BARRIERS TO CARE
Justin Vanderleest
The healthcare system is being stressed to its limits. The pandemic was a catalyst, but the origin of the issue is more elusive. Emergency rooms are full. Patients line the hallways. Surgical wait lists are long. While the federal and provincial governments are talking funding, as always, inertia is a powerful force. The federal government has committed to increasing federal transfers, over the next ten years, but it wants better outcomes and healthcare innovation on the part of the provinces. With the usual stakeholders at the table and politicians gauging what’s necessary to hold power, as well as their will and ability to make big change, provincial governments will most likely double down on the status quo. Budgets will get drafted and passed, and the opportunities for systemic innovation will pass to future governments.
On the surface, some issues are obvious. There are too many patients, and not enough doctors, nurses and hospital beds. Six million Canadians can’t find a family doctor. Those people are getting sub-optimal healthcare, presenting to walk-in clinics and hospital emergency rooms with worse problems. That’s expensive to the system and the hospitals lack capacity. The doctors and nurses are burned out, and patients can’t rely on quality, timely care. That’s the primary care crisis in a nutshell.
It would seem that the solutions are more funding, more doctors, more nurses, and more hospital beds: more capacity. Those solutions seem obvious, that is, unless you’re a physiotherapist, or other primary practitioner, or allied healthcare worker, that is under-funded by the public system.
If doctors are operating at capacity, creating a systemic bottleneck, what if patients had better access to other appropriate professionals? Should patients have the option to differentiate their care according to their perceived need?
In some cases, this might require expanding scope of practice, for example, allowing pharmacists more leeway with prescription refills.
However, in the case of access to physiotherapists, it doesn’t require any change of scope. Outside of hospitals, physiotherapists are already primary practitioners, they just operate in a privately funded capacity. That, right there, is the barrier to care for many people.
When any service is privately funded, it creates a barrier for many Canadians who don’t have extended health benefits, insurance, or “disposable” income. How people choose to access the medical system is largely about who pays. Patients go in greater numbers to services that are perceived as free, or “covered.” That’s what drives patient volumes toward doctors and hospitals, instead of toward physiotherapists, mental health therapists, and other primary practitioners who can make a diagnosis and provide treatment, and in some cases, provide equivalent or better care.
Doctors are also the most expensive professionals in the system and the most time-consuming to train because of the breadth of their scope. So, when it comes to issues like orthopaedic injuries or mental health problems, often, there is a parallel professional with more focused expertise, who earns less. To policy makers, that should read like a unicorn solution. Instead of searching, far and wide, for more doctors, perhaps patients should have access to all the professionals that are recognized as primary care providers.
For anyone questioning quality of care, we have good research showing that physiotherapists diagnose musculoskeletal conditions on par with orthopaedic surgeons, and better than family physicians. Physiotherapists rely less on diagnostic imaging, suggest less wait-and-see, and provide more treatment options, as well as more conservative and less expensive treatment options. Physiotherapist examinations are more hands-on, more thorough, test function, and consider impairments that cannot be appreciated with imaging, like ROM and strength. In essence, physiotherapists are good at orthopaedics and they’re good at recognizing medical issues that require a doctor.
So, how big an effect could physiotherapists have on the primary system?
There are 94,000 physicians in Canada—45,000 in family practice. There are 27,000 physiotherapists in Canada—16,000 in private practice, working at arm’s length from the rest of the medical system. While doctors are overburdened, there are new graduate physiotherapists with sparse caseloads who are excellent at dealing with injured patients.
In family practice, orthopaedic injuries can make-up 10-30% of a doctor’s caseload. If some of those patients went straight to their physiotherapist, that would free-up physicians’ schedules to take more patients, reducing the number of people without a family doctor, reducing unnecessary emergency room visits, reducing unnecessary imaging, and improving outcomes. The systemic cost-savings could fund more physiotherapy and other primary care professionals.
This approach does have precedent. Physiotherapists have been integrated into emergency rooms in many countries, including in pilot projects in Canada. Some orthopaedic surgeons are working with physiotherapists to screen the referrals they get from doctors for appropriateness. In Ontario, the legislation for physiotherapists to order diagnostic imaging was passed more than a decade ago.
So, why aren’t physiotherapists ordering imaging? Why aren’t physiotherapists filling a role in these overburdened emergency rooms? Why don’t you have a family physiotherapist funded by Medicare?
This brings us back to inertia. This is how the system works and change is hard. It’s hard for politicians dealing with ballooning healthcare costs to consider adding another line item to the budget. But, it’s important to recognize how those line items affect one another. What is the full societal impact of improving access to high quality early intervention and treatment for musculoskeletal injuries, or mental health issues?
Scope of practice protectionism limits change, as well. Politicians bring doctors and nurses to the table as stakeholders in healthcare reform. Doctors tend to advocate for their role as the primary care gate-keepers; they say doctors need healthcare teams surrounding them—teams of allied health professionals, including physiotherapists. They don’t advocate for the full actualization of the physiotherapist’s scope of practice—as parallel primary care providers under Medicare.
Another problem is the powerful lobby from insurance companies that sell the extended health benefits for well-employed and wealthier Canadians. Those insurance companies are in the business of creating barriers to care so that people do not use their benefits. They profit by collecting the premiums and paying-out less. The less expensive benefit plans require a doctor’s note for physiotherapy; pay higher premiums and they waive that requirement.
Private insurance companies bolster their profits by requiring this unnecessary expense to the public system that creates a barrier to care for a patient, making them see one primary care provider to get permission to see another primary care provider. When you create barriers to care, injuries become more chronic and more expensive. People should be protected from these barriers through legislation.
The federal government has recognized the merits of these arguments for dental care, and they have plans to broaden healthcare to include dentistry. After all, if someone doesn’t have dental coverage, they cost the system more when they get an abscess, or when their mental health suffers. One hospital stay could be more expensive than decades of routine dental care. This approach looks at the system as a whole, not as separate, unrelated line items on a budget.
It doesn’t take much to imagine how other professionals like pharmacists, nurses, and mental health therapists could see expanded scope of practice to reduce the primary care burden on doctors and hospitals, while also improving patient outcomes. That’s what real innovation looks like: fewer barriers to care and more parallel collaboration between healthcare workers sharing that burden of care.
Politicians have proposed facilitating professional licenses for international doctors and nurses. Nursing advocates are saying better pay would keep nurses in the profession. Physicians are asking for improved system-wide electronic medical records to prevent duplication of services. Family physicians are saying they want to see more healthcare teams.
All of these approaches have merit. Some of these ideas present clear efficiency advantages. But, there has been no mention of the efficiencies derived by leveraging the primary care skills of the trained professionals that are standing on the sidelines, waiting to be recognized for their expertise.
It’s time to bring the widest range of healthcare providers to the table and have some real discussions about how the system could maximize the scope of practice of diverse professionals to better deliver the Canada Health Act promises of public administration, comprehensiveness, universality, portability and accessibility.
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ABOUT THE AUTHOR:
Justin Vanderleest - Justin is a senior physiotherapist in the Greater Toronto Area, working in private practice. He is a Fellow of the Canadian Academy of Manipulative Physiotherapists (FCAMPT) and is an adjunct lecturer at the University of Toronto. For the past 5 years, he was the owner/Director of Citrus Sports Medicine and Rehabilitation in Etobicoke. Now, you can find him at Field and Forest Physiotherapy in Milton.
The views and opinions expressed are those of the author and do not necessarily reflect the position of Air Quotes Media. Read more opinion contributions via QUOTES from Air Quotes Media.