Getting old is no fun

[Muggles]

Thanks, Micky. Hope you're doing well these days.

[Don Y]

Man of our hospitals are "non-profit". But, that doesn't mean that they don't *turn* a profit (i.e., take in more than they need to provide the services). Where does that surplus go?

But can they run a SURPLUS? Even if they "absorb" that surplus by spending it on, say, new "executive waste baskets" for everyone in Administration? Or, remodeling a waiting room, doctor's lounge, etc.? I.e., what's to stop waste, over billing, etc. -- the very same issues that US institutions face?

But, a doctor can decide to pay his staff *less* than some other doctor might. A doctor can opt to spend 5 minutes with each patient -- instead of 15 -- and "pocket the difference" (i.e., leave early for a round of golf).

Again, where are the controls that suggest you have a BETTER handle on providing more efficient ($$) care?

I don't see how that inherently won't also lead to the same abuses that we have here -- unnecessary procedures, etc.

Shirley you jest? We have many such "self-governing professional bodies" here. I think you have to be caught on national TV screwing a goat before they even THINK about slapping you on the wrist.

I just don't see anything different, here, that would account for the perception that it's "better" than our "money takes all" approach. I'd like to understand where the savings/efficiencies creep in. It just seems like you *might* have done away with share holders (?) but still left the providers to run surpluses that THEY control (surplus == inefficiency, from the patient's viewpoint).

[clare]

Sometimes they can apply a surplus to past deficits, sometimes it reduces the amount of funding they need from the government system next year - sometimes it goes towards expansion or new equipment, or hire back a few staff members that were trimmed last yer to meet budjet - but it is a very odd occurrence for a Canadian (ontario, anyway) hospital to run a surplus

The budget is so SLIM there is no room for significant waste - the budget is pretty closely scrutinized

Paying less than average means he's always looking for help Qualified staff don't grow on trees. As for time spent - everything is booked and open to scrutiny. The Ontario Medical Association (and other provincial groups) are self governing, self monitoring, self policing associations, but are open to public scrutiny.

They can only bill so many procedures, and we are far from having a surplus of doctors or opperating room space, so things get prioritized and abuses are very rare - and when they happen they are publicised. When doctors are charged it is news.

No shareholders, and no surpluses controlled by the medical institutions - and like our banking system, checks and balances are built in. On the whole, they work.

[dpb]

On 02/25/2016 11:48 AM, [e-mail] wrote: ...

It's been a while since quit the traveling road show supporting coal analyzers but when in Saskatchewan for SaskPower, the locals there routinely drove to Minot, ND owing to extreme waiting times for appointments. Don't know if it's improved or not...

We're in rural area with continuing shortage of medical professionals willing to locate outside the major metro areas where are amenities and potentially much more lucrative practices but there seems always a ready supply of Canadian doctors willing to give up the hassles of the system north of the border. We typically have from 3 to 5 in town at any one time. Like all the rest, the wives generally are unhappy with the locale so it's difficult in retaining them for long-term, but there seems an unending supply or replacements.

[Don Y]

And they don't want to run a deficit. So, that suggests they just omit expenses when they approach their budgetary limits.

I.e., how do you budget for an unknown "consumption" pattern? Unless they only "sell" so much "product" and then close up shop...

In theory, that is true in our "nonprofit" AND "for profit" institutions. Waste cuts into profit. Or, cause your costs to be higher than another facility -- that can end up driving YOUR reimbursement rate ("Hospital A is willing to accept $X for this procedure. Take it or BEAT it!")

That, of course, would depend on the local market. If there are a surplus of "health care professionals", then there is downward pressure on at least *some* wages.

Are patients going to complain that Dr. Bob's phlebotomist is "a bad shot" while Dr. Tim's is "always spot on"? Are they going to just pick up and move to a different/new practice? Do they even have that choice? (why would a practitioner want MORE patients than he can already handle -- "quotas"?)

OK, that's a difference. Here, the anti-big-government folks fight any attempt to create registries and INFORM consumers (ANY type of consumer!)

I assume a doctor can't up and move to a different province and hang his shingle anew? Here, that's entirely possible! Walk away from your past performance/problems... (unless you're jailed!)

We've supposedly got LOTS of checks and balances -- ambulance chasing attorneys being the biggest "check". But, they don't seem to work. Too many ways to game the system.

My PCP has a stake in the other organizations to which he refers me: for XRays, Lab work, etc. Should he be prohibited from making those investments? Should he be prevented from directing me to one of those providers -- perhaps to an inferior provider?

[Don Y]

OTOH, US citizens seem to enjoy slipping NORTH to buy meds. (But, of course, those aren't as GOOD as the US versions... "Say what??")

Do those who "give up" slip back north of the border? Or, move further south/bigger communities?

[clare]

And there is one of the BIG differences between Canada and the USA

We are what yiu folks call a "socialist" country. We demand our government do things Americans won't let their government even think about.

It does happen occaisionally -but each province has it's own medical association - and to practice you need to be a member.

If you have been disciplined by one, generally all the others will find that out. Some get away with it for a little while - - -

[clare]

A lot of doctors have left Canada for the USA over the years - and a vast majority come back when they realize the grass isn't any greener and isn't any more palatable on the other side of the fence.

There was a time a few decades ago when Canada produced more nurses than we had jobs for, and a lot of them headed south. Quite a few stayed..Some went on to further their education and became doctors. A lot of others married doctors - - -

[Tony Hwang]

At least my daughter will never go South for what? To be pushed around by $$$ sign? She always says "I did not become a doctor to get rich" Nowadays keeping busy during her off shift at refugee clinic here.

[clare]

Thankfully MANY Canadian doctors have the same outlook. Many who have gone south for the dollar come back appreciating the fact there is more to doctoring than money, and here in Canada they don't have to chase patients for payment and fight with HMOs tooth and nail.

[dpb]

On 02/26/2016 11:00 PM, Don Y wrote: ...

Over the long-haul I have no way of knowing. I know of only one who went directly back to Canada since we've returned to the family farm (15 yr now) and that was a specific family hardship case. The others leave for "greener pastures" within the States at least initially; East and West coasts are primary target areas of course; anywhere but "flyover country".

W/ the changes in US medical practices, many are becoming more frustrated but that's not restricted to the Canadian imports; it's pretty universal throughout.

The reductions in Medicare/Medicaid pay schedules has forced several of the rural hospitals into closure so we have several multi-county areas now with no emergency response facilities at all...the local is hanging on but it's "iffy" even though while still small by city standards at least are one of the higher-populated counties with a regional retail hub from the surrounding area as far as into SE CO, far NE NM, and the OK and TX panhandles.

[(PeteCresswell)]

Per [e-mail]:

Some years back I saw a documentary on health care in France - where doctors are on salary and make house calls.

The doctor and wife they featured were not getting rich by any means, but they lived at a very high standard (nice car, nice house, restaurant meals when they felt the urge...and so-forth....)..... The bottom line per that couple was that they thought they had a really good life and medical school was 100% worthwhile to the guy.

[Don Y]

If, IN PRACTICE, that's what ACTUALLY happens, you've obviously got more oversight/involvement than we do, here.

[Don Y]

So, they've voted with their wallets to stay?

From discussions with my MD and other medical professionals (connections at one of the local hospitals), this seems to be the case.

On the one hand, you can say its sour grapes as now pressures are being brought to bear (that hadn't previously) on how they practice medicine. The semi-god-like reverence for doctors has faded significantly over the course of a single career; I'm not sure that's easy to accept.

OTOH, there may now be too much of a move to "bean counting". E.g., the new coding system breaks things down into such fine detail that i wouldn't be surprised if some of the codes are only "applied" ONCE, in a year, NATIONWIDE: "eye injury; left; fall; trip; child's roller skate; while texting"

OToOH, my peeks inside medical practices suggest they are long overdue for rethinking. Do you REALLY need all those bodies to deliver healthcare? How do places with fewer staff "manage to cope"?

I think we have ~10 hospitals. But, only one "trauma center". The area covered is pretty large -- most hospitals have (and use on a regular basis) helipads to airlift patients in.

There's also a bit of "book cooking" that happens, esp with INS involvement. E.g., a truck full of "illegals" that crashes will have them all treated at a local facility; but, INS won't assume CUSTODY of them until afterwards (leaving the hospital trying to get payment from the "patients" -- which will soon be deported).

Of course, hospitals can play that game, as well: advertising to more affluent Mexicans that they should come up, have their baby delivered here (US citizen!) and get in a few days of shopping before going back across the border...

[Don Y]

Here, the "demand" would be (artificially) increased to fit the supply. Then, the supply again increased to ensure wages stay lower :-/

[Don Y]

My PCP is a "doctor" -- in much the same way that I'm an "engineer". Neither of us wants to deal with the messy "business side" of our professions.

I think this is something you can pick up on if you are observant.

E.g., I have friends who recount how their doctor made them come back for a second appointment (instead of addressing TWO problems in a single visit). I bring a laundry list of questions, issues, etc. and my MD is very happy to address all of them in a single visit.

At the same time, he's aware of how the billing system works and you wouldn't be surprised to hear him say: "You're better off going to XYZ to have that addressed because *we* would bill you $$$"

This is unfortunate as it just adds to the delivery cost (i.e., the fact that he has to KNOW those things; or, that there are two different prices for the same service provided in two different ways/providers)