Monday, April 13, 2009

What do Quebec and Australia have in common? Not much, yet

On March 30, reported that “No one wants Quebec’s limited private health insurance.” The small story said that wait times for the procedures that commercial insurers are permitted to cover—hip, knee, and cataract surgeries—have fallen by six months since the enabling legislation, Bill 33, passed in 2006 consequent to the Chaoulli decision. The shorter waits combined with the expense of the policies killed their market.

An attempt to find coverage of this elsewhere yielded nothing, even in the French media. What prompted to publish the story when it did is unclear, but despite the lack of interest in the media at large, it has important implications.

Quebeckers rejected this insurance because they don’t need it. They were understandably unhappy with the long waits for elective surgeries in the early 2000s, but the situation has changed. Of course, some of these procedures are now outsourced to for-profit clinics, but the funding is public. If public funding can provide adequate care, private funding is superfluous.

Australia provides an instructive contrast. In 1984, universal health care was enacted. Before then, commercial insurance was necessary for most Australians, but in that year, they began to abandon for-profit coverage because their needs were met by the public health-care system. They saw no need to buy duplicative insurance to gain access to private hospitals. The government, however, was determined to maintain a role for commercialized care, and in the late 1990s, it began enacting measures to subsidize private insurance and encourage people to buy it.

Only heroic, expensive government measures kept the private system afloat in Australia, which is the antithesis of the free market. Meanwhile, the publicly funded system has been in slow decline, which also increases demand for commercial alternatives. This incoherent policy and the fragmented two-tier approach have created what one Australian commentator called “a mess, rather than a system.”

So if the Chaoulli decision in Quebec resulted in a situation in which private insurance is unnecessary, why is Brian Day suing the province of British Columbia to enact its own Bill 33? Does he think residents of BC are that much more eager to buy expensive insurance than Quebeckers? Of course they aren’t.

The lessons from Quebec and Australia are clear: commercial health insurance competes poorly with a single-payer scheme unless publicly funded care is deficient, privately funded care is perceived as superior, and commercial insurance is heavily subsidized. Proponents of a universal, equitable health care system have to be on guard for efforts by commercial players to degrade public care and shift tax dollars toward their enterprises.

Randall F. White, MD

Saturday, March 28, 2009

BCMA’s progressive addiction policy

The BCMA has done something good. It has called for accessible and publicly funded treatment for substance-use disorders and compulsive gambling. The inadequacy of treatment resources for people with addictive disorders is well known to patients and their families, and to physicians of British Columbia. The stigmatization of these disorders, however, robs patients and families of a public voice. Alcoholics Anonymous has its name for a reason. Physicians must be advocates for such people.

The BCMA published a policy paper which has received significant media attention, including a headline story in the Vancouver Sun. The summary of recommendations includes a call for the ministry of health to “recognize addiction as a chronic, treatable disease.” Furthermore, the BCMA asks the province to “ensure that access to addiction care is accessible without financial and other barriers throughout BC; this includes the elimination of per diem fees, minimization of language barriers, and access to inpatient addiction care.” The request goes further: “Create and fund” 840 new treatment beds.

Organized medicine in Canada seems ready to turn surgical care and imaging services over to for-profit enterprises. It is refreshing for a provincial medical organization to advocate for public delivery and funding of treatment for chronic diseases that devastate individuals and communities, and that place a massive burden on acute-care hospitals.

The deliberate inclusion of gambling as an addictive disorder that deserves publicly funded treatment is noteworthy. Although the policy paper does not point out government’s conflict of interest as the regulator and beneficiary of “gaming” revenues, the authors must recognize government's responsibility to those who become addicted. Lotteries in particular are a regressive, albeit voluntary tax that many North American jurisdictions rely upon. Perhaps it is too much to ask that the BCMA call for the elimination of government-sponsored gambling.

Randall F. White, MD

Saturday, March 14, 2009

Family physicians and patients need more information about specialists

Why can’t family physicians easily find the best specialist with the shortest wait time for a new consultation? In BC, information on wait time for certain surgical procedures is available on a provincial Web site. The figures, however, account only for the waiting time once the surgeon has determined that an operation is necessary. Wait times for the initial consultation with a surgeon or with a non-surgical specialist are unavailable.

Lack of coordinated referral networks is an aspect of the Canadian system which has led some to call it a cottage industry. Doctors work in their isolated offices, create local networks for referrals, and have little knowledge of or access to specialists beyond that. This, along with the low physician density in Canada, has contributed to the growth of specialist wait lists.

Without reliable information, family physicians cannot adequately help their patients find the quickest consultation and, if needed, operation. A BC business has exploited this situation and, for a fee, will match a patient with a specialist. The company’s Web site, though, quickly informs the reader that “the need for private medical services is thriving in Canada,” and that the company “is able to expedite most types of private medical services from diagnostics to virtually all types of surgery.” The option of having treatment in a public facility doesn’t seem to merit mention.

Vancouver Sun editorialists recently pointed out this company’s services and asked why the government can’t provide information on availability of specialists to patients and family physicians. Good question! The public is paying for the services, after all, and is entitled to some accountability.

Documenting wait times is a necessary aspect of quality improvement in medicine. Collecting and publishing such information for the public should be part of a universal health care system. Aside from patients, family physicians have the most to gain and should advocate for this despite any resistance from specialists. Commercialization will continue to gain ground in health care if obvious solutions such as registries of specialists’ wait times and pooled wait lists are ignored.

Randall F. White, MD

Sunday, February 1, 2009

Brian Day gives new meaning to doctors without borders

Medical tourism is the new hope for the North American economy and the health care systems of the United States and Canada. Skeptical? Just listen to Dr. Brian Day, whose proposal was published on January 26 in the National Post. Day suggests that once Canada has taken care of Canadians who are waiting for operations, it would then do the same for the world. More specifically, he seems to covet the business of US citizens stymied by the lack of affordable treatment in their country.

With 47 million un- or underinsured people in the United States, Day sees a huge untapped market. Why fly to Asia or drive down to a dodgy hospital in Mexico? Just come to Vancouver, Toronto, or Montreal for excellent care at 60 to 90 percent the cost of treatment at home. He also suggests that US insurance companies would gleefully buy discounted treatment from their friendly northern neighbour.

How he arrived at the discount figures is unclear, but it’s well known that administrative costs are much lower in Canada because of the single-payer system. Canadian doctors are also paid less than US doctors, at least in the publicly funded insurance scheme. Although he suggests that public hospitals in Canada would participate in this industry, that seems unrealistic. Would the lower costs hold in a commercialized, for-profit Canadian context? Unlikely. Day, in fact, has vigorously promoted activity-based funding, which may increase the administrative burden in clinical settings and fuel inflation.

The suggestion that developing Canada as a “medical tourism” destination would benefit US citizens is absurd. It would benefit medical entrepreneurs like Brian Day, but taking patients away from home and family, or bringing family along, would be costly and stressful. Those costs would be borne by individuals. Furthermore, this model would perpetuate the bad habits of US health insurance companies, which are always seeking to shift costs and maximize profits. And it would provide further rationale to avoid meaningful health-care reform in the United States.

Day argues that the costs borne by Canadian citizens who are disabled while waiting for imaging or surgery are unacceptable. With that, all can agree. The solution, however, is a well-organized, universal, fully resourced, publicly funded health care system, and Canada is not there yet. Adding a for-profit tier is a false solution.

Because of the transborder health-care asymmetry, a US health-care entrepreneur is suing Canada to enter the market here, but nothing stops Brian Day from establishing clinics within the United States. Maybe he’s too busy with his own lawsuit. He and the organization he helps lead, the Canadian Independent Medical Clinics Association, have initiated legal action to force British Columbia to allow commercial insurance for medically necessary care. If successful, this would bring the Canadian Supreme Court’s Chaoulli decision into force in BC.--Randall F. White

Saturday, January 17, 2009

Jeffrey Turnbull, candidate for CMA presidency

Being enthusiastic about medical politics isn’t often easy, but I’m pleased to exchange the pen of cynicism for the pen of hope in writing about an election in Ontario. Dr. Jeffrey Turnbull is a candidate for Ontario nominee as Canadian Medical Association president. If elected, he would assume the presidency in 2010.

What makes Dr. Turnbull special? I’ve never met him, but he has impressed many, including the Ottawa Citizen which called him “renowned for developing novel solutions to difficult problems.” He has worked in places as diverse as the slums of Dhaka, the homeless shelters of Ottawa, and the dean’s offices at the university of Ottawa. He is a clinician, educator, advocate, researcher, and administrator. He has served at many levels of leadership in the medical establishment. He is supremely qualified to be the president of the CMA.

Dr. Turnbull is also a proponent of health care delivered in a comprehensive, publicly funded and administered system. While some call for the Canada Health Act to be “modernized,” Dr. Turnbull knows that this legislation, in its simplicity, allows for an array of services and solutions to health care needs as broad as this country. It merely requires that these services be delivered equitably, and that displeases those who want to profit by exploiting the demand for scarce personnel and resources.

The change we really need is in the imagination and will of physicians, administrators, and politicians. By devising innovative and inclusive approaches to health care, Dr. Turnbull has shown that he can provide leadership and vision so necessary at a time when Canadian medicine is plagued by opportunism and mercantilism.

Both leading candidates call for a national pharmaceutical care plan. On this, Canadian physicians may be approaching consensus.

Members of the Ontario Medical Association may vote in the election from January 15 through February 26.

Randall F. White, MD

Wednesday, October 29, 2008

What does Brian Day say (or not) about privatized medical education?

In August, the Canadian Medical Association passed a resolution during its annual meeting in Montreal calling for “public-private partnerships to facilitate the expansion of medical school capacity.” According to Brian Day, an orthopaedic surgeon and immediate past president of the Canadian Medical Association, Canada has a single-payer problem in medical education and in payment for physician services, which he said means “splitting up a pie that’s not big enough” resulting in a “rationing of resources.” During a talk to the University of British Columbia Clinical Faculty Association in October, he emphasized that Canadian health care is underfunded, and he predicted that, consequent to the Chaoulli decision, all provinces will follow Quebec`s lead to allow private funding of medically necessary services.

According to Dr. Day, private funding is needed: “That’s the way we’re going to get better health care for more people and how we’re going to get better funding for medical education.” He gave examples of private funding for medical infrastructure in Vancouver: the Jack Bell Research Centre, the Pattison Pavilion of the Vancouver General Hospital, and the Gordon and Leslie Diamond Health Care Centre. “This is all private money going into ‘public health care,’” he said, but if he meant to illustrate how the profit motive can enhance health care, his examples failed him. All three of these buildings, which are part of the Vancouver General Hospital clinical, education, and research campus, were named for prominent BC philanthropists.

I join Dr. Day in applauding the generosity of these donors, and I hope that wealthy people will continue to enhance medical research and education in Canada through charitable giving. But donation is not the same as investing in health care funding and delivery in order to generate profit. Surely the distinction does not escape Day, so his confusion is puzzling. Furthermore, he mentioned none of the problems that commercial health care can bring, which Dr. Marcia Angell presents in a recent Canadian Medical Association Journal essay. You can read more about peer-reviewed research on the downside of privatization on the CDM Web site.

As the meeting drew to a close, Day pointed out that Canada has too few physicians. Given a physician density of 2.1/1000 compared with a mean of 3.1/1000 among OECD countries, few would argue that Canada should not train more doctors. Day then brought up the proposal of a new medical school situated in BC’s Fraser Valley and affiliated with Simon Fraser University. This is the best thing that could happen to the UBC clinical faculty, he said, because UBC has a monopoly. He suggested that clinical faculty, some of whom are unhappy about UBC’s unwillingness to bargain with them collectively, would be better off if another institution provided competition. When an audience member asked about the role of a public-private partnership in the venture, he said the medical school would likely be in Surrey, BC and added, “I know more than I can tell you.”

According to two members of the SFU Faculty of Health Sciences, the medical school they and their peers envision would promote primary care and community medicine. Brian Day is not known as a champion of these issues. He founded a private surgical clinic, and during his remarks, he said that once Canada eliminates wait lists, medical tourism can develop as a “big industry” to provide procedures for well-off foreigners. This would be a source of funding for domestic health care, but he didn`t go so far as to say it could also create profit for investors and clinic proprietors, such as himself. Before the meeting ended, Day and some supporters obtained a hasty vote, with as many abstentions and nays as yeas, in support of the concept of a second medical school in BC.

Do we need more medical graduates? Yes, and UBC has just expanded its entering medical class to 256 students. It’s unlikely that the province will support another medical school right away, given the establishment of campuses in Prince George, Victoria, and Kelowna. Private money may be necessary to open a second faculty of medicine, but private-school graduates would come away with high debt, and if Day’s vision of commercialized payment and delivery prevails, perhaps an indoctrination.

Randall F. White, MD

Wednesday, October 1, 2008

More on Howard`s complaint and its significance

by Randall F. White

Melvin J. Howard wanted to build "the largest privately owned health center in Canada.” According to documents filed with Foreign Affairs and International Trade Canada, he incorporated Regent Hills Health Centre in January 2003 in the province of BC. The original plan involved purchase of 9.5 acres in Vancouver, and he had begun securing financing and undertaken negotiations with the Canadian firms DGBK Architects and Ledcor Construction, Ltd. The scheme involved a Delaware company which would raise funds by selling bonds through Ziegler Capital Markets, a U.S. investment bank specializing in health care financing, "exclusively to American citizens, funds and companies." The loan would have passed through TD Bank in Vancouver, but the money would have flowed from and to the United States.

The Regent Hills Health Centre intended to offer outpatient surgery, laser dentistry, diagnostic imaging, physical and occupational therapy, ambulatory and medical education programs. The 215,000 square-foot building would have housed 14 operating rooms and 110 beds. Nowhere in the documents is a mention of how many physicians and nurses would be needed, how they would be recruited, or any acknowledgment of the peculiarities of health care financing in British Columbia such as the Medical Services Plan.

Howard wanted to open Regent Hills in February 2007, but given the dates on the documents, his plans in Vancouver have been derailed for some time. In the NAFTA complaint, Howard alleges obstruction of permitting by "municipalities or city officials," and loss of deposits on contracts to purchase 5 separate land parcels. Documents suggest he may have shifted his plans to Surrey after Vancouver denied him permission. Furthermore, he mentions "community activist (sic) opposing the private surgical center."

All this indicates that Mr. Howard doesn't give up easily. He is angry, aggrieved, and perhaps grandiose. But according to Todd Grierson-Weiler, Canadian attorney who specializes in NAFTA arbitration, Howard’s submission is amateurish and has little chance of advancing. As for his threat to invoke the General Agreement on Trade in Services, according to Ellen Shaffer of the Center for Policy Analysis on Trade and Health, only the U.S. government could initiate this action against Canada. Unlike NAFTA, the World Trade Organization, which administers GATS, does not permit investor-initiated actions against member states.

So perhaps this is a tempest in a teapot, but dismissing the “NAFTA bogeyman,” as Grierson-Weiler does, fails to acknowledge the crucial lesson. U.S. corporations are not going to give folksy Canadian entrepreneurs a free run. If a market in health care develops in Canada, multinationals like Minneapolis-based United Health International will be at the ready, and for them, NAFTA will be an essential tool.