The case against user fees
NationalPost.com – opinion
Aug. 17, 2011. Noralou Roos And Raisa Deber, National Post
Here it comes again – an idea that surfaces regularly in Canadian health-care debates and seems to hold sway with those who advocate common-sense principles: user fees.
Some people think that charging patients when they use the health system would help control healthcare costs, ensure that people are getting the care they need and are not overusing the system. Others believe that user fees would bring in muchneeded revenue.
Unfortunately, the evidence doesn’t support the aspirations. Re-search to date suggests two good reasons why patient-financed health care doesn’t make sense.
First, user fees discourage patients from seeking both unnecessary and necessary care. This is often penny wise and pound foolish.
While, in theory, user fees might deter patients from seeking medical care they don’t need, that theory would require average citizens to be accurate judges of their health and any unusual symptoms – in short, to be medical experts. Common sense, and sound research, would suggest this is not the case. One study published in the New England Journal of Medicine involving fairly healthy adults showed that user fees led to a 20% increase in risk of death for people with high blood pressure because people were less likely to see a doctor and get their blood pressure under control.
The same thing happened in Canada in 1996, when Quebec began requiring patients to pay part of the cost of all drugs purchased. As a result, according to a study in the Journal of the American Medical Association, patients reduced their use of less essential drugs and essential drugs, with negative effects on their health … all of which were expensive for the health-care system to respond to.
User fees mean we have to decide whether or not symptoms warrant medical attention. Do we really want parents to make the decision about whether to take their child to the doctor on the basis of whether the user fee will leave enough money to pay the rent? After all, the onset of a potentially fatal case of meningitis appears at first to be much like the ordinary flu.
Which leads to the second finding.
Health care financed by patients does not save money. It transfers costs from third-party payers to patients, but the total cost is often higher. While user fees sometimes discourage sick people from filling hospital beds or booking appointments with a medical professional, these freed-up resources are not closed down. Instead, they often end up providing people who can more easily afford the user fees care they may not need. User fees may – ironically – encourage unnecessary or marginally useful care in order to make sure physicians and hospital beds stay occupied.
Most people don’t want a heart transplant or a hip replaced just because it won’t cost them anything the day of the operation. Doctors, not patients, determine who gets access to most health-care treatments. So what do user fees really discourage? They discourage the frugal and the poor from getting the care they really need.
One type of user fee that might make sense was recently proposed in Europe: add user fees to low-value services and eliminate them from high-value services. This approach has never been tried, and it would be a complicated process determining which services would require a fee and which would not. But it is an idea worth studying.
In the meantime, the scientific evidence supporting publicly financed care is long and strong. So why do discredited ideas like user fees keep coming back?
? Noralou Roos is professor of the faculty of medicine at the University of Manitoba and the co-founder of EvidenceNetwork.ca. Raisa Deber is a professor of health policy, management and evaluation at the faculty of medicine, University of Toronto, and an expert advisor with Evidence Network.ca.
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