05/25/2014 18:53 EDT | Updated 07/25/2014 01:59 EDT

Continuing the Discussion on Productivity...

The new minister of Health and Social Services, Gaétan Barrette, is admired by some for his "audacity." We propose a few reforms he could implement to improve access to health care. Let's see whether he is really as audacious as people are saying!

We refer in particular to one of his first public appearances after he became minister. Two weeks ago, he told the Association québécoise d'établissements de santé et de services sociaux (AQESSS -- Québec association of health and social services institutions) that there would be consequences for its members if they didn't apply the policies decided by cabinet. He even went so far as to say that he wouldn't tolerate obstruction from them (which, in my opinion, is presuming bad faith on their part).

Clearly, the new minister didn't accept the AQESSS's public remarks this spring, when it basically said that the minister was offloading onto managers the responsibility of deciding where the cuts should be made. The AQESSS considers that these are decisions that should be made by politicians, with the role of managers being to see to the best way of implementing them.

Three reforms that would confirm the minister's audacity!

We propose three reforms and a truly audacious moratorium that would provide permanent control of rising costs in the health-care system without reducing the purchasing power of unionized employees in the system year after year, and without reducing services to the population.

1. Overhaul how doctors are paid;

2. Review the contribution of other health-care professionals, in particular nurses;

3. Stop acting powerless about the rising costs of prescription drugs (Rx);

4. Stop cutting back on support services.

This week, I want to discuss how doctors are paid. There are many countries where they aren't paid on a fee-for-service basis as they are here in Québec. This was a concession made by Canadian provincial governments when our public system was implemented back in the late 1940s.

Other governments that didn't make this concession have more control over costs in the budget line for doctors' remuneration.

Will the minister dare to put the method of remunerating doctors on the table? For over 50 years, it has never been the subject of any serious debate worthy of the name. Remember, in 2009, after negotiations that were scarcely mentioned in public, doctors received a raise in pay of 67 per cent over five years.

Just to be clear: I have no problem with the fact that doctors are some of the best-paid professionals in Québec. The problem I see is that they are paid on a fee-for-service basis. This system causes major distortions in the delivery of services.

A few examples of distortions:

• Operating rooms that are only used half the time. Once the hospital no longer has the budget to pay for operations because of the fee-for-service system, it has to stop using the facilities. Yet these facilities are very expensive and aren't being fully used.

• Since they are paid on a fee-for-service basis, it is in doctors' interests to resist any change that could allow other professionals to perform a few of the acts reserved to doctors. For example, if doctors were part of a team of employees (while continuing to be very well-paid), it would be easier to discuss who was the best person to perform this or that act. As well, the true value of each member of the team would be recognized.

• Their field of practice is without a doubt the one with some of the most elaborate and complicated protocols. However, one of the consequences of the fee-for-service system is to compartmentalize care. Yet the starting point for doctors should be a comprehensive view of the patient. Unfortunately, doctors don't have much interest, at least not much monetary interest, in developing this comprehensive view.

• Furthermore, in this context, doctors are not encouraged to engage in activities that are important for the population, like prevention, home care and teaching (because these activities have only a tenuous connection with the fee-for-service system).

It's the world upside-down. The health-care team and institution have to adapt to the method of paying doctors instead of choosing the best ways of providing services for the population. The only way for institutions to control costs is to limit the acts performed by doctors, which often amounts to reducing services. It should be the doctor who adapts to the resources of his or her team and institution so as to make the best possible use of all the qualifications and skills of staff.

It is only then that the institution can develop an organization of work that services the patients. This debate is urgently needed, and what I have said here is just the tip of the iceberg. Are you audacious enough, Mr. Minister, to put this debate on the table?

Next week, we'll look at how to increase the contributions made by other professionals, in particular nurses, to improve access to health care.