Should Canadians be able to use after-tax dollars to purchase health services that are already covered under the provincial health plans schedule of benefits?
F or those opposed to private, for-profit solutions, the evidence seems so clear-cut, debating it feels like arguing over whether water is wet. All the same, the debates continue in the media and in our living rooms and legislatures. No side is able to deliver a definitive knock-out blow.
An important aspect often unexplored in these debates is the vulnerability of patients in a system that encourages for-profit delivery. In particular, almost no one mentions the costs and difficulties of creating appropriate levels of active oversight to prevent them from being exploited.
In the past several months I have personally been approached by several individuals whose experiences suggest that some providers may be playing fast and loose with the rules governing publicly-funded, but privately-delivered care. The most recent example is from a good friend, now in his eighties, who was referred by his optometrist to an ophthalmologist for cataract surgery. During his appointment with the surgeon, my friend was told:
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he needed the surgery,
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he’d have to wait 9 months for the operation in a hospital;
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the surgery in the hospital would be free, but he’d be out of pocket $400 for the “right” lens for him; and
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if he preferred, he could pay $1500 and have the operation in 2 weeks at the surgeon’s private clinic.
I found out about this at a weekend chamber music get-together. My friend wanted to share his story with someone who knew about the health care system because he felt something wasn’t quite right about what he had been told. Subsequent information gathered on his behalf over the next few days, only confirmed my initial suspicion that this patient was being manipulated for gain.
Did he need the surgery? All day Saturday, my friend played his violin and was both delighted and rather surprised to find he had no trouble reading the music. In fact, he was so encouraged by this he thought he might even be able to wait for the “free” care. My thoughts turned to research by Dr. Charles Wright suggesting that cataract surgery might be offered “prematurely” in some cases – his study on elective surgery outcomes in the CMAJ found that more than one-quarter of patients (27%) reported either no change or being worse off after the surgery.i Was my friend being sold on a surgery before he really needed it?
Was the wait for “free” surgery really 9 months long? Popular doctors often have very long wait lists, but patients can often receive faster service by switching to practitioners with more room in their schedules.ii This option was not discussed with my friend. When I checked on-line, none of the hospitals or clinics had wait times anywhere near 9 months.iii For August-October 2007, the shortest wait in his geographic area was 73 days, the longest 161 days, with an average wait of 116 days. If he was willing to travel to other towns, even faster service was available– several hospitals reported waits of 5 to 8 weeks. But no one told my friend about these options, either.
Were there alternatives to the $400 lens? While it is perfectly legal to charge for an intra ocular lens that is not covered by OHIP, every practitioner is also honour-bound to offer a fully-covered alternative. The failure to do so is against the rules.
In Alberta, a report issued by the Consumers’ Association documented wide variation in the fees that used to be charged to patients for these “enhanced” lenses depending on where they lived and which surgeons they sawiv, and raised questions about their actual therapeutic advantage. In Lethbridge, for example, patients were fully covered for both types of lens, but in Calgary and Edmonton they were often offered the option of paying for the “foldable” one. Wanting to end the controversy that emerged over this issue during an election campaign, the Klein government ultimately extended full coverage for both types of lenses.
Isn’t charging patients directly for faster access against the law? In a word, yes. Offering the operation in two weeks in exchange for $1500, is completely illegal in Ontario, and indeed in the entire country. And yet who monitors such practices? Are patients entirely on their own when it comes to understanding the fine points of what’s allowed and what isn’t?
It gets worse. Although we discussed all of the points above, in the end he returned to his optometrist whom he likes very much and trusts completely. When he told her his concerns, she referred him to the same surgeon again -- only this time, to a non-profit clinic, yet another location where the surgeon works. I’m still sputtering at this. Why would she refer him to the very same doctor who seemed so eager to perform a wallet extraction? Why couldn’t she have suggested someone else when there are dozens of surgeons performing this operation locally? I can only think of one reason and it is not a very flattering bit of speculation. Was this optometrist getting a finder’s fee (also known as a kickback) for her referrals?
To avoid putting vulnerable patients in exploitive situations, we’d do better to focus on improving non-profit and/or public models instead of turning to the private sector. After all, we don’t just want access to any kind of health care, we want access to appropriate (meaning needed, safe, high quality) care. Debates about private sector roles are only distracting us from a far more urgent agenda: to improve the system’s safety and quality.
links to other presentations on this or related topics
references
i Wright, Charles J., Chambers, G. Keith, Robens-Paradise, Yoel .Evaluation of indications for and outcomes of elective surgery. CMAJ 2002 167: 461-466
ii . It’s important to emphasize that there is no objective information about the relative quality of care offered by surgeons with short versus long wait times.
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