Canada Health Coalition

The CHC published a report this week on the private clinics of Canada. They used anonymous telephone calls to multiple private or semi-private clinics throughout Canada to garner information as well as publicly available information. The study excluded clinics for purely non-necessary medical care (e.g. cosmo clinics) but did include mixed clinics. For instance, some are private but also under contract to a provincial government to provide care as stipulated under the Canada Health Act.

In a nutshell, the Canada Health Act, states that any "medically necessary care" will be provided through public funds. If a province allows private clinics to provide "medically necessary care" for profit then the transfer funds from the federal to provincial governments will be cut by that amount. Eg. people pay a total of 500,00 for private care then the public purse is cut by that amount.

The debate is what constitutes a violation of the Canada Health Act. Enforcement is also variable and subject to the reigning government's belief on private pay care. The report details which clinics exist, which "violate" the act and how they "violate" it.

The CHC also draws conclusions about the impact private care has on health care personnel supply and wait times. They've concluded that it adversely affects both. From a purely scientific point of view, I found the study design of low quality* (anonymous phone survey) and highly biased so I think they've over-reached with their conclusions. I think private clinics have been in existence for too short a time and in too limited a capacity to draw any real conclusions about wait times or their impact on personnel. We could also look to a mixed system such as the UK to get a better assessment of the impact.

That being said, it is a reasonable cross sectional survey of the current situation in Canada and worth a read.

*the asked the front desk person how the clinic used public pay systems. "do I need to bring my medicare card", etc... while biased they also write the text of the coversation so the reader can judge for themselves if the conclusions are warranted.

Carbon Taxes and Health Care User Fees

What do carbon taxes and health care user fees have in common?

The Liberal Party of Canada has announced the Green Shift. A tax shift program where industry is taxed based on the amount of carbon it produces. The increased cost incentivizes' companies to find production solutions with a lower carbon footprint. The additional costs to the citizen are compensated through lower income taxes and tariffs are placed to equalize the playing field for non-Canadian companies.

Not surprisingly, the concept is not sitting well with Canadians. In a time of economic turmoil, it's an inopportune time to suggest a new taxation system.

It raises an interesting contradiction in the Liberal Party platform (as well as the Green Party since the agree with the strategy). The carbon tax is social engineering through taxation. Conceptually, there is little difference between it and health care user fees.

Health care user fees incentivize people not to use the health care system. Where there is abuse and overuse the effect is positive. Where there is poverty and marginalization the effect will be horrific. I wonder whether the same would apply to the carbon tax?

Where companies are operating with willful disregard to the amount of carbon produced, in markets where the margins are thick and the competition weak there is no excuse for not lowering emissions. Where technology is lacking, margins thin and competition fierce the carbon tax will cost jobs.

Without taxation, we cannot be strong as a nation. If we hand over the basis for taxation to whatever elected officials declare the latest cause do we run the larger risk of wild fluctuations in revenue? One could equally argue that taxation should be based on homeland defense, obesity, crime rates or any other key issue.

The larger question is do we, as Canadians, want to leverage our tax system to the vacillating opinions and priorities of elected officials.

Health Care Debate Overshadowed by the Economy

In both the United States and Canada debates were held on Oct 2, 2008. I was torn as to whether to watch the Biden/Pallin debate or the Canadian Leaders debate. With the train wreck of an interview Pallin gave to Katie Couric wetting my appetite I wanted to watch the most public I.Q. test ever given.

Alas, my civic duty overshadowed my voyeuristic streak and I watched 5 Canadian Leaders duke it out on National T.V. The video below (in 2 parts) is the health care portion. For international readers, here’s a quick civics lesson.

Canada has a parliament with the Prime Minister being the leader of the majority party. Currently that’s Stephen Harper of the Conservative Party of Canada who, prior to elected office, had been a staunch advocate of privatization of Canada’s health system. The other parties are the Liberals, Green Party, Bloc Quebecois and the NPD. The Bloc is a separatist party from Quebec so they argue most issue’s with Quebec’s interest in mind exclusively where they allow private clinics. The other 3 parties (Liberals, Green and NPD) have come out against private health care.

The Liberals, Green and NPD came out swinging against Harper. Accusations were made that the Conservative's main intent is to allow big businss into health care. There were a couple verbal punches thrown but in the end this is how I saw the facts. All the parties seemed to agree that:
1. excessive wait times and scarce resources are a genuine problem in Canadian health care and not just another political scare tactic
2. many of the problems stem from when the system was underfunded in the mid 1990’s which cut doctors, nurses and hospitals
3. some provinces allow private clinics more than others so there are regional differences in access to care
4. lowering wait times, adding pharmacare and improving access to doctors cannot be accomplished without increasing the health care budget

The Liberals, Green Party and NPD seem to stand united on this issue in their health care platforms. They believe that universal health care means not only a public purse for health care but restrictions on private care to maintain uniform access.

To solve the problem, the Liberals and NPD want to increase funding. The Green Party is looking for cheaper alternatives (e.g. restructuring health care education, expanding multidisciplinary teams, increasing community health, etc…). The Conservatives have slowly increased funding and transfers to the provinces. The have also taken on a few initiatives such as wait times funding, increased electronic health record funding, cancer care and increased spaces for new doctor training as was agreed in the 2003 Health Accord between the Federeal and Provincial governments (not all of the agreements have been met leading to accusations of broken promises).

The 1,000 pound gorilla of course is how and where privatization will creep into the system under Conservative leadership. Both Harper and his Minister of Health Tony Clement have been previous proponents of it and the Canadian Medical Association has just elected a president that runs several private MRI/CT centres in Quebec. Obviously a change is in the wind.

My take on this is that the current situation cannot go unchanged and no-one has the stomach to increase taxes. I believe Harpers' intent is altruistic in that he wants to improve our health care system, even if it does include private care. The Liberals, Green Party and NPD have given scant evidence to the manner in which they will fund health care. During the debate, Elizabeth May of the Green Party seemed to suggest that simply enforcing the Canada Health Act would solve the problems; if it were so simple.

The only alternative left is to allow some privatizations’ (or user fees, which no-one supports) so that people can choose to direct more of their own money to health care. The down side could be that care may become more expensive* as stake holders take their share of the revenue. Another potential downside, could be loss of control over the degree to which we privatize. As a recent NAFTA law suite has shown, opening the door to privatization may also open a can or worms for US health care companies looking to profit in Canada.

Conservatives, at least, have made slow, plodding decisions to improve care and access and I cannot argue with the method so far. I would ask Mr. Harper to apply this litmus test to any change. If a mother is deciding whether or not to take a sick child to the doctor she should not have to consider whether or not the family can afford it.**





*even though there is greater distribution of the revenue in a private system my estimate is that private is roughly twice as efficient as public.
**interestingly mothers make the choice every day now because access is so limited it means a lost day at work almost every time as they wait in clinics.

The Conservative Health Care Plan

In the third part of my series on Canadian Health Care policy I’m discussing the Conservative party platform. Where the Green party’s platform was detailed but unrealistic (I would argue unobtainable), the Liberal party’s was non-existent the Conservative’s have made there health care plan an extension of their current time in power.

The platform is relatively straight forward. The conservatives have pledged to fund patient wait time guarantees, improve cancer care, continue investment in healthcare IT through Infoway Canada (created under the previous Liberal government), reduce toxic chemicals and funded increased positions for physician training.

The subtext, however, is a little more complicated. The reality of Canadian heath care is that access is limited at the discretion of the doctor or hospital depending on need (or occasionally who you know). The current Minister of Health for Canada was the previous Minister of Health for Ontario; Tony Clement. In his role as the provincial Health Minister he earned the nick name “Two-Tier Tony” by allowing privatization of clinics for MRI & CT (which where subsequently bought back by the next government).

Under the Canada Health Act billing for services that are insured under the public purse and/or extra billing is illegal (for a detailed discussion click here) punishable by loss of transfer funds from the federal to provincial governments. The federal government exercises’ it’s power by decreasing transfer payments when provinces allow dubious billing. However, penalties are rarely enforced and much smaller than the benefit from doing the practice. Unless, Provinces discourage the practices or there are federal penalties they can go on legally.

One could argue that the patient wait time guarantees encourage private clinics in order to meet the wait time mandates. Certainly, previous statements from the Conservative party lead one to believe that something will change. In my opinion, the current system is unsustainable without increased funding. The Conservatives are being forthright in their disclosure on how they plan to obtain that funding. I think user-fees would be a better route (because it would decrease use and increase funding) whereas private clinics increase funding but limit public health care personal hours. Still, other parties are promising the world with little substance to how they’ll deliver.

Are Private-Public Alliances the Cure for Canada's Ailing Healthcare System

The incoming head of the Canadian Medical Association , Dr. Robert Ouelett gave his inaugural address to 400 of the 67,000 physicians he represents in Canada. Dr. Ouelett envisions a private/public mix of physician services where surgeons, for instance, provide 90% of their services in a public system and 5-10% in the private.



Dr. Ouelett's position however is not without bias. He currently runs several private radiology clinics in Quebec, where they have benefited from the de-facto ban on such clinics in the neighboring province of Ontario. Ontarians have had to make the trip across the border to jump the queue for faster CT's and MRI's at private clinics like those that Dr. Ouelett runs.



The truth of the matter is that health care wait times and family doctor:population ratios have not seen significant improvement for many years. There is also good evidence that private clinics provide care with greater efficiency, albeit at greater cost. A change is required and Dr. Ouelett is a harbinger of things to come for the Canada Health Act.



The fall will likely bring a Federal election, and if the polls are to be believed, a Conservative government who is more friendly to private enterprise in the public health care system. Canadians will then have to make a choice between higher taxes, greater user fees, private clinics (owned by physicians) or private enterprise clinics (with non-physician investors).



While I agree with Dr. Ouelett's assessment that change is needed I fear that a private-public mix will generate greater inequality to the system. Canadians have been able to pride ourselves on the fact that care is rationed out with greater equality than other systems. The questions is, are we willing to fund the system so that the quality of care matches the same standards? As access to care retreats and quality suffers there will be a far greater cry for privatization than we are hearing now. The real question is how will privitazation manifest itself in Canada?

Birth of a New Industry

The Ottawa Business Journal is reporting on Wait Time Insurance.

"A new health-care insurance plan that sends Ontario residents waiting for public treatment to out-of-province private clinics". The intent of the plan is to "cover the cost of transportation and treatment costs for policyholders forced to wait more than 45 days for treatment in Ontario's public system"

Even though Canada is a combination of private and public funding, health care clinics and doctors are not allowed to operate in both for insured services. For instance, it would contravene the Canada Heath Act to see private patients in your clinic Mondays and Thursdays and public patients Tuesdays and Fridays (Wednesday is for golf). Physicians have to either opt in or out of the system for insurable services. A more relevant example is MRI clinics. In the same way, they either have to be completely private or public.

Where the wait time insurance kicks in is to cover the cost of people going outside of Ontario. Private MRI's and CT's are discouraged in Ontario because the current government views them as a threat to the public system and has vowed to shut them down. To this end, it is difficult to get a radiation safety certificate for a new CT or MRI machine and there are few (if any) private clinics left. But if you cross the border into neighboring Quebec, private MRI clinics are readily accessible.

Where things get complicated is in the regional differences. For instance the previous Ontario provincial government viewed private diagnostic imaging as the salvation of Ontario's system (shortly after they where thrown out and the new government began shut-downs) but Tony Clement, who was the provincial Minister of Health (and orchestrated the private clinics) moved to the Federal Minister of Health seat. Not surprisingly, life has gotten easier for private clinics across the country.

Similarly, certain provinces will allow private clinics (and register them) and others will not. Some provinces allow private insurance and others will not; you will notice that the firm providing the wait time insurance is based in Alberta, Canada where private insurance is legal.

So a seemingly innocuous story about some minor insurance turns into one major symptom of the problems in Canada's health system. The tenants of the Canada Health Act include portability, universality, accessibility and freedom from charges for insured services. Where one government demonizes private clinics another allows them which creates greater regional disparity. Those differences, are at odds with the concepts of the Canada Health Act.

In the end, most of Canadian Health Care, including hospitals, are private not-for-profit entities run by community boards but publicly funded. We are not truly socialized where physicians and nurses are employees of the government. I think that will be the loop-hole that facilitates greater private coverage through federal legislation. The writing is on the wall that exclusively publicly funded health care does not meet the demands of the public so funding will have to increase. Whether that funding happens through private or public means is at the discretion of the provincial governments but I think the federal government intends to make the choice between the two easier.

Nova Scotia Moves to Private Facilities

In a move to decrease surgical wait times Nova Scotia is moving some elective surgery to private centres to decrease waiting lists. See the Chronical Herald OpEd piece by the premier for the politcal spin and the Canadian Free Press piece about what is happening. I'm not sure how I feel about this. From a personnal point of view I have a year long waiting list for OHIP (public sector) covered surgery and if I was able to do it in our own surgicentre it would be done within a month.

On the other hand I think it's an end-run of the Canada Health Act and is a step towards privitization (albeit much more efficient than the current facilities). Enjoy the read.



Ian