Tuesday, June 13, 2017

A Few Bad Apples?

I've been working a locum this month, hence less blogging than normal. But I couldn't avoid sharing my 2 cents on this one.

Anyone with an interest in health care and health policy has probably read the Globe and Mail's recent investigation into private medical clinics in Canada. It's an excellent piece, and coming from the more centrist and staid Globe, might carry more weight with the movers and shakers than an investigation by the Toronto Star, which is often too anti-doctor for its own good. The nuts and bolts of the issue is this:

In Canada, any service paid for by the provincial health insurance (Medicare) plans cannot legally be offered or paid for privately. The only exceptions to the law are seen when the medical service is funded through a third-party insurance plan like Workman's Compensation, or the patient is a non-resident of Canada and therefore not covered under Medicare. 

Fees to access a medically necessary service, like a membership fee at a clinic, or charges over and above what Medicare pays the doctor and facility (extra billing) result in dollar-for-dollar clawbacks in transfer payments from the federal government to the provinces. These are the penalty provisions of the Canada Health Act, and every province has its own law outlawing user fees and extra-billing to comply.

The Globe found that private clinics - most of them doctor-owned - and many of the doctors that staff them were committing all sorts of acts in violation of College of Physicians policies, extra-billing laws, user-fee laws...if there were a way to violate the spirit or the letter of the law in pursuit of a buck, the Globe found a clinic guilty of it. To make matters worse, the various regulators have been slow to react (if at all). All the while, patients of modest means have been charged large sums of money for services that should be covered in a timely manner in the public system, without the need to fork over a dime beyond their taxes and hospital parking fees.

There's been the usual chatter and umbrage, in the press and on social media. And make no mistake, what's going on is indefensible. To shake down desperate people for thousands of dollars to jump the queue, then paint yourself as a crusader against wait times, is more than a little galling. Then again, we should be no less upset at regulators that have been asleep at the wheel.

I don't see a point in directing my personal disapproval at these doctors or their facilities. I don't have all the facts, it's not my job, and I'm in no position to cast the proverbial First Stone. Instead I'd like to look deeper than the immediate malfeasance, because this sort of thing will happen again and again, no matter how much regulation is put in place.

The first thing to point out is that the private clinic problem constitutes a tiny number of clinics across Canada, and fewer than 1% of the nation's 80,000-some doctors. It's not to forgive it, but this is not a case of system-wide dysfunction or corruption. These clinics could all be put out of business within a day, and it would be back-page news.

And to those who might paint the entire profession with the same brush, I got news for ya: the rest of us hate this too! There is nothing more annoying to conscientious doctors than more regulation, more oversight, and more paperwork, all on account of a few unscrupulous operators. And when these headlines come at the outset of doctor-government negotiations? How much leverage is lost in an instant?

Ultimately, private clinics - whether you see them as out to gouge people or simply providing a service that's in demand - are a symptom, not a major problem in and of themselves. No, the problem is that the health care "system", to the extent that it can even be called a system, is built atop a rickety and obsolete insurance plan, nothing more, nothing less. It was never intended to be all things to all people, and 60 years of experience has proven that health care does not obey the ordinary laws of supply and demand. That we do as well as we do, running above capacity at all times, is a testament to both the quality of the health care workforce and the robust Canadian economy footing the bill.

There is no singular fix to the problems of health care. In business, there's the old adage of "good, cheap, or on time...you can have two". In health care, we're apparently shooting for: comprehensive, evidence-based, modern, accessible everywhere, accessible every-when, equitable, timely, patient-centered, efficient, affordable, accountable, and sustainable. The logical impossibility would be laughable, if it weren't for so many health professionals burning out from trying their damnedest.

Our policymakers almost never sit down and decide on a singular, meaningful effort at reform, think it through carefully, fund it adequately, and stick to their guns when the hiccups inevitably arise. It's just a never-ending stream of pointless and half-baked initiatives in a thousand different directions, dreamed up by political staffers who can't see past an election cycle, planned by people working in a sclerotic bureaucracy rife with groupthink and rigid hierarchies, and executed by hard-working professionals whose feedback goes completely unheard. Why? Because the scammers give all of us - doctors, nurses, everyone - a bad name, and give the politicians every pretext not to listen.

So where do we go from here? We hope that the conversation doesn't stop at a regulatory crackdown on private clinics. Rather, we should have a careful and nonpartisan national dialogue, on what people should expect of the health system, demand of the health system, and contribute to the health system.

1 comment:

  1. Yes, a national dialogue is needed. I believe that doctors without conscience is a bad thing, but the CPSO disagrees. The CMPA requires it, from what I can see.