Canadian Hospitalists: A North-of-the-Border Lesson in Negotiation

In late September, I had the honor (or honour, I guess) of speaking at the 5th Annual Canadian Hospitalist Conference, held in beautiful Vancouver. It was an eye-opener.

About 150 hospitalists from all over Canada were there, and they really are delightful people: enthusiastic, energetic, and really jazzed about doing something new and important.

Whereas in the U.S., hospital medicine was initially catalyzed by the economic advantages that accrued to managed care organizations and hospitals for safely shortening LOS and lowering hospital costs, those haven’t been the key issues in Canada. Instead, family physicians – their dominant providers of primary care – have all-but-fled from Hospital-World, leaving a gaping hole.

Who filled the gap? In the U.S., nearly 90% of hospitalists are internists, mostly general internists who found the opportunity to focus on hospital care attractive. However, in Canada, there are very few general internists – the tradition (as in the UK) is for internists to be consultants to family physicians and teaching attendings in academic hospitals; the primary care docs are nearly all FPs. The relatively small number of internists in Canada rarely stay “general”: most differentiate into subspecialists, particularly drawn to the more highly reimbursed procedural specialties like cardiology and GI. (Note to Michael Moore: so it’s not that different).

So, it was family physicians who morphed into hospitalists in Canada, and nearly all of the conference attendees were FPs. Even though family medicine training in Canada is a bit more inpatient-oriented than it is in the U.S., folks generally agreed that two years of family medicine is not the ideal hospitalist training recipe, particularly since FPs get relatively little ICU and peri-operative experience. We brainstormed about what a 3rd year Canadian “hospitalist fellowship” might look like, perhaps followed by some kind of hospitalist certification. There is precedent for this in Canada: a fair number of emergency physicians are FPs who received an additional year of post-FP-residency emergency medicine training.

In addition to this FP/internist difference, the other thing I found interesting was the flow of dollars. Here, there were striking similarities to the American story, but some profound differences. Similarities: primary care physicians began to find providing non-procedural, coordinative care of sick inpatients unattractive. A group of physicians, finding this an appealing niche, embraced this role. And the dollars available to pay them from the traditional forms of billing were insufficient to create sustainable positions. (That, of course, is a big “duh”: if the dollars were plentiful, the other docs wouldn’t have willingly left the building).

Here’s where the stories diverged. In the U.S., this dynamic led hospitalists to identify the hospital as the critical deep pocket: the stakeholder that (because of DRGs, and, more recently, because of the quality and safety imperative) had a sufficient interest in hospitalists to potentially open the piggybank. You remember the course in college: Return-On-Investment 101.

In Canada, hospitals don’t really have the money to do this, nor the market-based incentives that lead to these kinds of ROI decisions. So who was the deep pocket? Well, under a single payer system, “It’s the Government, Stupid.”  

This situation creates one of the main raisons d’etre of Canadian hospitalist confabs: to strategize amongst themselves regarding their government service agreements – agreements that are struck either with the provincial governments (thought they’re hard to get to) or the regional health authorities constructed to be intermediaries.  

With this complexity, Canadian hospitalists quickly recognized the need for unique approaches to plead their case effectively. First of all, they identified the importance of public support, which led them to develop an aggressive media strategy. Several people commented on the key role of “stories in the newspaper” about the value of hospitalists or the lack of alternatives to hospitalist care.

The second difference was the fact that the docs were out of their league when it came to negotiating with the government. In the U.S., most of us who run hospitalist programs have had challenging negotiations with our hospital CMO, CFO, or CEO, arguing for the resources needed to build an effective, thriving program. Imagine a world in which these discussions were not with your hospital leaders, but rather with provincial legislators or bureaucrats.  

At the Vancouver conference reception, the crowd hushed when one person entered the room – a chatty and irreverent middle-aged man whose longish blonde hair made him look like a surfer dude a few waves past his prime. As he walked toward me, several people whispered to me that this man, Murray Tevlin, might well be the most important figure in the Canadian hospitalist field. Who was he, I wondered? A brilliant diagnostician, a superb administrator, perhaps a mesmerizing lecturer…

No, he was the hospitalists’ lawyer, who had used his entire bag of tricks to secure a better hospitalist contract from the province (“these young docs are too nice,” he told me): a charm offensive, mediagenic sound bites, and – when it didn’t look like British Columbia was going to blink (the health minister bellowed that the province would not be “held for ransom on this issue”) – a bit of brinksmanship, in the form of a near-walkout in June, 2006. The result: a reasonable contract that the Canadian hospitalists are largely satisfied with.  

Although I’d take the Canadian healthcare system over ours in a heartbeat, I found myself in the unusual position – in the healthcare policy world, at least – of being glad I lived in America when it came to hospitalist negotiations. I’ll take sitting down with my Chief Medical Officer, who knows me and my group extraordinarily well, to facing a government health minister or a provincial bureaucrat (“so, what exactly is a hospitalist?”) any day. The Canadians are to be congratulated on pushing the ball downfield under these circumstances, and I look forward to watching and learning from their continued successes.

6 Responses to “Canadian Hospitalists: A North-of-the-Border Lesson in Negotiation”

  1. Brian Clay October 26, 2007 at 8:38 pm #

    Since the time may well be coming where the United States converts its healthcare payment and delivery to a more “Canadian-style” structure; we should keep an eye on how this hospitalist-government dynamic in Canada evolves as their population ages and provincial budgets for health care get even tighter.

  2. James Gaulte November 1, 2007 at 2:21 pm #

    With only two years of post M.D training and little ICU training experience I am sure I would not be eager to be in the hands of a Canadian hospitalist if I were faced with a serious ICU type illness. In light of their arguably inadequate training and the fact that a Canadian patient cannot opt out of their system ( short of heading south if they can afford it) I don’t understand your statement that you would take the Canadian system of the the U.S. system in a heart beat. (I tried to enter my URL but were told it was not valid.It is http://www.mdredux.blogspot.com)

  3. Bob Wachter November 1, 2007 at 2:31 pm #

    Thanks, James. As I implied, I too think the two years of FP training isn’t optimal for hospitalists (most of the Canadian hospitalists I spoke to don’t think so either, but it is what it is, and they are filling a striking need).

    My comment regarding preferring the Canadian system referred to their overall system of tax-dollar funded healthcare with universal coverage, not their hospitalist system. Sorry if I was a bit vague.

  4. Marcel Dore November 2, 2007 at 3:49 am #

    From a north-of-the border hospital in Ontario, and one of the more “mature” programs (only since 2002), we are representative of most hospital programs across Ontario. Work-sharing between 10 full time hospitalists ( 7 family physicians, 3 specialists [gen IM, geriatrician from the US, and an ID specialist]). Our program (as most) does not cover ICU, so that is the greatest variation from your US system. We are (in most hospitals) strongly supported by a parallel system of internal medicine subspecialists who function as general internists when they are on call. There are a few remaining general internists, however, most prefer to subspecialize. The internists love us because they can spend most of their time in their offices or doing procedures. I totally agree that we are not qualified to do ICU work and other interventions that are still under the realm of the internist. Our hospitalist experience is primarily the non-critical adult medical inpatient. I feel we get the best of both worlds.
    On the topic of remuneration and finances, I currently sit on a committee with representatives from the Ontario Ministry of Health (our payer) and the Ontario Medical Association in which I am the provincial chair of the hospitalist section. I promised to keep you posted as things develop in the establishment of a sustainable provincial model of hospitalist program funding. We are starting at a slightly different point compared to our British Columbia colleagues …. no lawyers involved yet, but I did get Murray’s card as back-up! More soon.

  5. ksivjee November 7, 2007 at 6:28 pm #

    I think Jame’s concerns are legitimate. Most family medicine residencies in Canada require a total of 2 or 3 months of inpatient (acute care) medicine. Moreover, many practicing Canadian hospitalists are GPs having completed a total of 1 year of post graduate training.

    At Sunnybrook Health Sciences Centre, a teaching hospital affiliated with the University of Toronto, we have created a one year hospital medicine fellowship targeted at FP graduates who want to “specialize” in hospital medicine. We are in our third year and have grown to 6 fellows per year. Our curriculum is based on the core competencies from SHM and fellows spend 10 months on the acute medicine service which includes 9 ICU beds. More info at the URL included in this post.

  6. ksivjee November 8, 2007 at 12:57 pm #

    The URL for the above mentioned Canadian Hospital Medicine Fellowship is: http://www.sunnybrook.ca/education/Hospitalist

    It’s also worth mentioning that Canadian Hospitalists have taken a very proactive approach to this issue of training and credentialing. A national committe has been formed within the Canadian chapter of SHM. This committee is carrying out a needs assessment and will develop guidelines for credentialing in conjunction with the colleges in Family Medicine and Internal Medicine.

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