Are we dinosaurs?

This morning I heard someone speaking on the CBC about the proposed Physician Services Agreement, and this evening I paid for my office insurance for the year and as an aside I worked out my overhead costs – roughly 25% of my billings, not including taxes. It really drove home the current economic reality for physicians. If we agree to the new PSA all previous cuts from government unilateral action will stay, and doctors’ fees will be funded at a level that is expected to keep up with growth in demand for service. We’re not going to be making more money, and between cuts and inflation our actual income is going down.

It occurred to me that it would cost me less in overhead to treat fewer patients. If I didn’t take new patients I wouldn’t have to have a website so they could find me. I wouldn’t have to handle as many phone calls or deal with as many scheduling issues so I wouldn’t have to hire staff. I could rent part of an office by the day, and not buy furniture. I might not have to keep an electronic medical record, and if I didn’t have that, I wouldn’t have to have electronic fax service either. If I didn’t have electronic systems I could probably get away without paying insurance against Cyber security disruptions. Provided I could still fill my schedule, I could bill the same amounts as I do now. Sadly, given the demand for psychiatric services, one could probably make this work fairly easily.

Supposing that money follows creation of value, you would think it doesn’t make sense to try to run a tiny practice and see the same bunch therapy patients every week. Publicly funded health insurance is a strange market-distorting effect, though, such that running a small therapy practice might actually do better financially than running a more complex one with more patients.

Here’s another thing to consider, though – in the next few years, the funding agreements are likely to change. Someone once told me that people who do the kind of work I do in private practice are on the way out, and I told her we would change when the funding model changed. Looking back, maybe we were both right. One psychiatrist treating one patient is turning into a luxury that we cannot afford as a society with massive government debt, an aging population to look after, and an economy propped up by a massive housing bubble. It probably would not be wise to put more money into services that only benefit a handful of people even at the best of times. Whether we like it or not we are most likely moving into an era of one-off consultations, group-based treatment, and possibly even hard caps on the number of individual visits per year. As much as I like individual therapy, these are probably changes that need to happen, so that there won’t be a financial incentive to shrink instead of grow. Throwing more money into a process that doesn’t work efficiently probably isn’t good in the long run. Being in a city the size of Toronto and still struggling to be seen by a psychiatrist is a sign that something isn’t right. I think we should still do individual visits – there is a place for that – but they should be a lot more precious. Another possible benefit (questionable benefit to the doctors affected, maybe) of the squeeze on the solo practitioner is that it might drive more psychiatrists out of the big cities, especially where the cost of doing business is very high. This might just improve access across the province.

I don’t really like reading what I’m writing. I love coming into my office and handing things off to my secretary, who I don’t have to share with anybody, and seeing my patients, some of whom I’ve gotten to know over a number of years. I have a view from my office of a tree-lined street and the pace is relatively relaxed. At what point will this hobby become too expensive to maintain, and talking about “my patients” is a thing of the past? It’s hard to say, but it does feel strange to think of oneself as possibly one of the last of a group that may soon disappear. I like to think that we can find a way to adapt – become more efficient and effective, and be compensated for doing it. With another opportunity to negotiate with the government, now may be our chance.

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