Understanding the audition

I commend Dr Kirkwood for raising the issue of patient “auditions”1 in a forum where the topic can be discussed by family doctors across the country. I offer the following comments in the spirit of extending the “fruitful discussion” on this subject that Dr Kirkwood has initiated.

The first point to be clarified is whether patient “auditioning” is, in fact, occurring. Anecdotally, patients in the office and emergency room have informed me that this does happen. Patients themselves, however, are not in a position to know why they are still without family doctors (although they might assume that elements of their medical history have worked against them): perhaps a random selection took place and they lost out. On the other hand, the fact that detailed medical information is requested strongly suggests that it is playing a role in the patient selection process (if it isn’t, one wonders what a privacy commissioner would have to say about this collection of information). The close attention to this issue paid by both the College of Physicians and Surgeons of Ontario2 and the Ontario Human Rights Commission3 also supports the view that these are not isolated occurrences. Only limited public information about how physicians actually use these patient applications is available4; perhaps those family doctors who employ this process should go on record with a description of how it works.

Although we might lack firm evidence of exactly what is happening in these patient-selection events, there is one factor that provides a plausible explanation for the rise of the “audition.” Over the past few years (I speak from my own experience in Ontario) patient capitation systems (in which physicians are paid primarily by fixed rates for the patients they have on rosters, rather than for medical services provided) have been strongly promoted by the provincial government, and incredible effort has been expended in making them financially attractive to physicians. It requires only elementary mathematics to understand that being paid a monthly fee for a patient you are unlikely to see (ie, a healthy patient) is better compensation than being paid that same monthly fee for a patient who could require multiple monthly visits (ie, a sick patient). Therefore, a capitation system provides a perverse incentive to “stack” the roster with healthier patients—maximizing revenue and minimizing work. Whether or not this factor plays a role in an individual physician’s decision to “audition” patients is impossible to say, but it would be naïve to ignore the possibility.

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