Cherry-picking the healthiest, wealthiest patients: the reality of private pay healthcare

Most Canadians might be surprised to learn that major decisions about how our healthcare system will operate in the future could be decided by our courts -- and not by our democratically elected parliamentarians. But that’s exactly what is happening in British Columbia right now.

A Charter challenge is underway at the Supreme Court of BC, championed by Dr. Brian Day, owner of the Cambie Surgical Centre. Day is arguing that the laws currently prohibiting doctors in Canada from practicing in the public and private health sectors simultaneously should be struck down, along with the prohibition on the extra billing of patients for services already covered by the provincial health plan.

From Day’s perspective, such restrictions prohibit patients from seeking the best care possible, thereby violating the Charter of Rights and Freedoms. But critics argue the case is more about doctors’ potential to earn more money than patient choice or quality care.

Right now, we have a single tier of publicly funded health care (with a limited private sector covering certain non-insured services). If Day succeeds with his challenge, those who are financially able will have access to an “upper” tier of health services too, one where doctors charge whatever they want. Those who lack funds will only have access to the “lower” public tier, where doctors adhere to a provincially-mandated fee schedule, much as it is today.

What’s wrong with such a two-tier system? Evidence from other countries demonstrates it too often benefits only those who can afford to pay – and makes the publicly-funded system more expensive and less efficient.

Day and his lawyers argue such a two-tier health system is the solution to medicare’s problems. They assert that the creation of parallel private payments will alleviate resource strain on the public tier, ultimately leading to shorter wait times for all Canadians, regardless of which level of care they access.

Wait times became longer after private-pay system introduced

Unfortunately, it’s not that simple -- as Australia discovered.

Australia had a publicly funded health care system like Canada’s before introducing a parallel private-pay system in 1999. As a result, wait times in the public pay system became longer, not shorter. Turns out, many specialists spend more time in the private pay system than in the public, “cherry-picking” the healthiest, wealthiest, and most profitable patients, leaving the most complex, vulnerable, sickest, and costly for the public system to handle.

The second major argument being waged by Day in his Charter challenge involves a more general claim regarding the viability and desirability of European health care models -- so let’s have a look at a few.

Switzerland has the second most expensive system in the world, right behind the USA. Private insurance is mandatory. Out-of-pocket payments are exceptionally high with low and middle income families contributing more to the financing of the system than families in high-income brackets.

The French have a private/public hybrid system, but their private insurance only helps cover the extra billing that was introduced to add more money to the system. They also have some of the greatest financial and geographical inequities in access to health care in Europe.

The German health care system is also a public/private mix, but patients have to choose one or the other. Germans with public health insurance – about 90 per cent of the population -- wait three times longer for some care than those with private insurance. More importantly, the private insurance sold in Germany is for those wealthy enough to leave the public system entirely. They can never come back, no matter how expensive their care becomes.

Some believe the UK’s National Health Service (NHS) is a comparable system to Canada’s. It’s not. NHS doctors are salaried employees of the government who must work a 40-hour work week with additional evening and weekend call hours before they are allowed to see private pay patients on top of their public practice.

So if Europe doesn’t offer an obvious solution to improving Canadian health system performance, where should we turn? Canada has some good home-grown evidence.

In BC, the Mount Saint Joseph Hospital Cataract and Corneal Transplant Unit employed production-line efficiency and shared patient lists to decrease wait times from 12 to 16 weeks to eight weeks. Likewise, the Richmond Hip and Knee Reconstruction Project used staggered operating start times and standardization to reduce wait times from 20 to five months. The Alberta Bone and Joint Institute was able to reduce wait times from 11 months to nine weeks for hip and knee surgery through centralized intake systems and reducing hospital stays.

These models depend on changing how we deliver care and are about improving quality of care. Our legislators, policy-makers and health practitioners together could help make such Canadian ‘best practices’ – and more – a reality across the country.

So let’s not pretend the Day case is about ‘patient choice.’ Instead, let’s take a radical approach and modernize and innovate within Canada’s public health care delivery to benefit everyone.