The AVDHA also reduced the Valley Regional Hospital’s food services budget by $100,000. While cafeteria hours were reduced – impacting hospital staff and visitors – Knox continued a subsidized lunch program for 160 white collar staff at the health authority executive offices across town. Two snacks a day, plus two choices of lunch entrees, are trucked across Kentville from the hospital to executive offices. This also requires food services staff be on-site to dish out snacks, meals and drinks to these office workers.

https://helphealthcare.wordpress.com/2012/06/07/curious-cuts-to-care/

Knox’s history is of executive indulgence, so it should be no surprise that in the week when people in Cape Breton complain about a lack of wheelchairs and other care, we learn Knox had authorized the purchase of $250,000 in office chairs, sofas and boardroom fixtures. We can rest assured that the NSHA executive team (seen here: http://www.nshealth.ca/about-us/executive-team ) aren’t inconvenienced.

So, rather than play politics over on-going gaps in judgment, blame the right person. Janet Knox has the titles, pay and perks and should wear the responsibility for her choices.

Of course it’s difficult to direct complaints to the NSHA since no phone number is listed for the executive offices. The NSHA website lists numbers for services and enquiries about hospitals, but not for the executives. They do give a mailing address:

Nova Scotia Health Authority Provincial Office
90 Lovett Lake Court, Suite 201
Halifax, Nova Scotia   B3S 0H6

And this laughable email address: wearelistening@nshealth.ca

Good luck complaining. Health executives don’t entertain public complaints. Instead they treat any contact as “feedback” which is then interpreted to fit their messaging.

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