Corrine, Thanks for taking the time. I hope that the discussion will
help us provide some worthwhile solutions to health care woes.

I agree with almost everything you've said.
a) Sadly we do have an illness system. I was intrigued when Carolyn
Bennett the Minister for Public Health said we suffer from the "tyranny
of the acute". I would be happy to contribute to efforts to improve the
effectiveness and efficiency of public health, health promotion and
disease prevention activities.

b) I agree with you that the current system prevents patients from
choosing their preferred provider. Physician services are insured, so
patients are encouraged-by economic incentives to see doctors when
nurses, physiotherapists, psychologists and many others could provide
worthwhile (perhaps even more valuable) advice.  One consequence is
that  patients including adolescents are often forced to see
psychiatrists and subject to drug risks, when a psychologist or
occupational therapist, or other thoughtful and sympathetic ear would be
sufficient.

c) At least in Nova Scotia, many of us have been asking the Province to
develop systems that would provide appropriate remuneration for primary
care nurses working with other health professionals. In a primary care
coop members would have the choice of where to direct funds and what
services they most value.

Our clinical group had suggested a model where primary care nurses would
receive  the same compensation per visit as the doctor and would
contribute to the infrastructure costs (currently a visit in Nova Scotia
is about $24.00) on the same basis as the other clinicians (currently
doctors). Neither nurses we spoke with informally, nor governments
encouraged us to move the idea forward.

A cooperative would be uniquely positioned to carry your idea of nurse
clinicians forward since they would decide how the coops resources would
be spent.

Michael Rachlis recently reported a Saskatchewan practice where it took
3 primary care nurses to look after the patients previously cared for by
one family doctor.  I suspect that government fears the cost of direct
payment to nurse practioners would be too high and that is why they
didn't encourage us.  I would love to see the experiment carried out in
a rigourous way with measures of patient outcomes, costs and satisfaction.

d) I was sorry to hear Corrine suggest that patients wouldn't value
getting results by e-mail. In my practice  some patients are delighted
to be able to communicate by e-mail.  Many patients with chronic disease
know as much, and sometimes more than the clinicians caring for them. It
seems silly for an intelligent person with diabetes, or who is on
anticoagulants to have to communicate directly with a clinician. People
with chronic disease often know how to deal with their ailments. If some
were able to care for themselves, than others, more needy could use the
clinical time that is freed up.

e) The monthly dues would be distributed as the members of the
cooperative see fit to distribute them. Religious organizations don't
expel people who can't make financial contributions, why would
coooperatives.

f) If the people are satisfied with the insured services they are now
receiving, including comprehensive continuous care, timely access to
services, and care by an appropriate multidisciplinary team than they
wouldn't join the coooperative.  Those who value community participation
and engagement and care by a multidisicplinary team with adequate
practice tools might be more likely to join.

g) I especially agree with your last comment.  The cooperatives would be
able to support population health and disease prevention activities in
their community and they would be motivated to do so. Because they would
control how the funds flow they could encourage health maintenance
activities (they might even pay to open a school yard or school gym
after school so that members could be physically active).

h) The coop members might even become involved in self care activities
(You don't really need either a doctor or nurse to monitor blood
pressure-the list of activities we've medicalized and professionalized
is a long one)

Corrine, we seem to agree on what's necessary and you are clearly
motivated to improve health and health care.   I would be more than
happy to take the time to reflect on any alternative solutions that you
offer and that  might work.

Best wishes
David Zitner


Langill, Corrine wrote:

>I was fascinated to read how Dr. Zitmer attempts to co-opt the words of
>Tommy Douglas into support for his Primary Care Co-operatives scheme.
>Canadians DO make significant contributions to the health care system (which
>is, in fact, an illness care system...but that's another posting!), through
>our taxes.  Dr. Zitmer uses this quote out of context, in my opinion.
>
>I was also struck by Dr. Zitmer's characterization of nurses as
>'professional assistants' to physicians, who allow physicians to 'specialize
>in higher value activities'.  Dr. Zitmer may be surprised to learn that
>nurses (along with other regulated health professionals in Canada) have an
>established, self regulated scope of practice independent of medicine.  I'm
>sure that many would question the 'higher value' of activities provided by
>physicians.  The health of Canadians is promoted by the collaborative work
>of many disciplines; with differing approaches, but certainly of equal
>value.  I'm sure that many physicians would agree that an activity is not of
>higher value simply because it is provided by a physician.  Perhaps access
>to care would be improved if Nurse Practitioners and other regulated health
>professionals could be fully reimbursed for their services by provincial
>Health Programs.  Physicians currently monopolize this billing process, and
>are rigidly opposed to opening this up to any other health profession.
>
>I also wonder to whom these proposed monthly fees would be payable?
>Physicians?  The nurses who provide the service?  I find it hard to believe
>that anyone's health would be improved by renewing prescriptions by phone,
>or getting lab results by email (most people would need to have such results
>interpreted for them anyway).  People in Ontario already have access to
>health information through a provincial telehealth phone line, staffed by
>nurses.  Many Health Units also provide the same service.  Dr. Zitmer seems
>to be proposing that people pay more for services that already exist.
>
>I suggest that Health dollars would be more wisely spent by shifting focus
>from 'illness care' to those approaches that can prevent visits to
>physicians offices and hospitals in the first place.
>
>
>Corrine Langill RN, BscN
>Adolescent Health Specialist, Program Development
>City Of Ottawa, Community Services Branch
>495 Richmond Rd.
>Ottawa, ON
>K2A 4A4
>(613) 724-4122 ext. 26258
>fax: (613) 724-4148
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