[The author responds:]

Letters

CJEM 2002;4(1):3-6

Caution and judgement must be exercised whenever a body of power offers something. In the matter of alternate funding plans, it is ludicrous to say our government does not have a hidden agenda. The agenda is to control costs; at whose expense is hidden.

Dreyer and colleagues state that alternate funding plans (AFPs) are intended to exceed the current FFS pool, but I ask: When was the last time a government lined up to give doctors a raise and does this take into account the large clawbacks that some EDs on AFP have seen?

AFPs are based on numbers seen (CTAS data), and if physicians are less than diligent in the administrative task of "shadow billing," it will appear that our productivity has fallen, and this will translate into more cutbacks. Dreyer and colleagues suggest there are neither standards nor external monitoring of individual or group productivity, yet all organizations need monitoring and managers to function, and the government will develop systems to monitor individual and group productivity -- information that will not be used to give doctors raises.

Many centres with AFPs have opened "walk-in" clinics, allowing them to practise FFS for low-acuity patients and AFP for sicker patients. This drives ED numbers down and, as a result, the AFP pool shrinks. In an AFP, emergency physicians will become lackeys of the government -- motivated to please their employer rather than their patients.

The authors suggest that "cohesive groups" will find AFPs attractive, but I believe the converse is true: groups will be more cohesive if emergency physicians work independently. The more that individuals become aware of each other's workload, productivity and income, the more likely problems are to arise. Our system is in crisis not because of supply and demand economics (i.e., FFS), but because government has exercised too much control over the "supply side" of medicine. AFPs are just more of the same. Let's not jump on the bandwagon that promises nirvana.

Thomas Marshall, MD 
Peterborough Regional Hospital 
Peterborough, Ont. 
thomas.marshall@sympatico.ca