Recently a local social services office sent a letter to my clinic. In it I was informed that while the office had previously engaged in on-site drug screening, due to provincial funding cuts they could no longer continue. However, since drug screening was still considered essential, to solve their budget problem they would send clients who were also my patients to my clinic. There I could arrange for drug screening and fax them the results. A minor inconvenience at worst, right? Not if you're worrying about how much of the provincial budget gets spent on physician services.
There are two factors that allow this misuse of health care funds: 1) the mistaken impression that OHIP is "free" so using it for a non-medical issue is fine, and 2) the fact that physicians are trained to help individual patients, not manage OHIP costs. In this case had I refused to do drug screening because it was medically unnecessary, my patients might have suffered a severe social consequence. What doctor would say no? Even the most cost-sensitive among us would have a hard time doing so.
Here's another, more complicated story: a patient with chronic pain is struggling to keep working in spite of their condition. Unable to find anything but precarious work they are left without benefits, so when I suggest physical therapy they just scoff. Public funding for physical therapy has been severely limited since 2005, so it's now out of reach for many Ontarians. So what can my patient afford? Pain medication. Like many of my colleagues I have major reservations about long-term opioid use for chronic pain. But if I refuse to provide pain medication my patient might not be able to work. No doctor wants to be responsible for a patient losing their job, so I try my best with whatever options I have available.
But the pain gets worse and eventually my patient can no longer work. Now they are scraping by on the Ontario Disability Support Program (ODSP). At this point they qualify for a limited set of physiotherapy treatments, but it's not long term. Impoverished, disabled and lacking the meaning that employment provides, my patient becomes depressed. The depression makes their pain worse because mood and pain are intimately intertwined. Increased pain in turn makes the depression worse and so on in a vicious loop. But whereas ODSP only allows for a pittance of physical therapy, it will fully fund long-term opioid use. So what do you imagine this patient is asking for when they see me?
Primary care in particular is perfectly situated to absorb the costs of poor social supports.
In depression, psychotherapy can be life changing, but that too is financially out of reach. Antidepressants, however, are not -- they're covered. So with a restricted ability to access care that might truly make a difference in their life, my patient is forced to make do with what's available, which is mostly just me and ODSP medications. And since I am virtually their only resource, they see me again and again. Is this a cost savings? Removing services doesn't remove the need for care, it just pushes the fiscal strain onto a different area.
These are just two examples, but there are countless ways in which the health-care system is used to manage cost overruns in social programs or cope with social issues like poverty and the rise of precarious employment. In my previous blog there was an image that resonated with many of my colleagues. I wrote that "[d]octors are the duct tape that holds health care together when the government strips services away." When health care is positioned as a key way of managing social problems, we put enormous strain on the system. This forces us to be duct-tape doctors, trying our best to seal up the gaps in a patchwork system of inadequacies and shortfalls.
Primary care in particular is perfectly situated to absorb the costs of poor social supports. Ask any emergency physician how often during a shift they see a patient whose problem is primarily social rather than medical. When you have nowhere to go, at least the emergency department won't turn you away, even if your main problem is hunger or a lack of shelter beds.
Problems like homelessness, drug addiction, poverty or violence don't find lasting solutions in the hospital. It's also a big cost to the health-care system to funnel social problems through the emergency department, since each person seen there costs at minimum a few hundred dollars a pop. Hospital admissions are exponentially more costly, on the order of thousands of dollars per patient.
The evidence is clear that homelessness causes drastically increased use of emergency services and hospital admissions, and this issue grows ever more pressing as Canada's housing crisis worsens. What a frustrating and ill-thought out waste of our finite public resources. Social or mental health services are often less expensive than a trip to the hospital and can provide longer lasting and more definitive solutions that reduce future health care needs.
So why don't we focus on solving these social problems rather than relying on duct-tape doctors? Because it's politically expedient to mask the real cost of cuts to social programs by burying them in OHIP. Our "free" system of health care will always be there to swoop in and try to patch up the gaps, since physicians are taught to respond to individual patient needs, not manage system costs. This government knows full well that social issues are offloaded onto the health-care system. Yet Minister Hoskins complains about the cost of physician services, even though we have little control over patients choosing to see us because they lack other supports.
This hidden driver of our ever expanding health care budget needs to be measured and honestly accounted for, and we need to acknowledge that marginalized Ontarians are ill-served by this system. I don't relish my time spent duct tape doctoring, and neither do my colleagues. We want better for our most vulnerable patients, and we demand more from the government.
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