Are alternative funding plans a good idea?

M Godwin and colleagues are to be congratulated for their survey of the effect of an alternative funding plan on physician referrals; however, we have several concerns. First, the authors state that to interpret the “negative perceptions” of the respondents regarding the alternative funding plan one should “consider the confounding effect of other changes in the health care system in Ontario.” A control group should have been selected. Reductions in health care allocations in Ontario are not exclusive to the academic centre studied. Second, a null hypothesis would be that physician referral would not be affected by changes in funding. However, 39% of the surveyed physicians sent fewer patients to the study’s tertiary care institution, and 37% sent more to the tertiary care (nonstudy) institutions. Although we realize the limitations of post-hoc analysis, this shift is probably nonrandom. Moreover, the consultant physicians at the nonstudy centres who were already dealing with cutbacks were now forced to cope with an increased caseload deferred from the study centre. Fortunately, some physicians within the study centre opted out of the alternative funding plan and assumed a major increase in referral work, according to the authors’ data. Third, the authors infer support for the alternative funding plan among referring physicians by commenting that “only 39% ... indicated that they would not want to be part of an alternative funding plan.” This is a confusing interpretation. Their results show that only 35% of the referring physicians stated that they would want to participate in an alternative funding plan. Finally, the alternative funding plan is a funding experiment, requiring more bureaucracy, implemented without evaluative plans. For a publicly funded enterprise, citizens have the right to ask about the “value-added” features of this new bureaucracy. In the absence of unequivocal evidence of benefit, would it not be reasonable to terminate the experiment and restore the previous system?