SPECIAL REPORT * DOCUMENT
What makes Martin Barkin run?
Brian Goldman, MD It was yet another juicy rumour. Once again, Dr. Martin Barkin was supposed to be quitting his job as Ontario's deputy minister of health to head for greener pastures south of the border. There have long been rumours that Barkin, perhaps the province's most controversial physician, would be tapped to head Humana, the giant American health care conglomerate. In typical fashion, he outdid the rumour. CMAJ has learned that George Bush, the president of the United States, has spoken to Barkin. The topic? Would Barkin help him create a national health insurance plan for Americans. Doctors at the Ontario Medical Association (OMA) and hospital administrators across the province listen to the Barkin rumours with interest. They wonder if the man who brought the saying "Just say no!" to hospital budgets is finally going to go away and leave them alone. At least for now he won't be, but some say it took a last-minute plea from Premier David Peterson to keep Barkin in Ontario. In any case, the game of rumour and denial continues. Love him or hate him - they all respect him
Brian Goldman, a Toronto emergency ph'vsician, is a CMAJ contributing editor. 628
CAN MED ASSOC J 1990; 142 (6)
- Barkin watchers across the country agree that he is the most fascinating character to enter the Canadian health care scene in years. Change has been the opera-
man except Dr. Martin Barkin.
Before joining the government his career was built on enlightened self-interest. As a urologist he was a staunch defender of extra-billing, charging up to 10
"The biggest knock against Martin that I am aware of is that he really doesn't want to listen to anybody else." -OMA officer
tive word in health care in Ontario since the Liberals smashed the Progressive Conservative dynasty in 1985. Since then the government has pursued an agenda designed to de-emphasize the roles physicians and hospitals play in delivering care. It is trying to beef up regulations controlling physicians and their incomes, and it has drawn the line on growing hospital budgets. Given that context, Barkin, who in 1987 was handpicked to be deputy health minister by Peterson, is seen as the man who came to the right place at the right time. And that would be a fitting epitaph for the career of almost any
times more to reverse a vasectomy than the slightly more than $200 now paid by the provincial health insurance plan. As president and chief executive officer (CEO) at Sunnybrook Medical Centre in Toronto, he joined other hospital administrators in lobbying the Ontario government for more money. Yet, as deputy health minister he has learned to turn his back on his former colleagues, and this frustrates them to no end. "Obviously, there was great hope that here we had somebody who understood hospitals and also understood physicians", says Peter Ellis, the current president
and CEO at Sunnybrook and vicepresident during Barkin's tenure there. "In fact, if you look at what's going on currently, both hospitals and physicians have perceived, from the way the ministry presents certain of its opinions, that we are almost the enemy. I find that somewhat offensive." Doctors don't hesitate to complain either. "The biggest knock against Martin that I am aware of is that he really doesn't want to listen to anybody else", says one high-ranking OMA officer. "He has his prearranged agenda, which he's going to blow through, come hell or high water. . . . He is undoubtedly the Machiavellian mind behind the attempts to force physicians into alternate payment schemes." "Without question he has a very definite agenda to impose some type of salary [or] capitation [in place ofl fee-for-service remuneration for doctors, there's no doubt about that", says Dr. Jack Barkin, a Toronto urologist and Martin Barkin's first cousin. "I think one of his weaknesses is that his vision of health care is not well founded", says Dr. Henry Gasmann, past president of the OMA. "I think he may not be right, and I think the danger that he is not right is quite serious. I think there's a tremendous potential for harming the way medicine is practised in Ontario, and indeed in Canada." But there are also those who believe that Martin Barkin is doing a pretty good job, given the obstacles. "We are looking at a catastrophic problem here", says Ted Ball, a former senior official in Ontario's Ministry of Health who now operates a consulting firm specializing in health care policy. "The real world is that if nothing is done, within 8 years we would have a health care budget that would be about $40 billion. If you put that into perspective, the total budget for the province of
"Spending more than, say, Sweden, which has twice the over-age-65s that we do, ought to be taken as an alarm that says you're heading down a dangerous path." Dr. Martin Barkin
Ontario for everything today is [around] $30 billion. "Here is an extremely bright, very capable guy, a courageous individual who is prepared to do some nasty stuff', says Ball. "I've watched an awful lot of deputies and an awful lot of ministers in that job. In my judgement, I think that some day, when we look back on the history of the health care system, we may find that the major turning point in its structure occurred right now, during the tenure of Elinor Caplan [Ontario's minister of health] and Barkin." "I like the approach to developing health goals", says Dr. Michael Rachlis, a physician and consultant on health policy. "That is an important step forward. I think that the Ontario Health Survey which is going to be conducted is a good step, although it is very inadequately funded." Rachlis dismisses many of the criticisms levelled at Barkin by doctors. "Deputy ministers and physicians are in conflict in almost all provinces", he observes. By force of intellect and will Barkin has managed to seize the health care agenda and shape it into a personal quest, yet his mo-
tives remain an enigma. Admirers say he wanted the deputy minister's job because he believes he is the one person who can stop the health care system from bankrupting the province. Critics say he is driven more by insatiable ambition than by social conscience. But no one is certain just what makes Martin Barkin run. His resume yields only part of the answer. Now in his 30th year as a physician, his career accomplishments are impressive. After graduating from the University of Toronto in 1960 - he shared the Gold Medal that goes to the top student with a classmate - Barkin specialized in urology, completing his postgraduate training at Harvard University and in England. He returned to Canada to practise urology at Sunnybrook, where he quickly rose to the top of his field. As a researcher, he developed innovative techniques for correcting anatomical abnormalities of the genitourinary system. An expert in this relatively narrow and highly specialized field, he was courted internationally as a consultant, author and lecturer. His career as an administrator moved on a parallel path. CAN MED ASSOC J 1990; 142 (6)
629
Dr. Martin Barkin:: Heping the rubber meet the road Dr. Martin Barklin; Ontario's deputy minister of health, has a .tha.twhaeve.wr th.a.-t. allo.Q.cation is long list of critics who think you're getng the 1bes possible they can do his job better than rturn fm t. Thtns where the he can. To a large extent the critics aim at some of his more .What ;..he sees ..s.to be sungcontroversial viewpolnts, but gesting is.. .t.ha.t.. govermns Barkin says some of the criti- aren't having troublemeeting cism stems from physicians' the heathcar needs :of Canamisunderstanding of the role dian fo :want of money but Ihe deputy minister plays in beae of an inlty to get ;nmplementing health policy. the bes bang for the. buk. For istance, Barkin says "'There I don't think we're ;ocbors unfairly blame budget doing so hot", he admits. iutbacks on the Ministry of "Overall, cabinet decisions ricaithi. "'The ministry does not across the country have generhave autonomous funding dis- ally increased alloations to cretion", says Barkin, "nor health care at a rate that is does the minister. Requests to higher than they've Sncreased fIund get laid on the cabinet allocations for any other purtable, against the full priority of prose, a rate that runs about 2V2s govemment expenditure. That times the inflation rate. And at a rate that now puts Canada as is probably one of the highest futnctions of government: the higiest per capita spender whether to spend the next bil- on health care of any country ion dollars on roads or cities, with a national health systemn at time when Canada has one of tnf the environment or educathe youngest populations in the tion, or on [heart] bypass." Barkin says members of nword.u tie -th inlto.1 rt. An a Jt-lie Ontario cabinet aren't espe""Spending more than, say, cisally well informed on health Sweden, which has twice the care issues. Nevertheless, he over-age-65s that we do, ought says it's a misconception that to be taken a asn alarm that cabinet members make deci- says you're heading down a sions on health care funding on dangerous path."s Barkinsays that there are the basis of emotion, not fact. ;"They are usually not that emo- many indications of danger and tional inside cabinet", says Bar- he ofed aone of his favountes: kin. "Cabinet tries to apply the in thepaast7iyear the occupanultimate rationality. There is cy rate in Canadian hospitals no higher rational process, has increased by 27%. During whether you do it as an indi- the sames peri the: rate in the vidual or whether the govern- United States dropped by that mnent does it collectively, than percentae. rhyh Barkin says it boils determining how you will dedown to differewes in the way cide to spend your income." Barkin says that once the Canadian 'and Amerian hospicabinet approves a new pro- tals are managed. In 1982, gram the tough job begns. "Af- American thirdpay payer ter they've made the allocation such s Medic began paying l wo .......
--T-1- -.-_
630
CAN MED ASSOC J 1990; 142 (6)
hospitals a predetermined fee based on the condition treated - the diagnosis-related group, or DRG, system - instead of according to services rendered. "There was a powerful economic incentive for hospitals to admit, treat and discharge as quickly as possible", says Barkin, "because the highest cost of a hospital stay is not the technology that goes into the stay, but the length of the stay. Barkin would like to see Ontario physicians take a leading role in bnrnging that kind of system to Canada. Because of his own experience at Toronto's Sunnybrook Medical Centre, he believes that doctors can learn to take responsibility for cost effectiveness. He envisions a system in which doctors band together into group practices to manage the provision of services at a local level. The groups have various names - health service organization (HSO) is one, comprehensive health organization another. In each case, physicians use the group as a crucble for the sharing of skills and expertise, for the disseminatiorn of new knowledge, and for the application of peer pressure that upholds and improves standards of care. Barkin is impatient with physicians who have a laissezfaire attitude towards fiscal responsibility. "I dismiss categorically the comment that these kind of things are designed [to encourage] physicians to withhold care", says Barkin. "You can't suck and blow at the same time. You cannot say that physicians on fee for service never give unnecessary care in order
':'-' ....
~~~~~~~~~~~~~~~~................ .: ^S ..
.... .o..
--
--------------
.:
to make money,o but on a al ternae meh:od of dealing: 111 withhold care to make extra
abundance of primary care doc*tors in Ontario. .If you needed one doctor for ev.ery .2000 people, that's
Barkin's. critic dissmis his not a bad ratio", says Barkin. visio as a- carely packaged "Ontario should have about am t trol physiAc.ans 4500 primary care physicians, a charge.h :denies. "I assuming I had perfect distribudon'thin"k we're looking at . tion throughout the province. control ing. physicians' in- As far as we can tell, we've got -comes", he. says. "In fact, the maybe 8000 or 9000 primary only good marker we've got.is care physicians and another that physician- income for the 1000 specialists who are praclast decde has stayed about 5 tising primary care. Clearly, the -to 5½. times the mean industri- problem for us is a profligate use of medical manpower. If al wage. .In fct we're moving to it's used profligately in the al...ternte .payent xsystems to wrong places, it's very hard to p:;rotect incomes because under maintain compensation levels. "What is particularly ..existing method they are no lnr able. to.o stain incomes alarming in the rate of growth a levels< '.t:. they should. of doctors is not so much their :.Wefre se -this particularly in numbers but their mix and dis..critia c;are, and so we're prov- tribution. We have some areas :.iding other ways of compensat- of the province where we are ing physicians in order to make desperately searching for physithat. a reasonably compensated cians, providing additional incentives, and even reaching specialty. "Most goenemments under- down into medical school and stand that. you want to make underwriting education. We have some specialties that are sure that the income of a physictan. is as. high .relative to. the terribly underserviced that I am society as. it has ever terribly concemed about, par. ret ticularly in the areas of critical :been." b...... e.. . . In e: a -for-service system, care,. perinatal care, welltrained emergency physicians. d.to service thateincomei "&The biggest shortage that performed. Ba-rkin s concemed :abot the rate of increaseoin. we've got. relative to the burden of the .population is in mental provincialpaouts fr physc ser ics In 1988 payouts health. We're -not getting the far right doctor to the population a rose by 9 outs-t ed both inflation and that needs him the most." Are family physicians, parpopltingrwh.-:,He says. factors fuel ng ticularly those practising in te are s the. inrae 4nsthe grWing *major .cities, on. the Ontario government. hit list? Some docphyic°,,ia ..,.practisnumberof' tug in Ontario; a othr i tors think they are. In the last 2 years the provincial govem ounced plans to imme.ant:... ovr"I an "pblem he 6Q. say is v.what
.:~incomes,
...
* ..So
What makes Martin Barkin run?
Brian Goldman, MD It was yet another juicy rumour. Once again, Dr. Martin Barkin was supposed to be quitting his job as Ontario's deputy minister of health to head for greener pastures south of the border. There have long been rumours that Barkin, perhaps the province's most controversial physician, would be tapped to head Humana, the giant American health care conglomerate. In typical fashion, he outdid the rumour. CMAJ has learned that George Bush, the president of the United States, has spoken to Barkin. The topic? Would Barkin help him create a national health insurance plan for Americans. Doctors at the Ontario Medical Association (OMA) and hospital administrators across the province listen to the Barkin rumours with interest. They wonder if the man who brought the saying "Just say no!" to hospital budgets is finally going to go away and leave them alone. At least for now he won't be, but some say it took a last-minute plea from Premier David Peterson to keep Barkin in Ontario. In any case, the game of rumour and denial continues. Love him or hate him - they all respect him
Brian Goldman, a Toronto emergency ph'vsician, is a CMAJ contributing editor. 628
CAN MED ASSOC J 1990; 142 (6)
- Barkin watchers across the country agree that he is the most fascinating character to enter the Canadian health care scene in years. Change has been the opera-
man except Dr. Martin Barkin.
Before joining the government his career was built on enlightened self-interest. As a urologist he was a staunch defender of extra-billing, charging up to 10
"The biggest knock against Martin that I am aware of is that he really doesn't want to listen to anybody else." -OMA officer
tive word in health care in Ontario since the Liberals smashed the Progressive Conservative dynasty in 1985. Since then the government has pursued an agenda designed to de-emphasize the roles physicians and hospitals play in delivering care. It is trying to beef up regulations controlling physicians and their incomes, and it has drawn the line on growing hospital budgets. Given that context, Barkin, who in 1987 was handpicked to be deputy health minister by Peterson, is seen as the man who came to the right place at the right time. And that would be a fitting epitaph for the career of almost any
times more to reverse a vasectomy than the slightly more than $200 now paid by the provincial health insurance plan. As president and chief executive officer (CEO) at Sunnybrook Medical Centre in Toronto, he joined other hospital administrators in lobbying the Ontario government for more money. Yet, as deputy health minister he has learned to turn his back on his former colleagues, and this frustrates them to no end. "Obviously, there was great hope that here we had somebody who understood hospitals and also understood physicians", says Peter Ellis, the current president
and CEO at Sunnybrook and vicepresident during Barkin's tenure there. "In fact, if you look at what's going on currently, both hospitals and physicians have perceived, from the way the ministry presents certain of its opinions, that we are almost the enemy. I find that somewhat offensive." Doctors don't hesitate to complain either. "The biggest knock against Martin that I am aware of is that he really doesn't want to listen to anybody else", says one high-ranking OMA officer. "He has his prearranged agenda, which he's going to blow through, come hell or high water. . . . He is undoubtedly the Machiavellian mind behind the attempts to force physicians into alternate payment schemes." "Without question he has a very definite agenda to impose some type of salary [or] capitation [in place ofl fee-for-service remuneration for doctors, there's no doubt about that", says Dr. Jack Barkin, a Toronto urologist and Martin Barkin's first cousin. "I think one of his weaknesses is that his vision of health care is not well founded", says Dr. Henry Gasmann, past president of the OMA. "I think he may not be right, and I think the danger that he is not right is quite serious. I think there's a tremendous potential for harming the way medicine is practised in Ontario, and indeed in Canada." But there are also those who believe that Martin Barkin is doing a pretty good job, given the obstacles. "We are looking at a catastrophic problem here", says Ted Ball, a former senior official in Ontario's Ministry of Health who now operates a consulting firm specializing in health care policy. "The real world is that if nothing is done, within 8 years we would have a health care budget that would be about $40 billion. If you put that into perspective, the total budget for the province of
"Spending more than, say, Sweden, which has twice the over-age-65s that we do, ought to be taken as an alarm that says you're heading down a dangerous path." Dr. Martin Barkin
Ontario for everything today is [around] $30 billion. "Here is an extremely bright, very capable guy, a courageous individual who is prepared to do some nasty stuff', says Ball. "I've watched an awful lot of deputies and an awful lot of ministers in that job. In my judgement, I think that some day, when we look back on the history of the health care system, we may find that the major turning point in its structure occurred right now, during the tenure of Elinor Caplan [Ontario's minister of health] and Barkin." "I like the approach to developing health goals", says Dr. Michael Rachlis, a physician and consultant on health policy. "That is an important step forward. I think that the Ontario Health Survey which is going to be conducted is a good step, although it is very inadequately funded." Rachlis dismisses many of the criticisms levelled at Barkin by doctors. "Deputy ministers and physicians are in conflict in almost all provinces", he observes. By force of intellect and will Barkin has managed to seize the health care agenda and shape it into a personal quest, yet his mo-
tives remain an enigma. Admirers say he wanted the deputy minister's job because he believes he is the one person who can stop the health care system from bankrupting the province. Critics say he is driven more by insatiable ambition than by social conscience. But no one is certain just what makes Martin Barkin run. His resume yields only part of the answer. Now in his 30th year as a physician, his career accomplishments are impressive. After graduating from the University of Toronto in 1960 - he shared the Gold Medal that goes to the top student with a classmate - Barkin specialized in urology, completing his postgraduate training at Harvard University and in England. He returned to Canada to practise urology at Sunnybrook, where he quickly rose to the top of his field. As a researcher, he developed innovative techniques for correcting anatomical abnormalities of the genitourinary system. An expert in this relatively narrow and highly specialized field, he was courted internationally as a consultant, author and lecturer. His career as an administrator moved on a parallel path. CAN MED ASSOC J 1990; 142 (6)
629
Dr. Martin Barkin:: Heping the rubber meet the road Dr. Martin Barklin; Ontario's deputy minister of health, has a .tha.twhaeve.wr th.a.-t. allo.Q.cation is long list of critics who think you're getng the 1bes possible they can do his job better than rturn fm t. Thtns where the he can. To a large extent the critics aim at some of his more .What ;..he sees ..s.to be sungcontroversial viewpolnts, but gesting is.. .t.ha.t.. govermns Barkin says some of the criti- aren't having troublemeeting cism stems from physicians' the heathcar needs :of Canamisunderstanding of the role dian fo :want of money but Ihe deputy minister plays in beae of an inlty to get ;nmplementing health policy. the bes bang for the. buk. For istance, Barkin says "'There I don't think we're ;ocbors unfairly blame budget doing so hot", he admits. iutbacks on the Ministry of "Overall, cabinet decisions ricaithi. "'The ministry does not across the country have generhave autonomous funding dis- ally increased alloations to cretion", says Barkin, "nor health care at a rate that is does the minister. Requests to higher than they've Sncreased fIund get laid on the cabinet allocations for any other purtable, against the full priority of prose, a rate that runs about 2V2s govemment expenditure. That times the inflation rate. And at a rate that now puts Canada as is probably one of the highest futnctions of government: the higiest per capita spender whether to spend the next bil- on health care of any country ion dollars on roads or cities, with a national health systemn at time when Canada has one of tnf the environment or educathe youngest populations in the tion, or on [heart] bypass." Barkin says members of nword.u tie -th inlto.1 rt. An a Jt-lie Ontario cabinet aren't espe""Spending more than, say, cisally well informed on health Sweden, which has twice the care issues. Nevertheless, he over-age-65s that we do, ought says it's a misconception that to be taken a asn alarm that cabinet members make deci- says you're heading down a sions on health care funding on dangerous path."s Barkinsays that there are the basis of emotion, not fact. ;"They are usually not that emo- many indications of danger and tional inside cabinet", says Bar- he ofed aone of his favountes: kin. "Cabinet tries to apply the in thepaast7iyear the occupanultimate rationality. There is cy rate in Canadian hospitals no higher rational process, has increased by 27%. During whether you do it as an indi- the sames peri the: rate in the vidual or whether the govern- United States dropped by that mnent does it collectively, than percentae. rhyh Barkin says it boils determining how you will dedown to differewes in the way cide to spend your income." Barkin says that once the Canadian 'and Amerian hospicabinet approves a new pro- tals are managed. In 1982, gram the tough job begns. "Af- American thirdpay payer ter they've made the allocation such s Medic began paying l wo .......
--T-1- -.-_
630
CAN MED ASSOC J 1990; 142 (6)
hospitals a predetermined fee based on the condition treated - the diagnosis-related group, or DRG, system - instead of according to services rendered. "There was a powerful economic incentive for hospitals to admit, treat and discharge as quickly as possible", says Barkin, "because the highest cost of a hospital stay is not the technology that goes into the stay, but the length of the stay. Barkin would like to see Ontario physicians take a leading role in bnrnging that kind of system to Canada. Because of his own experience at Toronto's Sunnybrook Medical Centre, he believes that doctors can learn to take responsibility for cost effectiveness. He envisions a system in which doctors band together into group practices to manage the provision of services at a local level. The groups have various names - health service organization (HSO) is one, comprehensive health organization another. In each case, physicians use the group as a crucble for the sharing of skills and expertise, for the disseminatiorn of new knowledge, and for the application of peer pressure that upholds and improves standards of care. Barkin is impatient with physicians who have a laissezfaire attitude towards fiscal responsibility. "I dismiss categorically the comment that these kind of things are designed [to encourage] physicians to withhold care", says Barkin. "You can't suck and blow at the same time. You cannot say that physicians on fee for service never give unnecessary care in order
':'-' ....
~~~~~~~~~~~~~~~~................ .: ^S ..
.... .o..
--
--------------
.:
to make money,o but on a al ternae meh:od of dealing: 111 withhold care to make extra
abundance of primary care doc*tors in Ontario. .If you needed one doctor for ev.ery .2000 people, that's
Barkin's. critic dissmis his not a bad ratio", says Barkin. visio as a- carely packaged "Ontario should have about am t trol physiAc.ans 4500 primary care physicians, a charge.h :denies. "I assuming I had perfect distribudon'thin"k we're looking at . tion throughout the province. control ing. physicians' in- As far as we can tell, we've got -comes", he. says. "In fact, the maybe 8000 or 9000 primary only good marker we've got.is care physicians and another that physician- income for the 1000 specialists who are praclast decde has stayed about 5 tising primary care. Clearly, the -to 5½. times the mean industri- problem for us is a profligate use of medical manpower. If al wage. .In fct we're moving to it's used profligately in the al...ternte .payent xsystems to wrong places, it's very hard to p:;rotect incomes because under maintain compensation levels. "What is particularly ..existing method they are no lnr able. to.o stain incomes alarming in the rate of growth a levels< '.t:. they should. of doctors is not so much their :.Wefre se -this particularly in numbers but their mix and dis..critia c;are, and so we're prov- tribution. We have some areas :.iding other ways of compensat- of the province where we are ing physicians in order to make desperately searching for physithat. a reasonably compensated cians, providing additional incentives, and even reaching specialty. "Most goenemments under- down into medical school and stand that. you want to make underwriting education. We have some specialties that are sure that the income of a physictan. is as. high .relative to. the terribly underserviced that I am society as. it has ever terribly concemed about, par. ret ticularly in the areas of critical :been." b...... e.. . . In e: a -for-service system, care,. perinatal care, welltrained emergency physicians. d.to service thateincomei "&The biggest shortage that performed. Ba-rkin s concemed :abot the rate of increaseoin. we've got. relative to the burden of the .population is in mental provincialpaouts fr physc ser ics In 1988 payouts health. We're -not getting the far right doctor to the population a rose by 9 outs-t ed both inflation and that needs him the most." Are family physicians, parpopltingrwh.-:,He says. factors fuel ng ticularly those practising in te are s the. inrae 4nsthe grWing *major .cities, on. the Ontario government. hit list? Some docphyic°,,ia ..,.practisnumberof' tug in Ontario; a othr i tors think they are. In the last 2 years the provincial govem ounced plans to imme.ant:... ovr"I an "pblem he 6Q. say is v.what
.:~incomes,
...
* ..So
