Private health care delivery: one-tier vs. two-tier

The differences are quite fundamental; they must be faced if we are to have decent health care.

Working in Quebec's public hospital system, Dr. Nicolas Duval was in effect a part-time surgeon, rarely spending more than a day a week actually performing orthopedic operations...he told a Toronto conference yesterday...

A frustrated Dr. Duval finally opted out of medicare in 2002 and became Canada's first private orthopedic surgeon. The difference was dramatic.

This past year he did more than 470 procedures, including 200 total hip and knee replacements -- more than three times the number he carried out in the public system. And he maintains that his operations cost thousands of dollars less than those done in hospitals...

His patients pay for the procedures out of pocket -- to the tune of $11,000 for a hip replacement. But as the public system tries to cut painfully long waiting lists, Dr. Duval said it could probably duplicate his model, or at least contract out services to private clinics...

Dr. Michael Gordon, a vice-president of Toronto's Baycrest Centre for Geriatric Care, recounted examples of British doctors who work partly in the public National Health Service, but see patients far more quickly if they are covered by private insurance.

Ms. Grosso noted the idea of provincial medicare agencies contracting out services to the private sector is often wrongly "muddled up" with the two-tier medicine feared by Dr. Gordon, which involves a separate private system where patients pay for care out of pocket or with private insurance...

In reality there are three alternatives:

1) Eliminating private, for-profit delivery of publicly funded health care--the apparent aim of the Ontario Liberal government.

2) Improving publicly funded only health care by paying private, for-profit providers that do not extra bill--either to add capacity or because they can be more efficient. This would not violate the Canada Health Act as coverage is still universal.

3) Allowing the UK (and some other European countries') model. This combines option 2) with the addition of privately provided for-profit health services paid through private insurance, or cash. This model is the consequence of the Supreme Court's Chaoulli decision; it would violate the Canada Health Act since health care provision would not be universal.

Option 2) may seem an attractive compromise--see Ms. Grosso above--for those wedded to universal, publicly-funded medicare. But it does not address the fundamental problem of that system. The provinces that pay, even if private, for-profit delivery is included to increase capacity and efficiency, will still not have enough tax-raised money to pay for prompt delivery of needed services (unless taxes are raised beyond the breaking point). The current rationing system will continue though perhaps with a reduction in waiting times for some selected procedures--but no improvement for others.

It is only option 3) that in fact increases substantially the funding available for the health care system as a whole. It does this by adding in the resources of individuals who choose to pay for certain procedures which the publicly-funded system cannot delivery in a timely fashion. Insurance for those procedures would not be an undue annual cost for many people. Others, perhaps the majority, would still have the public system available. So they are not worse off and, as noted above, option 2) can improve that system for them to some extent.

Without this additional funding from individuals the waiting times for provincially funded health care can only be improved so much. The supply of procedures across the board will never be prompt given the tax-raising constraints and the ever-increasing demands of the rapidly-aging population.

To those who say that option 3) will reduce the availability of doctors in the public system, I would point out that the public system constrains severely the amount of work those doctors can actually do (see first and third paragraphs in the quotes above). Funding limitations will simply not permit the number of procedures by doctors provincially paid for to increase to meet demand in a timely manner.

We must abandon a failing system rooted in ideology for one based on a pragmatic appreciation of reality. The Conservatives are only willing to go as far as option 2); that is not far enough.

Posted by markc at January 31, 2006 10:14 AM | TrackBack