[Two of the authors respond:]
We commend Michael Jacka and Brian Milne for their thoughtful reading of our paper [1] and welcome the opportunity to clarify the 4 points they have raised.
First, comparison with physicians from nonacademic centres might be interesting but would represent a different study; our study was designed to document perceptions of immediate stakeholders in the alternative funding plan. One identified perception was that the alternative funding plan had less impact on service delivery than other contemporaneous changes in the broader health care system. Obviously, this does not imply that reductions in resources have been confined to academic centres.
Second, 71% of the referring physicians stated that they had not increased referrals to consultants participating in the alternative funding plan in Kingston or to consultants in other secondary care centres. However, 39% stated that they had decreased their referrals to consultants participating in the plan. This suggests that referring physicians themselves may be providing more care by eliminating marginally necessary referrals, a trend that must be considered as an improvement in appropriateness of care. Although not mentioned in our paper, the survey revealed that a similar proportion of consultants participating in the alternative funding plan (14%) and of those not participating in the plan (16%) reported increased referrals following implementation of the plan. In aggregate, we do not view these changes as indicating a large workload shift.
Third, 39% of the referring physicians stated that they would not wish to be part of an alternative funding plan. However, 26% were uncertain, and 35% stated that they would like to participate. We agree that this may suggest an ambivalence on the part of the referring physicians, in contrast to alternative funding plan consultants (again not mentioned in our paper), of whom two-thirds were pleased to be in the alternative funding plan, while one-quarter were not.
Finally, we agree that "citizens have the right to ask about the 'value-added' features" of the alternative funding plan. Jacka and Milne will be pleased to learn that the South Eastern Ontario Academic Medical Association commissioned 19 evaluation studies, in addition to an interim and final evaluation. Relevant aspects have been and will continue to be shared with the citizens' representatives, the Alternative Payment Branch of the Ontario Ministry of Health, to assist in crafting future iterations of the program.
Given the legitimate concern Jacka and Milne show for evaluation, we are puzzled by their suggestion that the South Eastern Ontario Academic Medical Association should "restore the previous system." The fee-for-service system has never been subject to evaluation showing "value-added" for the major stakeholder: the tax-paying public. On the contrary, it has been shown to encourage high-volume practice, bearing an undetermined relationship to patient need. [2]
Sam Shortt, MD, PhD
Marshall Godwin, MSc, MD
Queen's University; Kingston, Ont.
References
- 1.
- 2.