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A Snapshot of Private Healthcare in Canada
By John G. Smith, Executive Vice-President, International PET Diagnostics Inc
As readers of Macleans Magazine will know from its recent special report on private health care, private medical care in Canada has come out of the closet. The "Users Guide to Private Medical Care" in Macleans May 1st Special Edition describes the "relentless march of private health care across the nation."
For example, The Copeman Healthcare Centre has a private clinic in Vancouver, with plans to expand in other Canadian cities. For an up-front fee and annual fees, patients can buy a health care package including unlimited visits to family doctors and access to health professionals on a 24-hour basis. Copeman emphasizes the aspect of comprehensive preventative healthcare. Here patients are paying for access to family doctors - a monumental change in the Canadian healthcare scene.
Private clinics are rapidly increasing the options available to patients. What used to be limited to after-hours MRIs and cosmetic procedures has morphed into a dynamic, multi-faceted industry providing a host of treatment opportunities. Among recent developments are: Cataract MD, with plans for clinics in Ottawa and Vancouver, where a 34-week wait for cataract procedures will be eliminated; Clinique Medicale MD-Plus in Montreal, the country's first private emergency clinic; and the Westmount Square Surgical Centre in Montreal and the Cambie Surgical Centre in Vancouver which have added or soon will add knee replacements to their menus.
DRIVING FORCES
Three things are driving the private heath care industry:
First, the Chaoulli case has, at least partially, established that legal impediments to private health care can be trumped by the constitutional guarantees provided by section 7 of the Canadian Charter and similar provisions in the Quebec Charter. So the private sector is feeling more confident about its position, particularly in areas where there are unacceptable wait times.
Secondly, people are getting fed up. Every day there are anecdotal examples in the press of poor public service. There is a significant move towards patients taking charge of their own health problems, and a drive towards a culture of wellness preservation rather than sickness treatment. Patients are not getting what they need/expect in the public system and are looking for alternatives.
Thirdly, it is a matter of supply and demand. 875,000 Canadians are today waiting for medical treatment. Health care consumes more than a third of provincial revenues, threatening to rise to 44% by 2020. Medical expenses are going up by $5 billion a year, but waiting times and other improvements to health care (e.g. new technology) are not happening. After thirty years of adherence to the policies enshrined in the Canada Health Act, where bureaucratic edict rules in place of market discipline, the current public health care system is unsustainable.
The entry of private health care into the breach in Canada is not surprising if one looks at European and other countries' examples. What is different is that in European countries and, for example, Australia, their national systems provide specifically for the participation of the private sector in the provision of health care, using various incentives to encourage the use of the private sector system. There are two basic types of involvement of the private sector: a) where private providers of health care work side by side with public institutions within the publicly financed system, with both being publicly funded; and b) where private health care is both privately provided and privately financed, by having patients privately pay for procedures at private hospitals, or through private insurance plans, such as BUPA in England. In Canada there is no official system for the involvement of the private sector in the provision of health care, but it is happening anyway. There is no regulatory system, scheme or national policy to control it. It is unplanned and uncontrolled, but it is happening anyway, because of market demand.
The defenders of public health care, instead of seriously addressing the challenges of delivery of health care in time of need, are dividing Canadians. Five years ago, there was hostility towards "for profit" health care. Our health care system was a National Icon - part of our Canadian Identity. Prime Ministers Chretien and Martin fostered this attitude, and called on symbolic politicians like Romanow and Health Ministers like Dosanjh to defend the faith. Then the government propaganda machine began to be counteracted by Senator Kirby's Report, groups like The Fraser Institute, and some Press pundits. These, together with the Chaoulli Decision by the Supreme Court of Canada in June, 2005, have moved the public view to where it is today - confused but dissatisfied, and aware that there are choices to be made.
A GENERAL OVERVIEW OF PRIVATE CLINICS
A word about the phrase "private clinics". There are clinics which are private "for-profit" clinics which bill the government for all services. The Clinical Eye Centres in Alberta, the Shouldice Hospital in Toronto (where Jack Layton apparently didn't realize it wasn't a public facility when he availed himself of its services), and diagnostic labs such as MDS labs in BC are entrenched in the public system. If the government pays the bill, it's part of the public system. You pay with your health card. When I refer here to private clinics, I define them by reference to who pays. If the patient pays - for private care, for a diagnosis, or for faster access, it is a "private clinic".
1) Quebec
There are hot spots of private clinics across the country, Quebec and BC being the leaders. It is not by chance that the Chaoulli case came from Quebec and that the largest support groups for that case as interveners were private clinics in BC.
Quebec has the most comprehensive and advanced private health care in the country. It is the private health care capital of Canada. Over one hundred doctors have opted out of public medicine, compared to only a handful in the rest of the country. There are a variety of private cataract and radiology clinics, a private emergency clinic (Clinique Medicale MD-Plus), the Duval Orthopeadic Clinic, doing full hip replacements, MD Specialist, which does gastroenterology, a number of mobile medical services, several private family medicine clinics and executive health clinics. There are two private PET clinics in Montreal, both of which have state-of-the-art PET/CT scanners.
2) BC
In BC there are eye surgery centres, MRI and/or CT clinics, and free-standing surgical facilities offering procedures in orthopaedics, urology, gynecology, and general cosmetic, vascular and oral surgery. The Cambie Surgical Centre is the largest and most technically advanced private hospital in Canada. BC is also home to the Specialist Referral Clinic at which Canadians from anywhere in the country can book an appointment with a specialist without the need for a referral. Also, CIMCA originated in BC.
3) The Rest of Canada (less Ontario)
There is one private surgical facility in Manitoba, and a number of medical imaging facilities in Alberta, Manitoba and the Atlantic provinces. Despite Premier Klein's public position of opening the province to private healthcare, efforts to open a fully private clinic in Calgary have not yet succeeded. Alberta patients who don't want to wait get referred to BC.
4) Ontario
The Ontario situation is fascinating. The Commitment to the Future of Medicine Act is an Orwellian measure. Private clinics are banned from charging for medically necessary services. Patients can be fined $10,000 for paying for them. Corporations can be fined $25,000, facilitating doctors can be fined $10,000, and anyone who knows it is happening and does not report it, faces a fine of $1,000. So don't tell your mother.
As I have indicated before, the escape hatch from all of this is provided by the phrase "medically necessary". In Ontario, an MRI may be medically necessary, but an expedited MRI is not. You figure it out. Sports Medicine, pain management, etc is privately available. So are PET scans at the CareImaging Centre in Mississauga.
The anomaly of the Shouldice Clinic, a private clinic which exclusively does hernia operations, (which are paid for by the public system), has existed in Ontario for decades. Also now in Ontario, there is the Provis Infusion Clinic, a private cancer clinic, offering therapeutic cancer drugs not yet funded by the private system and a couple of other prostate cancer clinics.
There are a couple of difficult statutory hurdles to contend with in Ontario when considering private clinics. The first is that, to establish a clinic that does anything more than straight diagnostic services, one has to obtain an Independent Health Facilities Licence, and the present Ontario Government is not likely to issue any to anyone new. This is the Government that decided it was wrong for the previous administration to have licensed independent MRI clinics, and bought them all back. There are private CT clinics elsewhere in Canada, presumably doing "unmedically necessary" CT scans. There are none in Ontario, because of the requirement for a licence under the HARP Act - the Healing Arts Radiation Protection Act - whenever a facility operates equipment that emits radiation, and the province is just not going to issue such a licence except to public institutions.
PRIVATE MEDICINE IS BREAKING OUT ALL OVER
Aside from the Chaoulli case, there is a fundamental basis in law for the provision of private health care in Canada. The Canada Health Act doesn't make private clinics illegal.
As provinces struggle with mounting health care costs, they broaden the list of things which they deem not to be medically necessary, including new expensive technology like PET or new uses of technology, like CT in Cardiology. The way things are going, "medically necessary" is becoming less to do with what is regarded "medically" as "necessary," and more to do with whether it has been put on or left on the list.
Dr. Brian Day, who is in line to be President of the Canadian Medical Association in 2007, likes to sum it all up this way:
"Canadians are looking to new treatments and technologies to keep them in optimum health and are happy to pay for what cannot be provided in the public system. That leaves an important role for private healthcare. The public sector doesn't have the resources to purchase and utilize these new technologies. This is an interesting and dynamic time in this country. There's an enormous sense of frustration with the public system. There are close to a million on waiting lists and these people are tired of putting their lives on hold."
- John G. Smith
Note: The CIMCA is preparing a thorough review of independent medical clinics in Canada. It is expected to be published in an upcoming issue of 'Health Frontiers News'.
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