Dr. Brian Day’s rebuttal to Dr. Warren Bell’s June 13 opinion piece would benefit from clarification of some facts and issues, offered herewith. We agree with Dr. Day that the status quo no longer serves us. We disagree, however, on what’s broken, and what’s not. Our diagnosis is that the delivery system needs reform, not how we pay for care.
Physicians are ethically obligated to consider the patient first.
As Dr. Day correctly notes, physicians “must consider first the well-being of the patient.” We want patients with the greatest need moved to the front of the line. This is precisely why BC doctors overwhelmingly support a publicly funded health care system providing equitable access to care based on need, not ability to pay. B.C. doctors showed support for public funding when 55 per cent of voters elected Dr. Alan Ruddiman, not Dr. Day, to the presidency of Doctors of BC (DoBC).
We have no doubt Dr. Day considers the well-being of his patients too, but the concern seems to apply only to his patients. He has no apparent regard for all the other patients who have suffered or been harmed because they cannot afford the fees he and his colleagues charge at his private pay clinics.
When B.C. physicians work in dual practice, they provide medically necessary care to public-pay patients in hospitals and unlawfully charge others for the same care in for-profit surgical facilities. Since doctors can only treat one patient at a time, those in dual practice cause public-pay patients to wait even longer when they treat private-pay patients first.
Conflating financing and delivery
Dr. Day conflates private financing and private delivery, apparently misunderstanding the Canada Health Act (CHA). The CHA is silent on delivery.
It takes no position for, or against, private delivery, even private for-profit delivery. It only opposes private payment for medically necessary hospital and physician care, not private delivery of that care. We already have a mostly private delivery system — physicians generally work in “private practice”, and hospitals are usually privately owned by not-for-profit organizations.
The B.C. government even contracts out some care to private for-profit facilities, and MSP pays to ensure care is available to any patient in the province. This is a clear example of cooperation between the public payer and the private delivery sector. We have no objection, as long as monitoring, evaluation, and transparent financial records demonstrate that care in private facilities — whether for-profit or not-for-profit — is high quality, accessible to all, cost effective, publicly-funded, publicly-accountable, and provides good value for taxpayer money.
Dr. Day says that “physicians cannot and must not justify the pain and suffering of patients condemned to access care in a timeline that the government, rather than they or their doctors, dictate is appropriate.” Yet the government does not place patients on surgery wait lists. Physicians do. If some patients are waiting too long, it's the responsibility of physicians to expedite their care. There is no government monopoly on care delivery because, with few exceptions, governments don’t directly deliver care — they only pay for it.
One purchaser for hospital and physician services
Dr. Day is correct in saying that physician and hospital services in Canada are over 98 per cent publicly funded. And that is exactly as it should be — a monopsony, meaning a single payer, like BC’s MSP, in each province that publicly funds these services. Dr. Day wants to undo this elegantly simple payment system for hospital and physician care, creating instead a multi-payer system. This would be an open invitation under NAFTA for the US insurance industry to sell private “queue jumping insurance” in Canada.
A single public payer is unquestionably the most efficient and cost effective way to pay for care. Multi-payer systems are administratively complex and more expensive.
Fix how we deliver care, not how we pay for it
We could do a much better job of pressuring governments — provincial and federal — to collaborate with clinical leaders to improve care delivery systems through the many innovations we see in Canada and globally, still publicly funding the care we need, when we need it. If we did that, we’d have the best health care system in the world.
But rather than improving the way care is delivered for all Canadians, Dr. Day’s solution is to just let some people buy their way to the front of the line.
Patients dying on wait lists?
It is always sad when patients die, but there are no reliable data on how many are “dying on wait lists,” if any. The data Dr. Day cites in the 2007 Medical Post survey are suspect. The survey design was weak, relying only on physicians’ self-reported “belief” that their patients die on wait lists, a methodology notorious for bias. The survey is eight years old, the sample size was very small, the margin of error consequently large, and the results, even if they were valid, mean that at the higher margin, nearly 80 per cent of doctors don’t believe their patients have died on waiting lists.
Fortunately, most doctors are strong advocates for their patients, as is their sworn obligation, and don’t let them linger on waiting lists.
Unemployed physicians? Depends who you ask.
If we had an unlimited supply of physicians, maybe there would be room for an entirely privately-financed tier for those who wish to un-enroll from Medicare, but recent data says we don’t have an over-supply of orthopedic surgeons. Evidence in Table 3 of the Royal College Employment Survey shows that only 61 orthopedic surgeons responded of the 168 new certificants surveyed, and from among those, only 15 were “unable to find a job placement” in 2011 and 2012 combined, or about 7-8 surgeons per year.
In this CORA survey, only 15 orthopaedic surgeons were unemployed out of 176 respondents who graduated 2006-2011, or about 2-3 surgeons per year. Part of the reason there are unemployed surgeons is that older surgeons aren’t retiring. Close to 300 orthopedic surgeons in Canada are over 60 years of age, including Dr. Day. Another part of the reason is some doctors don't want to work where they are needed. Yellowknife currently needs two general surgeons, an orthopedic surgeon, and three internists. Take a look at the back of any medical journal — the jobs exist, just not always in urban centres in beautiful southern BC.
Importing private insurance from Europe?
European systems have some private insurance. It covers user fees — co-payments — introduced in France. In Germany, only the rich are permitted to buy private insurance to replace public funding, and if they do so, they must withdraw from the publicly-funded system and cannot return, except under rare circumstances. It’s a one-way door, not a hybrid payment system. Switzerland has multiple private insurers, instead of a single payer like MSP, and everyone is obligated to buy private insurance. But this insurance is not “queue jumping insurance” by any stretch of the imagination.
In some European countries where there are fewer queues than in Canada, it’s partly because there are more doctors, and they are paid less than here. If Dr. Day prefers the European system, we encourage him to turn his efforts to advocating for reduced payments to Canadian physicians, so we can afford more doctors. Then, like in Europe, we’d have enough spare doctors such that some could start doing house calls again, like in Switzerland.
Medical Services Commission was entitled, by law, to audit Cambie clinic
The Court of Appeal judges said that, “As matters now stand, the Commission is entitled, under statute, to proceed with an audit.” It’s a stretch to call that “volunteering” to undergo the audit. The auditors found “extra billing had occurred at both Specialist Referral Clinic and Cambie Surgery Clinic on a frequent and recurring basis, contrary to the Act” and that “the extra billing would often overlap with physician claims of MSP”. In other words, what appears to be double dipping. But rather than bickering over who said what, best to just read the audit report itself.
Liberty does not mean ignoring laws
The law in Quebec unfortunately no longer protects patients from longer waits caused by those who wish to buy their way to the front of the line, taking their doctor with them. An individual’s constitutional right to do what he or she wants at the expense of others is not protected by law. Our right to “liberty” does not mean we can ignore all laws. It is our sincere hope that B.C.'s court will agree that allowing private “queue jumping insurance,” for those who can afford it, will harm the rest of us who can’t.
Dr. Day wants to have his cake and eat it too.
B.C. physicians who want to treat private pay patients are free to withdraw from Medicare and charge as much as they wish. Dr. Day has not chosen to exercise his professional right to completely leave the publicly-funded system. MSP provides him a financial safety net he’s apparently unwilling to abandon.
If Dr. Day, and the rest of the surgeons operating at Cambie really wanted to help patients, they could have operated on them at the established fee schedule, within the publicly-funded system, and negotiated a reasonable facility fee with the government. Instead, for years they have been extracting money — very large amounts — from patients who want to obtain care ahead of others for a variety of reasons, including some in such pain they will pay anything to get relief. This is professionally unethical. A conflict of interest is inevitable because the desire for monetary gain intrudes into the doctor-patient relationship.
Personal attacks are unhelpful
Dr. Day’s penchant for personal attacks is unhelpful. We are all in the same boat in our efforts to improve Medicare so that it serves all patients equitably. If he put half the energy into working with others to improve Medicare as he puts into attacking individuals who disagree with him, we would have collectively found ways to improve Medicare ages ago. His single-minded focus on the payment side of the equation distracts Dr. Day from working collaboratively to improve the delivery side.
Dr. Day’s attack on Canadian Doctors for Medicare (CDM) is, unfortunately, predictable. CDM began when Dr. Day assumed the Presidency of the CMA in 2005, responding to the many physicians across Canada who don’t support his vision of a private pay system that serves the few, at the expense of the many. CDM believes we can create a better Medicare system — a high-quality, equitable, sustainable health system built on the best available evidence as the highest expression of Canadians caring for one another. He’s right that membership in CDM constitutes a small percentage of physicians. Or rather he was right until recently when, thanks to the Doctors of BC election, physicians have been flocking to CDM. Among physicians who voted in that election, 55 per cent rejected Dr. Day’s payment reforms.
Dr. Day’s attack on colleagues, such as Dr. Gordon Guyatt, a global leader on evidence-based medicine, and practicing internist who treats the sickest of sick patients, is a mystery. Dr. Guyatt says it is likely that certain patients wait too long, and we should carefully study the magnitude of the problem so we can plan how best to resolve waits. He’s right, of course. What’s not to agree with? Yet, still Dr. Day attacks his esteemed colleague.
Dr. Day’s lawsuit is costing British Columbians millions
Dr. Day’s pursuit of a private payment system, including “queue jumping” insurance for hospital and physician services, is costing British Columbians millions of dollars in legal defense fees. He could drop the case, but won’t, because he stands to personally benefit. Instead of working tirelessly to undermine our public health care system, he could contribute to making Medicare the envy of the world.