When the health reform cure is worse than the disease

Major decisions about how Canada’s health-care system operates could be decided by our courts - not democratically elected parliamentarians.

A Charter of Rights and Freedoms challenge is underway in the Supreme Court of British Columbia. Brian Day, medical director of the Cambie Surgical Centre, is arguing that the laws prohibiting Canadian doctors from practising in the public and private health sectors simultaneously should be struck down, along with the prohibition on extra billing for services already covered by the provincial health plan.

Day argues such restrictions prohibit patients from seeking the best care possible, thereby violating the charter. But critics argue the case is more about increasing doctors’ potential earnings than patient choice or quality care.

Right now, we have a single tier of publicly funded health care (a limited private sector covers certain non-insured services). If Day’s challenge succeeds, those who are financially able will have access to a tier of health services where doctors charge whatever they want. Those who lack funds will have access to only the public tier, where doctors adhere to a mandated fee schedule.

What’s wrong with a two-tier system? Evidence from other countries demonstrates it too often benefits only those who can afford to pay, and makes the publicly funded system more expensive and less efficient.

Day argues a two-tier system is the solution to medicare’s problems. His lawyers assert that the creation of private payments will alleviate strain on the public tier, ultimately leading to shorter wait times for all Canadians, regardless of which level of care they access.

It’s not that simple, as Australia discovered.

Australia had a publicly funded system like Canada’s before introducing a parallel private-pay system in 1999. However, wait times in the public pay system became longer, not shorter. Many specialists spend more time in the private system than in the public, cherry-picking the healthiest, wealthiest and most profitable patients. That leaves the most complex, vulnerable, sickest and costly for the public system.

Day also points to the viability and desirability of European health-care models, so let’s have a look at a few.

Switzerland has the second-most-expensive system in the world, behind the U.S. Private insurance is mandatory. Out-of-pocket payments are exceptionally high, with low- and middle-income families paying more into the system than families in high-income brackets.

The French have a private/public hybrid, but private insurance only helps cover the extra billing introduced to add more money to the system. They also have some of the greatest financial and geographical inequities in access to health care in Europe.

The German health-care system is also a public/private mix, but patients have to choose one or the other. Germans with public insurance – about 90% of the population – wait three times longer for care than those with private insurance. More importantly, private insurance sold in Germany is for those wealthy enough to leave the public system entirely. They can never come back, no matter how expensive their care becomes.

Some believe the United Kingdom’s National Health Service (NHS) is comparable to Canada’s. It’s not. NHS doctors are salaried government employees who must work a 40-hour work week with additional evening and weekend call hours before they can see private patients.

So if Europe doesn’t offer an obvious solution to improving the Canadian system, where should we turn?

Canada has some good homegrown evidence.

In B.C., the Mount Saint Joseph Hospital cataract and corneal transplant unit employed production-line efficiency and shared patient lists to reduce wait times from 12 to 16 weeks to eight weeks. Likewise, Richmond Hospital’s Hip and Knee Reconstruction Project used staggered operating start times and standardization to reduce wait times from 20 to five months. The Alberta Bone and Joint Institute reduced wait times from 11 months to nine weeks for hip and knee surgery by centralizing intake systems and reducing hospital stays.

These models changed how we deliver care to improve that care. Our legislators, policy-makers and health practitioners could help make such Canadian best practices a reality across the country.

So let’s not pretend the Day case is about patient choice. Instead, let’s modernize and innovate within Canada’s public health-care delivery to benefit everyone. 

Monika Dutt is the chair of Canadian Doctors for Medicare. She is a family physician and public health specialist in Nova Scotia, an adjunct professor at Cape Breton University, and holds a Master of Public Health and Master of Business Administration from Johns Hopkins University

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