And like any repair job, finding the right mechanic is one of the most important questions. There is no shortage of suitors for the job of health-care repairman. Yet how are we to separate the whiz kid from huckster? Which ideas could work, and which will only make matters worse for Canadians looking for reliable health care?
There are many ways to tinker with Medicare, but only some of them will get it running again smoothly. Here are a few that may have crossed your path.
Encourage Boutique Medical Clinics
Some argue that we need to offer more choice to patients and allow doctors to package services in such a fashion that they can combine traditional acute care with other preventative services. They can cater to executives and other with financial means to free up space in more traditional medical practices, thereby increasing access for all people. These "boutique clinics" offer a solution to Medicare by both increasing patient choice and acting as a pressure valve for the rest of the system.
As an example, last fall, the doors opened on the Copeman Clinic in Calgary. At Copeman, for an initial fee of $3,900 and annual payments of $2,900, patients can get guaranteed quick access to a doctor and an array of diagnostic, assessment and diagnosis services from a team of health professionals. The Clinic portrays itself as offering "preventative" health services as a supplement to basic health care. In addition to the patient fees, Copeman bills Medicare for essential services provided.
On the surface, this may seem like it solves two problems at once - offering more choice and reducing pressure on the rest of the system. Unfortunately, it solves neither.
In terms of reducing pressure, a research study released in fall of 20081 found that these clinics contribute significantly to physician shortages in the public system. They draw doctors from public practice and offer them caseloads that are one-third to a quarter of standard practices. Similar problems are found with other health-care professionals. These professionals treat a smaller number and narrower range of patients- patients who are often healthier, due to their economic status, than the population as a whole.
These clinics also play fast and loose with the Canada Health Act. "Many of the boutique physician clinics co-mingle medically-necessary with unnecessary services in an attempt to sidestep the Canada Health Act's prohibition on two-tiering.2"
As for patient choice, these clinics foster the myth that health care is a commodity like any other. Choice is an important concept for buying a car or choosing a brand of cereal, but it does not appropriately apply to health care. Canadians are not looking for a range of health services; they want the right treatment to cure their ailment or prevent disease. Plus, a regular marketplace assumes the consumer has the ability to inform themselves of the merits of the choices. This is simply not feasible in the complicated, technical and sensitive area of medicine. Canadians want access to health care when they need it, not the right to pay for a battery of tests and procedures of uncertain medical value.
A more valuable solution might be to put the health professionals employed by the boutique clinics back to work fully in the public system, where they will see more patients
Expand Role Of Nurse Practitioners And Other Health Professionals
A more reasonable direction to increase access to basic health care might be to expand the role of nurse practitioners (RNs with additional training to allow them to perform many physician functions) and other professionals (social workers, physiotherapists, counselors, dieticians, technicians, etc.) in delivering direct medical care.
In many respects doctors are the bottleneck in the health-care system. There are too few of them and their fee-for-service model is restrictive, creating long waits for many procedures and treatments. Many argue care is most effective when a range of professionals work as a team, offering a coordinated compendium of services to patients. Consequently, their idea is to foster interdisciplinary teams to provide more thorough, more timely care.
In Alberta, the Conservative government has turned the nurse practitioner model on its head. It has forbidden them from joining unions and is establishing a doctor-style fee-for-service payment system for them. The government is trying to make nurse practitioners the new health-care entrepeneurs, opening their own private clinics.
However, properly implemented, a team model, led by nurse practitioners, has the potential to greatly increase access to care AND reduce costs at the same time.
One of the innovations of the boutique clinics is to offer wholistic care that focuses on prevention. Why should this good idea be restricted to those who can afford to drop three or four thousand dollars? If we implement a similar model in public facilities, its advantages can be applied to all.
Allow Private Clinics to Access Public Funds
If boutique clinics are a concern because they siphon key resources (staff, resources, etc.) from the public system, maybe we can resolve it by allowing private clinics to fully participate in the public system by billing the government rather than the patient for their services.
This is a rapidly growing model for Medicare. Proponents argue this saves money and reduces waiting times, as the government does not have to invest in costly infrastructure, and the private clinic is more likely to stay up to date with technology and techniques. A recent study found that there are 130 private clinics operating in Canada and the vast majority takes both public and private funds.
This proposal neglects the fact that there is a limited number of health professionals in Canada and that the growth of private clinics only draws doctors, nurses and technicians from public facilities - which means waiting times are not reduced, only moved. More importantly when examining the costs of governments paying for-profit operators to deliver health care, "researchers found health spending was higher and increased faster in communities served by for-profit hospitals compared
to non-profit communities."3
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A SAMPLING OF ALBERTA'S PRIVATE, FOR-PROFIT HEALTH CLINICS Alberta has 31 private, for-profit clinics, most of which receive money from Alberta Health. Here is just a sample of them. Boutique Clinics:
MRI/CT Clinics:
Surgical Facilities:
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Also, for-profit clinics often offer "upgrades" or "enhancements," directly billed to clients, that can be hard to restrict. Why get that rusty old government-issue hip when you can get a fancy titanium-alloy, kryptonite-coated hip for only a few hundred dollars more?
In many respects, sending public patients to private clinics serves to only create a captive market for these health-care entrepreneurs that they can upsell other products.
More damning, evidence suggests that private clinics are LESS efficient than public clinics. In the past few years the Manitoba NDP government had a policy of quietly buying up private clinics and returning them to the public fold. Plus it has prohibited private clinics from both billing publicly and privately. Due to its policies, Manitoba has only two for-profit clinics (that have so far refused to sell to the government), compared to Alberta's 31 (see sidebar).
In 2001, Manitoba bought the Pan-Am private clinic which now operates as a public facility with no extra fees. The number of procedures out of this state-of-the art clinic has more than doubled since it entered public hands, and the cost per procedure has dropped. Showing that non-profit, public health care can get more done.
Have the Money Follow the Patient
There is a lot of talk these days about "patient-focused" health care and about the concept of having the money follow the patient, regardless of where they go. In the parlance of its proponents, "patient-focused" means putting the interests of patients first and allow them to choose how to spend it.
In one regard this is an ideological relative of "patient choice," of attempting to commercialize health care. However it is more than that.
The most likely mechanism for patient-focused funding are Medical Savings Accounts (MSAs). This is the model where the government, instead of paying for health services directly, provides money to every person who then uses that money as they see fit. Usually MSAs are seen as a supplement to core health care; the government would continue to pay for "catastrophic" care, but other services could be moved to this model. MSAs could also be used to pay the premiums for private
health insurance.
This model is seen as a way to increase individual choice and autonomy, while managing costs for the government. It also finds a way for Albertans to purchase health insurance independent of their workplace, as only a small percentage of workers have workplace insurance plans. Second, proponents argue it will facilitate efficiency and productivity among health facilities as they compete for patents.
The proposal falls down on three fronts. First, it, too, builds upon a marketplace assumption, where free agents make rational choices using best information. It is simply not possible in health care. Information is too hard to gather, and the reasons for accessing health care (i.e., illness) are not times when a consumer is able to make rational, carefully considered choices.
Second, it inappropriately applies an RRSP model to health care. Medicare is like a defined-benefit pension plan - you pay in with your taxes and when you need health care, you are guaranteed a certain level of care. MSAs flip that around, giving you money upfront but making no guarantees of any level of benefit. How do you know that you have enough money in your MSA to pay for that laser eye surgery? Or that physiotherapy? In short, you don't.
Third, the proposal is designed to create more space in health care for private insurance companies and for-profit clinics. And as we have seen, that leads to greater privatization, higher costs for both government and patients, and unequal access to medically necessary health care.
Move to the "Second Stage" of Medicare
Ultimately, repairing Medicare might mean finishing the original construction job. The best direction for the future of Medicare may lay in expanding it - as was originally intended.
Noted health-care policy expert, Dr. Michael Rachlis, has recently been suggesting that the time has come to implement what he calls "The Second Stage" of Medicare. As Dr. Rachlis explains the original vision of Medicare held by Tommy Douglas and his CCF government was of a more comprehensive program, both in what it covered, but also in how it envisioned health and how it delivered health-care. Political realities (the doctors' strike, opposition from other provinces) forced Douglas to put off the second stage.
Rachlis is arguing we need to restructure health care delivery and our approach to illness and health. He sketches out what the second stage might look like. It includes:
- Expansion to include pharmacare, dental care and universal home care;
- Moving away from physician fee-for-service and toward salaries for doctors;
- More coordinated, community-based care, provided by teams of health care professionals;
- Focus on wellness rather than sickness;
- More community, democratic control over health care provision; and
- Focus on equity - how to reduce disparities in health outcomes among populations.
The model addresses many things simultaneously. It addresses the pressure points currently experienced by Medicare and it effectively eliminates the growing risk of privatized, for-profit medicine.
Plus, it will lower costs while making people healthier. In Tommy Douglas's own words: "All these programs should be designed to keep people well - because in the long run it's cheaper to keep people well than to be patching them up after they are sick."4 (Douglas, 1984)
REFERENCES
- "Eroding Public Medicare: Lessons and Consequences of For-Profit Health Care Across Canada", Natalie Mehra, October 2008.
- Ibid. p. 47.
- "Mythbusters: For-profit ownership of facilities would lead to a more efficient health care system", Canadian Health Services Research Foundation, 2004.
- "We Must Go Forward", T.C. Douglas, in Medicare The Decisive Year, Lee Soderstrom (ed.), 1982.
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