The Myths of Private Medicine

Like most Canadian physicians, I have been watching the debate on healthcare in the US. In Canada, we have had public healthcare since the 1960s and earlier in some provinces. No system, no matter how well funded is perfect; if you get a group of docs in a room, it will soon turn into a support group on how badly their system treats them.

I treat chronic pain which is of course terribly underfunded across our country. I am also an anaesthesiologist and as such am entirely dependent on hospitals for that part of my income. If they close a room or if my cases are cancelled due to budget cuts or overruns, I earn no money.

There was been a lot of discussion in Canada on how a supplemental private system would help the crisis in public healthcare. This seems to based on a number of myths.

1. Doctors will earn a lot more in a private system.

That will be true for the doctors who own private clinics or who invest in private hospitals. It will also be true for a small number of procedurally based physicians who have procedures for whom patients or insurers will pay a lot more than is currently paid under Medicare (these people are largely already well paid under Medicare). For the rest of us, expect to get paid exactly how much or less than you would get under Medicare. Having established a benchmark for what we will work for, why would anybody pay more.

2. Unused public hospital space can be used in a private system on evenings and weekends to expedite surgery and tests like MRIs.

I wonder where they plan to find this unused hospital space? Our hospital is staffed to run two rooms all evening on week nights and all day on weekends. Everyday they scramble to find enough nurses to run the rooms. Likewise public MRI suites operate evenings and weekends to cover the demand.

And of course where are they going to get anaesthesiologists. There is still a shortage in Canada. Now if it was financially worthwhile, I might come in on Saturday to do some private cases, I actually did that once. Our workers comp board will pay an extra $200 per case for expedited surgery, so someone asked me if I wanted to do that and I did. I came in worked half a day and with the extra $800 for 4 cases it was like I worked a full day. If this became a regular gig however, I just might want Mondays off, so we would be short somebody on that day. In fact, in our city we have so many anaesthesiologists now anaesthetising boob jobs and wisdom teeth for big bucks that we have a shortage.

3. Rich people will pay more for the expedited service.

Rich people did not get rich by spending their own money; they got rich by spending other people's money. Every rich person I have ever treated without exception haS been the biggest cheapskate since the last rich person. I remember filling out forms so the wife of a local billionaire (with a hospital named after him), could have the medication I prescribed covered under the provincial seniors program.

Rich people don't wait anyway. They make a few phone calls and go to the head of the queue.

4. Healthcare costs are spiraling out of control.

I might believe this if I hadn't been hearing this for the past 25 years. If healthcare costs really had been spiraling out of control, they would now be consuming the entire provincial budget. They aren't. The problem for a politician if that the public now expects health care. I have always said that if a politician had a ribbon-cutting photo op every time somebody got a hip replacement, we would not have any wait lists.

In Canada we are offering services never dreamed of in the 1960s to a larger and older population for the same amount of money adjusted of course for inflation. And in fact most jurisdictions in Canada have been able to cut taxes!

5. A private option will inject more money into the system.

So you don't have enough money to fund a public system and your solution is to add a system that is way more expensive. If the orthopod is doing private arthroscopies on Monday, do you think he going to stop doing his public arthroscopy list on Tuesday? Also in Canada, medical expenses over a certain level are tax deductible. That means that depending on the tax bracket, patients who get private surgery or MRIs will be getting a certain percentage back in the form of lower taxes. As private medicine will be more expensive, once the tax deduction is taken into account, the private procedure may well cost as much or even more than the public procedure. We also have to take into account the fact that many people who get private procedures are people who would possibly not get the procedure in the public system; one of my ortho colleagues saw a patient with knee pain, decided he didn't need an arthroscopy (which means he REALLY didn't need one). The patient when to private clinic in Vancouver and paid $10K for an arthroscopy.

The other question is who is going to deal with the complications from private procedures? Most of these now end up being treated in the public system.

Whether it is collected by taxes, paid to an insurance company or paid directly to a doctor, money is money.

6. Private systems are more efficient.

This may be true. It is however hard to compare the minor procedures done on ASA 1 and 2 patients in a private suite with even the same procedures done on ASA 3 and 4 patients in a public hospital. It is even harder to compare the efficiencies with more complex cases. In Calgary a private hospital, currently does total joints under contract with the health authority. They are only able to do this because the health authority pays them a 10% premium. The same has been shown for cataract surgery. There are a lot of inefficiencies in the public system; I would rather they be dealt with. Certainly as a private system gets bigger and with the ability to pass costs on, you can expect them to become more inefficient.

I in fact work partially in a private pain clinic. This clinic subsists mostly thru having obtained a contract to treat patients from the local health authority. It is incredibly inefficient.

The other issue is of course billing. Currently I submit my claims via the internet for $25 a month although if I acted as my own submitter I could do it for free. My claims are paid within two weeks. Compare this with having to deal with multiple insurance companies, plus charging patients directly. A former colleague moved to Australia and works now in their private system. He told me that while he makes more, 22% of his billings go to overhead, largely to collect money.

7. Wait lists are inherently bad.

Actually wait lists within reason are not a bad idea. Some patients actually get better. Much of my time in the Pain Clinic is dealing with complications of surgery.

The fact that the surgeon has a wait list also ensures that his list is fully booked which helps my income.

8. Only Canada, Cuba and North Korea prohibit private healthcare.

Right wing newspaper columnists love this one.

So..... I see a patient in my pain clinic which is in a hospital owned by a Catholic order, I submit a bill to the public insurer which pays my professional corporation, I write a prescription which the patient takes a private pharmacy and either pays for it himself or has his insurance pay for it.

So where is the public monopoly?

There is in fact nothing to stop any doctor from charging patients directly for his services (with of course ethical and professional exceptions set by licensing bodies). What most provinces have said is:

a. You can't accept a fee from medicare and bill the patient as well;
b. You can't bill the patient directly for some procedures and medicare for other procedures
c. You can't bill some patients directly and some under medicare.

There are in fact so many exceptions allowed to those rules which are rarely enforced. If you visit any doctor's office now, you will see a menu of fees charged for prescription refills, phone calls, forms and even missed appointments.

In closing.

Working in any large system is frustrating. Despite this we seem to make a good living doing what we do. Part of the problem is the unwillingness of doctors to prioritize patients, triage and ration scarce resources. I have learned that no matter how well funded a system is, the funding is not infinite. Healthcare becomes a zero sum game, treatment given to one patient is treatment denied or postponed for another. We also have to accept that a lot of the inefficiencies in the public system are generated by doctors; not using OR time efficiently, keeping patients in hospital too long, doing futile procedures, doing procedures they know don't work and of course ordering too many tests.