October 4, 2012

The Medical Post

By Dr. Vanessa Brcic

For-profit care is not the right direction for the health of all Canadians

As many of us are aware, controversy is brewing over the Cambie Surgical Centre in Vancouver.

The British Columbia Medical Services Commission recently found that Cambie charged patients nearly half a million dollars in illegal billings over just a 30-day period, including $66,000 in double-billing to the Medical Services Plan (MSP). Dr. Brian Day, the owner of this for-profit surgical facility, refuses to stop these illegal billing practices. He argues—despite the law stating otherwise—that his patients have a constitutional right to buy their way to the front of the line.

This is a big claim that undermines the core foundation of our public health-care system that allows us to triage patients based on medical need, not on ability to pay.

It is undeniable that medicare is underfunded for some services (but not for most), and that some patients are waiting too long for procedures. It is true that medicare is not living up to its full potential, and we need to change that. It is also true that Dr. Day has great determination and skill in developing a for-profit delivery model. But we have no evidence of whether this model is efficient or whether it delivers quality care. Privately held companies are not publicly accountable, so the outcome data from Cambie are not available for critical peer-review and analysis.

And even if Dr. Day’s for-profit model was found to be efficient and to provide high-quality care, that does not mean we need to question the foundation of our public health system and introduce a two-tiered, profit-driven system in B.C. Instead, why not integrate these alleged efficiencies into medicare? Since when do doctors run away from the system that pays them, and pays them well, instead of trying to improve it? I suppose since they realized they can make millions doing so.

There are important reasons why these billing practices are illegal. Charging patients more than the approved MSP fee schedule is a violation of both the B.C. Medicare Protection Act and the Canada Health Act. Although Dr. Day says he is advocating for people suffering on wait lists and for personal choice, he also stands to make millions by continuing these billing practices. The profit motive can’t be ignored.

Cherry-picking

As a family physician, I know how the game works: In a fee-for-service system, I will make more money if I avoid patients with complex-care needs, chronic pain, multiple comorbidities, patients in poverty, frail elderly, patients who are “non-compliant,” the list goes on. Simply put, I make more money if I treat healthier patients with one problem per visit. But that doesn’t mean I should do so for my own financial gain. It also doesn’t mean that I should call into question the laws that deter doctors from cherry-picking certain patients to enhance their profit margin.

International evidence shows that in a two-tiered system, patients with less money but more pressing health-care needs will wait longer for surgery than healthier, richer patients paying to get to the front of the line. Why? Profit-driven delivery models lead to faster (and usually not better) care for a select few, while everyone else waits longer in a system that is drained of doctors and nurses. The public system is further burdened by a caseload of higher relative complexity after the wealthy, healthier and less complex patients have been skimmed out of the system.

We must remember that medically necessary procedures are generally covered by provincial insurance plans, paid for by our tax dollars, whether they are delivered through public, not-for-profit settings or private, for-profit settings. But it costs more to deliver the same care in for-profit facilities. The Workers’ Compensation Board of B.C. “paid almost 375% more ($3,222) for an expedited knee surgery performed in a private clinic than for a non-expedited knee procedure in a public hospital ($859),” according to a study published in the August 2011 Healthcare Policy by epidemiologist Dr. Mieke Koehoorn (PhD) of the University of British Columbia and colleagues. Yet the return to work of those treated in the public system was marginally better.

There are two paths for medicare: the path where the wealthy few get speedy care, and the rest of us wait longer, or the path of solidarity we’ve already chosen, where we care for each other based on our health needs, not our ability to pay. We should continue to choose our public medicare system and speak up to make it better—it’s not only the most equitable path, it’s also the best deal in town.

Dr. Vanessa Brcic is a Vancouver family doctor and an executive board member with Canadian Doctors for Medicare

Tags: for-profit care private delivery Vanessa Brcic Brian Day