WHO knew? While Ralph Klein muses about the "third way" on health care, and Alberta is declared the privatization capital of Canada, Calgary's for-profit health sector has nothing on Montreal's.
According to an investigation by the Montreal Gazette, 90 city physicians have opted out of medicare entirely, and there are a dozen private MRI clinics. The Duval Orthopedic Clinic is a private hospital offering patients $12,000 hip and knee replacements. The Westmount Square Surgical Centre bills patients $2,000 to repair knee and shoulder problems, but its physicians continue to practise part-time in the public system. Elsewhere, there is a private emergency clinic.
The largest for-profit health sector in Canada cannot emerge without the complicity of the Quebec government, which licenses the facilities and allows doctors to maintain a foot in both the private and public camps. Is the 'Montrealization' of medicare something to worry about, or is it vive la difference?
Here's how it was supposed to work:
Ottawa commits tens of billions of new dollars to the provinces for health care. The provinces agree to beef up programs like home care and reduce wait-times. Most of the money is unconditional. The provinces renew their commitment to the principles of medicare as enshrined in the Canada Health Act. Medicare is reinvigorated, and the privatization temptress is spurned.
This is health-care sponsorship on a grand scale. But, yet again, Ottawa seems to have mastered the art of getting nothing for something.
Two strange bedfellows -- Alberta and Quebec -- now preside benignly over a proliferation of private clinics, where patrons can buy their way to faster service. Canada Health Act (CHA) violations? Usually. Want to talk to Ottawa about it? Nah. Didn't you promise to uphold the CHA? Yeah, well, compliance is in the eye of the beholder. Butt out.
Federal Health Minister Ujjal Dosanjh has talked tougher and more passionately about the principles of medicare than his recent predecessors. He believes the private, for-profit clinics are a threat to medicare, and that queue-jumping is on the rise. So one would expect Ottawa to withhold cash from offending provinces, especially now that it has purchased (several times over) the moral authority to enforce the one piece of legislation that creates some semblance of principle-based unity among the provincial health-care fiefdoms.
But nothing is ever simple in health care, and nor is this issue. Some practices violate the letter of the CHA, others violate the spirit. Here's what's black, what's white, and what's grey.
The Canada Health Act prohibits charging patients for "medically necessary," publicly insured physician and hospital services. Your doctor can't charge you more than the fee negotiated by the government and the provincial medical association. Doctors can't bill patients extra -- or, rather, if they do, Ottawa is obliged to withhold the value of all such extra fees from its transfer payments to the province.
The CHA does not govern purely private arrangements, where no public money is involved. Doctors can opt out of their provincial health plans entirely, and charge patients what the traffic will bear. The province reimburses neither the doctor nor the patient. Some physicians in Toronto offer purely private primary care for a hefty annual fee -- they see relatively few patients but give them (or so they promise) premium service.
Doctors can bill patients for services that are not "medically necessary," like an examination required by an employer or an insurance company. Here's where the problems begin. Many private MRI clinics, for example, serve both publicly insured patients, and those who pay out of pocket. The former are by definition getting a "medically necessary" service; the latter by definition are getting a medically unnecessary service in order to avoid violating the CHA.
Why would anyone seek and pay for a service that isn't necessary? Either because they're suckers, or because the public system lacks capacity to meet legitimate medical needs -- meaning the service is medically necessary after all, except in law. Confused? Small wonder.
Doctors can bill patients for services not covered by medicare. They can, for instance, charge for "extras" such as higher-quality lens implants for cataract patients, or rental of a recovery room with a big-screen TV. But they can't charge a facility fee for an insured service -- the CHA defines these as user charges, which are prohibited.
Some provinces allow doctors to practise on both sides of the street -- they can serve patients under medicare and accept provincial fee schedules and other rules part of the time, and also work in a private clinic where no public funds are involved and profit maximization is king.
Provinces that allow either extra-billing or user charges for insured services must, by law, estimate the value of these levies and disclose them to Ottawa. Ottawa in turn must make "mandatory dollar-for-dollar deductions from the federal transfer payments" on receipt of such information. Yet, in the last 20 years Ottawa has withheld a total of less than $9 million -- a mere rounding error in the health-care accounts.
On the surface, the rules are pretty clear. But medicare is a constant flashpoint of federal-provincial relations, and for all the tough talk on the Health Canada website and Minister Dosanjh's fervour, Ottawa has shown a remarkable inclination to fold with a straight flush. It negotiates collegially with provinces committed to the letter and spirit of the CHA, but it is all-too-often spineless when told to go to hell by Alberta and Quebec.
As for Alberta, the smoke is often thick but there's relatively little fire. The government and the Calgary Health Region have backed away from entering into a P3, or public-private partnership, to build a new hospital. Premier Klein has said that contracting out public services to private clinics at a steep price is good value for money, and is content to see doctors to split their time between the for-profit and public systems.
Alberta law formally prohibits queue-jumping through the private sector, but monitoring whether this is taking place and enforcing the law are, of course, another matter. Dosanjh has written to Alberta and three other provinces to express his concerns about the realities of patients fast-tracking through the private-clinic portal to the public system.
Perhaps surprisingly, last week's Innovations Conference in Alberta, feared by medicare advocates as a celebration of privatization, focused mainly on the nuts and bolts of improving health care -- investments in information technology, dedication to quality improvement, and getting doctors more fully integrated into the system.
The most ideologically charged proposal came from Janice MacKinnon, former NDP finance minister in Saskatchewan, who advocated making health-care services a taxable benefit. A regressive measure that would make most neoconservatives blush, it was roundly rejected by the gathering.
But back to "Montrealization" and its consequences. Patrons of private diagnostic clinics get quicker access to follow-up care in the public system. Armed with their diagnoses ahead of those using public diagnostic services, they effectively jump the queue. As for the care itself, nothing is entirely private. If there are complications at the Duval Clinic, off the patient goes to the ICU in a public hospital. There is no A to Z private, parallel system in Canada.
In essence, the private clinics thrive on patients with money, skim off high-volume, lucrative procedures, and rest secure in the knowledge that the public system will be there for the tough jobs. And they lure physicians away from the public system -- which, when supply is scarce, can only lengthen wait-times and undermine public confidence. Once the trend reaches a critical volume, say adieu to solidarity.
Ottawa is afraid of the provinces, some governments are lukewarm on medicare, and everyone is afraid of doctors. Accommodations are made, money is shovelled, assurances are uttered. Practices guaranteed to create two classes of service and serious problems for the public system proliferate unchecked. For-profit entrepreneurs sense a growing market, and the public -- even in that most social democratic of provinces, Quebec -- shrugs.
Ten years ago, then-federal health minister Diane Marleau wrote to the provinces to express two concerns: the impact of extra-billing and user-fees on accessibility, and the threat posed by privatization to the stability of and support for the public system. The letter eloquently expressed what the principles of medicare mean to the federal government, and was intended to check the growth of private clinics and two-tier medicine.
Written when Ottawa was starving the provinces to get its own fiscal house in order, the letter, and Marleau herself, were widely ignored. Perhaps it's worth re-reading now -- not least as a reminder of what Ottawa's job is, and why it ought to do it.
Steven Lewis is president of Access Consulting Ltd. in Saskatoon and adjunct professor of health policy at the University of Calgary.
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