he role of private care within Canada’s health care system is evolving. Health care is not static and it must adapt in order to accommodate changing demographics, new scientific and medical advances, and financial realities. The option of using after-tax dollars to purchase health services already covered under provincial health plans’ schedules of benefits has potential to help Canada’s sagging health care system overall. The need for a hybrid Canadian system should be considered at two levels; at a financial level and at an emotional level.

At a financial level the sustainability of a one-tier health care system with the only provider of medically necessary care being the public purse is in serious doubt both currently and in the future.

Costs to provincial health care systems have been rising by roughly 7% per year across Canada despite efforts at finding efficiencies. Provincial health care budgets are taking up more of the total provincial budgets across the nation.

Close to 50% of most provincial budgets now goes to health care. As health care consumes a greater percentage of financial resources, there is less government funding available for education, social programs, aging infrastructure including bridges and roads, sewer and water systems, and environmental projects, all of which impact overall health and well-being of Canadians.

This does not mean that health care should continue to be rationed as extensively as has occurred to date with resultant shortage of providers, treatments denied on the basis of cost-effectiveness, and wait lists that last months and even years instead of days or weeks. It means that other revenue streams for health care in the coming decades must be found as the volume of services and volume of treatments required exceed government’s ability to fund them. Other OECD countries have managed very well to combine public systems with options for private care without the serious wait times and human resource shortages that Canada’s monopoly system helped to create and which it continues to experience.

The ability to fund all medical care for all patients does not exist in Canada now. In cancer care alone, new expensive medications for some cancers have the potential to make what were once terminal illnesses into chronic diseases with expensive treatments provided for years. In some provinces, this care is denied through the public system. Patients with inherited metabolic diseases such as Hunter’s disease are refused funding for expensive new treatments now available. Autistic children in some provinces wait on lists until the treatment they’ve been waiting for is no longer effective. It is clear that our Canadian system is failing many patients and that the concept of one-tier universal care is pretense.

Private care can partially buoy up the public system by removing the burden of having all medically necessary care covered by it and freeing up more coverage for the sickest and most vulnerable patients through the public system.

The current reality is that health care in Canada is not universal or comprehensive or necessarily accessible as the principles of the Canada Health Act would imply. There simply is not sufficient funding to do this with ever increasing numbers of treatments and technological advancements with seemingly infinite demand.

Some people believe that the growth in Canada’s GDP will be sufficient to offset the growing costs of health care in the future. But our aging population has not even begun to crest with its shrinking tax base and the full impact of this will not be seen for twenty more years. We are only beginning to climb uphill in terms of health care. Despite 2.5 million more immigrants over the next few years, the dependency ratio is not likely to improve and our productivity as a nation is at risk. Ontario in particular has seen a decline in its economy recently. Canada also lags behind other nations in innovation and this will be a concern for long term economic output. Counting on increases in GDP over the long term to save our monopoly system could be a very serious mistake. More flexibility as provided by the option of private care is needed.

Allowing more private care within Canada would have the potential to improve innovation and provide motivation for individuals who understand how to satisfy Canadian need for efficient health care, including chronic care programs and preventative care programs, and new screening modalities.

It is not surprising that Canada has dragged its feet in establishing health IT infrastructure that could be helpful in achieving more efficiency. The funding required to initiate such a system and to maintain it will be significant as indicated by the UK experience. It is also difficult to justify spending millions on health IT, which could become billions, when patients cannot get the care they need now.

The ability of our health care system to adapt to the changing medical environment will be enhanced with more private provision of care. Private providers who take the risk to innovate and to provide care to patients efficiently will enhance the overall health care system by providing templates for care and even a mirror for the public system to examine itself in a more accountable way. It is well known that large, cumbersome bureaucratic systems have more difficulty adapting rapidly to change. Smaller, more nimble organizations are adept at responding and the pace of change in health care and science has never been quicker than it is now.

In the future, new industries are likely to develop around the use of genomics to screen patients for disease and for inherited genetic susceptibility to various disease processes. New medications will also come available based on increased genomic understanding. This has already begun for some types of cancer where better result outcomes and avoidance of adverse effects have been accomplished by choosing one drug over another based on genetics. But this comes at significant cost and the adoption of new programs and new medications will be limited by finite government funding.

Will all of these new developments only be available to those who can pay as our government monopoly system ceases to add new tests or new treatments to its schedule of benefits? A better solution is to provide these options in a publicly funded system while allowing more private provision in other areas as patients and their families see the need. This will require Canadians to embrace the concept that paying privately for one’s care is acceptable and as long as benchmarks for treatments and procedures are maintained in the public system, more patients will receive care in a way that is acceptable to them.

Private health care has a role to play in empowering patients in their own health care beyond the dependency of a public monopoly. Participating financially with after-tax dollars will be necessary as our population ages. Aging itself is not a significant cost to our health care system but the accompanying treatment of chronic diseases including cancer, diabetes, joint disease, cardiovascular disease, visual disorders, renal disease, Alzheimer’s disease, mental illness and cost of long term care will all make demands upon our system as never seen before. The epidemic of childhood obesity that Canada is experiencing now will translate into chronic diseases of the future which will all require funding. Prevention alone is not likely to put off the aging process to which many of these diseases and treatments are so closely connected. Patients must be empowered to help themselves where possible and private care will need to play a role.

At an emotional level, the question under consideration often receives a knee-jerk reaction. Claims of “two-tier medicine” ring out loudly and clearly from a variety of sources. The reality is that there are already many tiers of care in Canada. A one-tier system does not exist. The idea that care should be based on need and not ability to pay is a good one but a “free” system that one dies waiting to access or which refuses you required care after many years of funding through your personal taxes is of questionable value. It is estimated that millions of patients across Canada do not even have access to a family physician.

As for the fear of profit within medical care, all providers must make a profit whether they are health care providers or bandage makers. It is not “for-profit” care that drives up cost necessarily but the levels of bureaucracy that are inherent in large institutions, whether it be within a government funded health care system or an insurance company. Minimizing levels of bureaucracy is necessary to improve efficiency and private providers are well-suited to do this particularly in a setting of competition.

Fears that privately paid medical care will siphon doctors away from the public system are also unfounded. In 1970, shortly after public health care was introduced, Canada had one of the highest physician to population ratios in the developed world. Almost 40 years later, Canada has one of the lowest. The reality is that our shortage of providers has occurred in part as a result of our monopoly system which uses provider numbers to control access and hence costs to the system. Now that a shortage has clearly been identified, medical school positions have been increased significantly across the country and plans to use alternative providers and physician extenders are in progress which would need to continue if and when more private care is permitted.

In addition, physicians are a diverse group with some believing staunchly in public provision only and others with a perspective of a balance of public/private provision. As long as physicians are given the freedom to practice in both systems, a balance is very likely to be achieved.

Unfortunately, in Canada we have developed an attitude of “saving the system” instead of “saving the patient”. We need to find a better balance of tolerance and compassion within our health care system where the sickest and most vulnerable patients receive developed world care and this includes private provision of medically necessary care. Patients who are in the minority with rare diseases or unusual medical conditions or circumstances should not be pushed aside to preserve a fictitious one-tier system for the majority as is happening now in Canada. Let those who are able and willing to pay for their own care, do so to enable more public care to be provided for more patients.

If Canada is to move forward into the coming decades with a strong public health care system, the benefits of private care alongside a publicly funded system must be understood. Demonizing individuals or groups based on distinct belief systems should be avoided if we are to find the necessary balance in health care for future generations.

Most often, solutions are found through compromise.

links to other presentations by Dr. Fullerton

• Reducing MRI, CT Scan Wait Times