Honest talk about private health services is long overdue

Posted on November 10, 2015 in Health Policy Context

TheGlobeandMail.com – Globe Debate
Nov. 10, 2015.   André Picard

Last week, Saskatchewan passed legislation that allows patients to pay privately for MRIs. Quebec also introduced legislation that will allow physicians to bill for a range of “ancillary” products and services, ranging from eye drops to colonoscopies.

These moves were greeted with predictably histrionic warnings that the end is nigh for medicare. In fact, rarely does a week pass that we are not warned about the horrors of privatization and the death of medicare as we know it.

The reality is that every universal health-care system in the world – including Canada’s – has a combination of public and private payment, and a blend of for-profit and not-for-profit delivery of services.

The discussion we really need to have is what is in the so-called medicare basket of services and what is outside the publicly-funded basket. And what we need to do is not ban private care, but regulate it, as part of a broader, long-overdue reform.

Canada has the most singularly bizarre health-funding model in the world. It is, to use the technical term, bifurcated – meaning there are two distinct categories.

“Medically necessary” care, defined as hospital and physician services, is paid 100 per cent from the public purse. Selling these services privately is, with few exceptions, illegal or subject to punishing penalties. That’s why there are essentially no private hospitals in Canada, and few physicians who sell their services on the open market (opting out of medicare is permitted only in a few provinces).

The rest of health care is, by default, not deemed medically necessary, but still gets varying degrees of public funding. Only about 6 per cent of dental care is paid publicly, as are almost half of prescription drug costs, and about two-thirds of long-term care costs.

There’s really no rhyme or reason to why health costs are allocated this way, other than it is an artifact of history, but the end result is that we have the least-universal universal health system in the world.

Does anyone honestly believe that all physician and hospital care is essential? Can anyone rationally argue that some drugs, home care and long-term care are not essential?

Some delineation is positively absurd: Some provinces pay for cancer drugs if you take them in hospital, but not if you take the same drugs at home. Psychiatric care is covered, but most psychological care is not.

Even the most ardent supporters of medicare will grudgingly admit that a public health-insurance plan cannot and should not pay for everything for everyone.

When you cut through the rhetorical extremes, from private care is evil, to privatization is a panacea, there is a pretty broad consensus that we need to make the medicare basket of services wider, but less deep.

What that analogy means, practically, is formally extending medicare into other areas such as prescription drugs, home care and long-term care, but putting restrictions on what is covered in each category. It also implies allowing hospitals and physicians to sell some services privately.

This approach, which is the norm in most of the developed world, is often referred to as two-tier medicine. That term is not really correct because few countries have clear, parallel public and private systems. Rather, most jurisdictions have highly regulated hybrids.

For example, in France, a physician can work in the private system, but only after performing requisite hours in the public system.

The new legislation actually takes a similar approach. While Saskatchewan will allow patients to buy MRIs, private clinics offering this service must do an additional procedure, at no cost, for the public system. (The most common fear is that allowing private providers will drain resources from the public system, and this type of regulation counters that risk.)

In Quebec, the reality is that so-called ancillary services are commonplace, and the new legislation aims to cap fees to protect consumers (and, in doing so, formally recognizing the practice).

For years, governments have been fiddling around the edges of what is covered and not covered publicly.

Getting the mix of public and private care right means ensuring everyone has access to essential care in a cost-effective manner, and still allowing patients a modicum of choice, and the ability to supplement their publicly funded care with other services.

At some point, we have to make some clear, coherent decisions to ensure that happens. Doing so begins with asking, and answering, the question: What is really “medically necessary”?

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