Protect the Rights of the Rich? The College of Physicians and Surgeons Grapples with Concierge Clinics

F. Scott Fitzgerald once said to Ernest Hemingway, “You know, the rich are different from you and me.”  Hemingway replied, “Yes.  They’ve got more money”.*

I was sitting in a meeting of the Council of the College of Physicians and Surgeons when F. Scott Fitzgerald’s comment came to mind.  It’s true.  The rich are different from you and me.  For one thing they don’t have to advocate for themselves; others will do it for them.

The Council Meeting

The College of Physicians and Surgeons regulates the practice of medicine in Alberta.  The College is governed by a Council—13 doctors and 4 lay people—that meets four times a year.  And bless Council’s little heart;  the public is welcome to observe their meetings.

Ms Soapbox, with her esteemed colleagues, the Whitemud Citizens for Public Health and the Consumers’ Association of Canada, attended the May 31 Council meeting.

Things were going swimmingly until Council reached Item 11.1, Concierge Clinics, then all hell broke loose (in an understated and orderly fashion, these are doctors after all).

What is a Concierge Clinic?

A “concierge clinic” is a private medical clinic that offers “a host of services to clients who pay a substantial annual fee.”**  Some services are “insured” ie. paid by the government with your tax dollars and some are “uninsured” ie. paid by the client by way of an annual fee.

(Disclosure:  I joined a concierge clinic in 2007 when I moved back to Canada and discovered, much to my dismay, that virtually no doctors in Calgary were accepting new patients).

Why is the College of Physicians and Surgeons concerned?

The Queue Jumping Inquiry exposed the fact that some doctors working in concierge clinics pushed their patients to the front of the colonoscopy screening queue.  The bad press generated by this revelation prompted the College to examine its Standards of Conduct governing the ethical practice of medicine.  Were the existing standards “robust” enough to ensure that doctors working in concierge clinics met “the College’s expectations regarding delivery of care in these settings?”**

A less delicate way of asking the question is:  Were doctors in concierge clinics complying with the standards governing the delivery of publicly funded healthcare to Albertans.

Dr Mazurek’s report to Council

Council staff presented their initial findings in March 2013**but Council was not ready to make a decision and requested an additional review of the standards in place across Canada.

Dr Mazurek conducted this review and presented her findings and recommendations to Council on May 31.  Her recommendations were based on the principles Council had (apparently) agreed to at a retreat in Feb 2013.

Suffice it to say that her recommendations kicked over a hornet’s nest (albeit in an understated and orderly kind of way).  Dr Mazurek didn’t make it past the first principle before Council members started peppering her with questions:

Why did you use the more stringent standards from Ontario and Manitoba?  Why didn’t you go with looser standards from more lax provinces?  Alberta’s standards are among the most lax in Canada.  Council had asked Dr Mazurek to tighten these standards, not loosen them even further.

Why is this a College problem?  (In other words, the government and Alberta Health Services created this mess, let them clean it up).   The College regulates the profession and disciplines its members.  It owes it to the doctors to make the standards governing their behaviour as clear and transparent as possible.

Maybe we should define bad behavior and then work our way back up to the principles.  At this point I had to resist the urge to jump up and say:  Hello!  Did you read Dr Mazurek’s Feb 21/13 memo?  You’ve already agreed to a set of principles.

And here’s the one that took my breath away—Are we introducing discrimination based on a person’s ability to pay?  (In plain English:  are we discriminating against the rich?)  This is what triggered my F. Scott Fitzgerald moment.  The rich are different.  They don’t need to attend a Council meeting to argue in favour of unregulated concierge clinics.  They simply convey their views to a Council member who happens to work at a Calgary concierge clinic and he carries their message for them.

All is not lost

The meeting dissolved into confusion as the doctors debated among themselves.  Were MRIs and CT scans “insured services” or not?  Should all doctors get “standby pay” or was that a violation of Standard 18 (9)?  Is it better to create “principles based” or “rules based” standards?  The Council President tried to push for a decision and failed.  The doctors were deadlocked.  In the end the President resorted to the tried and true tactic of referring the matter back to the staff (again) for further study.

There was one bright light in all the confusion.  It came from an unexpected source.  Dr Trevor Theman, College Registrar, admonished his fellow Councillors with this:  “I’m offended as a member of this College by some of the things I’ve seen in the press and I’m distressed that I’m not getting signals of distress from others around this table.  You set the ethical guidance for the profession—the ethical standard…”  His words hung in the air.  No response necessary.

The rich have more money, but…

The rich are different from you and me.  They have more money.  But we have Drs Theman and Mazurek who are forcing Council to recognize a simple fact–failure to tighten the standards to prevent inappropriate behavior in concierge clinics will send a devastating message to the public about who’s in charge of Alberta’s public healthcare system  (Hint: it’s not the public).

Dr Mazurek’s follow up report will be presented to Council in the fall.  Guess who’s going to be in the audience to ensure that the good doctors don’t lose their resolve!

*Deirdre N McCloskey, European Review of Economic History, 12, 138-148

**Memo to Council by Dr Karen Mazurek, Feb 21, 2013, available on the College of Physicians and Surgeons website under About Us, Council, Council Meeting Schedule, Mar 7 & 8, 2013 

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18 Responses to Protect the Rights of the Rich? The College of Physicians and Surgeons Grapples with Concierge Clinics

  1. Nigel Bankes says:

    Brilliant and thank you for following this.

    Nigel

    • Thanks Nigel. It was clear to us that increased oversight of doctors providing concierge services is necessary. For example, concierge clinics claims that one of their “extra” services is “timely access” in the form of timely appointments and extra time for complex cases; but Standard 18(7) as it exists today prohibits doctors from collecting a fee in advance for “being available to render insured medical services”. So why does timely access appear in every concierge clinic’s list of additional services?

  2. Julie Ali says:

    Hi Susan,

    This was an illuminating post for me.

    I mean I knew that there was a cadre of doctors making big bucks from these private clinics but I did not know that they had so much clout in their council.

    This part of your post was very painful to read:

    Are we introducing discrimination based on a person’s ability to pay? (In plain English: are we discriminating against the rich?)

    Wow.
    What an eye opener.
    I’ll bet these rich doctors who have their interests well protected by this council also have their interests well protected by the government of Alberta.
    Why else would the doctors settle their dispute with the province without any big changes to the contract?

    This chatter at the council meeting — is a sad state of affairs and brings me to the conclusion that the interests of the ordinary citizens in the public healthcare system has been replaced by the interests of the rich (doctors/ and clients/politicians) in the healthcare system.

    This taking care of the rich—-seems to be the case in almost every area of our nation. Just look at Senategate and the care taking work of Mr. Harper’s chief of staff –who kindly provided Mr. Duffy with a $90,000 cheque.

    This sort of taking care of the rich is corrupt and very damaging to our democracy.

    In the case of this Council—it not only makes them appear very greedy but it also makes the public more cynical about doctors. It also makes it seem pointless for us to attend this meetings if the doctors are only concerned about their richest patients.

    After all if the game is rigged–why bother to attempt to participate when your participation will not change the outcome?

    The fact that the folks at the council yapped in this self serving and less than professional way made me feel very dismayed.

    If the medical leadership is flawed to think only of personal profit –then how are we–the people–to expect much in terms of improvements in our healthcare system?

    Are we to understand that the folks destroying the system are not only within the government itself but among the richest professionals in our province–the doctors themselves?

    The doctors I have encountered have been dedicated professionals. Some of them lack hospital privileges and don’t earn the salaries earned by folks in the oil patch. They work long hours.

    I have never met a doctor who would yap like this. So this is why I am amazed that these doctors yapped in public like this as it demeans their profession. I would say this sort of chatter of discrimination against the rich is disgusting. The folks on this council need to start waking up to the fact that the public is who they serve and not the rich doctors among them or their richest clients.

    The contract shows we have been exposed to recently in Alberta have been really educational for me. I have been very naive about all politicians and also about the professionals themselves.

    The doctors’ dispute, the teachers’ dispute and then the billionaire payback via the Capital region board’s regional collaboration grant for the Katz arena–these contract shows have left a lasting impression that we –the people don’t count beans and we don’t have any power.

    Then to read your account of this sort of spectacle in the chambers of the most respected professionals –the physicians of Alberta—well I feel that this is further proof that Alberta needs work by ordinary citizens.

    I’m so glad you are covering these council meetings.

    I never knew they were open to the public and that they were full of such Charles Dickens-like aspects.

    Who is in charge of the public health care system? I would say rich Tories who are also doctors.

    • Great comments Julie. We were very surprised by the candor in the room. Frankly I think the doctors connected to concierge clinics were so busy protecting their interests that they forgot we were there. That might be why Dr Theman interrupted the discussion. I didn’t put everything he said into the blog, but at one point he told the doctors to consider the message they were sending to the rest of Alberta’s doctors, the public AND the audience (then he looked at our little group lined up against the wall). Soon after that the President gave up trying to get anyone to make a motion to accept the amended Standards and referred the whole mess back to the staff for further work. I pity the staff. How will they ever come up with a set of amendments that will be acceptable to doctors who have their own business interests, as opposed to the public interest, at heart.
      I should point out that not ALL the doctors were in the self-interested camp. Many of them spoke out in support of the amendments, unfortunately they were unable to carry the day.

  3. Linda says:

    Susan, virtually every private service offers those who can pay with the ability to queue jump. Private MRIs lead to quicker diagnosis and thus a jump in the queue for other services such as surgeries.
    As private boutique clinics expand and grow I have no doubt we will start to see specialists as part of the organization and thus the ability to bill the public system while gaining access to specialists that treat only those streaming through private clinics, billing the public system for services that includes preferential, expedited diagnostic testing after the initial private diagnostic test.
    At one point Alberta physicians had to be either in or out of the public system, but not in both. I’m not sure how or when it was changed, but the effects are real. Also, because we do not have physician payments disclosed, as B.C. has for years, we have no idea how these “boutique” high fee docs compare in payments from the public system to those docs billing only the public system. In other words, we have no way of knowing if they are just topping up a full publically paid income with private membership fees for patients. Further, in spite of these physicians receiving public funding, we don’t have any right to have a look at their income or profitability on the publically paid portion of practise or how the two compare.
    I don’t hold out a lot of hope for any transparency from the College if the past is any indication, particularly here in Alberta where they have been implicated in potentially illegal and unjust treatment of physicians in our province.

    • Linda, great explanation of why using a private MRI clinic still constitutes queue jumping. I fully agree with your comment that we need greater transparency in doctors’ billing practices and would add that we need it in both the public and private sectors. The amendments put before Council would have forced ALL doctors to be more transparent about what services were “insured” and paid by the government and what were “uninsured” and paid by the client. For example, it turns out that doctors are not supposed to limit a patient to one aliment per 10 minute visit which forces the patient to come back 3 times on 3 separate days in order to fully explain their symptoms or join a concierge clinic that allows him to talk about all 3 ailments for 45 minutes provided he pays extra for a service he’s entitled to get in the first place under the public system. Both the public and private doctors are ripping off the taxpayer and neither the public patient nor the concierge client realize it. No wonder we’re cynical.

  4. Elaine Fleming, Whitemud Citizens for Public Health says:

    Susan, having attended the College of Physicians meeting in March I was anticipating the regulations that would be presented concerning fee-charging, or “concierge” clinics- by way of protecting the Alberta public as patients and “consumers”, and also our system of universal access to health care. It was very concerning to see this discussion completely hi-jacked by a few doctors who do not want to see regulations put into place. I was dismayed that none of the other doctors sitting around the table nor the public members who are supposed to represent us, defended any of the College principles that Dr. Mazurek put forth, like, “… access to insured medical services must be based on need, and not on the patient’s ability to pay”. This principle, by the way, is also stated in the Canada Health Act. Even if it wasn’t, I would hope the doctors would have this as a moral and ethical guide. However …

    It was interesting to note that an exasperated Dr. Mazurek reminded the college members that they already have (since 2010, I believe) regulations regarding charges for uninsured services, that talk about the “block fees” concierge clinics charge: “… the physician must not … Refuse to accept a new patient because the patient chose not to pay a block fee.” Which begs the question, why has the College not been enforcing their own regulations instead of allowing/enabling these types of clinics to proliferate in our province?

    Dr. Theman spoke to deaf ears, apparently, when he went on record stating that block fees have to be broken down so that patients know what they are paying for, and that they cannot be charged for medically insured services. (For one thing, this is an outright violation of health legislation, and the other thing is, just how many times does a tax-paying patient have to pay?) And besides, any sizeable purchase of services by a consumer in any other situation involves a breakdown of costs, does it not? Dr. Theman also reminded college members that a MAJOR stumbling block they cannot get around is that a doctor cannot place a financial (or any other) barrier between a patient and their ability to access medically necessary services. Do these doctors, some of whom hold very prominent posts, really have to be reminded of this?

    Another point- I have to wonder about all the lab tests and diagnostic procedures these clinics perform on their “members” too. Are they charging Alberta Health (taxpayers) for them? Are they beyond medical guidelines? There is currently much debate by health policy people, and doctors, about patients getting “over-screened”. Besides the costs, time, etc. are there risks involved?

    It is apparent that this important issue should not be left to the doctors to decide. But having raised the problem of “concierge” clinics with Health Minister Fred Horne, and one of our Members of Parliament, James Rajotte, over the last two years, it is apparent the government doesn’t want to stand in their way either. So, who will protect us? The courts? C’mon Susan, some legal advice here (free) please!

    • Excellent question Elaine: Who will protect us if the doctors’ own disciplinary body turns a blind eye to practices that go well beyond what is allowed under the College’s Code of Ethics and Standards of Conduct, let alone the Canada Health Act? The Health Professions Act gives the College all the powers it needs to protect the public interest. Unfortunately the certain members of the Council of the College appear to be unwilling to use them.

      In law we have a concept called “self help” which we use when all else fails. It’s a quaint term which means, do what you think is right, damn the consequences. So here are some thoughts.

      A law suit won’t work. The patient needs to show physical or emotional harm and the doctors’ insurance company, the Canadian Medical Protective Association, will fight it tooth and nail. Bottom line: legal action is too slow, too expensive and if by some miracle it was successful there’s a good chance that the “concierge” doctors would simply tweak their practices to avoid this particular problem but not overhaul the entire system.

      A second alternative is to file a disciplinary complaint with the College. As you and Linda have pointed out, this is a crapshoot–the College has a troubled reputation when it comes to investigating and disciplining the appropriate people. We saw this when the College went after Dr Raj Sherman of all people! Nevertheless I think it’s worth a shot, especially given the strong support that Drs Mazurek and Themen gave to these amendments. A flurry of complaints would demonstrate public’s dissatisfaction with the treatment they’re getting from some “concierge” doctors and give Drs Mazurek, Themen and others more ammunition (backbone?) to push for changes. These complaints should be copied to Health Minister Horne, the Wildrose, Liberal and NDP health critics and your own MLA. This brings the College’s failure to act into the political arena and would increase the politicians understanding of how unsatisfied the voters are with “concierge” doctors who ignore the standards of practice and code of ethics.

      Lastly there’s the tried and true media blitz including demonstrations on the steps of the Legislature. It’s very sad that we’ve come to this but the PDD demonstrations show that if there’s enough public outcry the politicians will listen.

      If the College continues to refuse to enforce its existing standards and create new ones to regulate this for-profit medical/business model, then we should ask our government (yes, I heard that heavy sigh) to take away the doctors’ right of self-government. A College that can’t be trusted to govern the profession properly doesn’t deserve the privilege of doing so. With great power comes great responsibility (quote from Spiderman).

      In the meantime, you, Wendy and I will continue to attend these meetings. That tells the College that we, the public, are watching and telling Albertans what we’ve seen. And so far, it’s not reflecting well on most of the people around the Council table!

  5. Carlos Beca says:

    Interesting post as always.

    Elaine I am not at all surprised that no doctors came to the defence of our Universal Health Care or Dr. Mazurek’s report. A lot of doctors are just waiting for the opportunitty to go from well off to the pinacle of making money. In a society like our present one it is really not that outside of the common atittude. Everyone is hoping for that limitless money pit and the chance to buy everything we desire or dream. I guess that is what we have chosen as a society and we just have to wait for the consequences which are already becoming obvious.

    Susan I must say that I was surprised with your disclosure that you belong to a Concierge Clinic. You seem to be a person that strongly believes in Public Health Care but you chose to support the very first steps of the two tier system which is in its infancy in Canada. I understand that it is not easy to find a family doctor but Iike many of us in that same situation we use the medicentres and some of those doctors become family doctors anywyay. Medicenters do not refduse people and I have to say that I have waited less and got the very same level of service I do now with a family doctor. In fact people here in Edmonton now go to Medicenters to get their prescription drugs faster. I have done it because my doctor at one point refused to give me longer than 3 months and refused to accept faxes or phone calls from the pharmacists. I have not heard of these concierge clinics here in Edmonton and I will never join them anyway.

    Yes Elaine you are absolutely right that the Government does not want to stand in the doctor’s way. They obviously want the private service except that they know that they have to get us brain washed to it and it has been a while but it is coming. Once installed it will never go away again. It did in the 60s because in those days corporate power was very limited. Now it is a different story and they will never let the gold mine go ever. The doctors will be their very first defenders anyway.

    • Elaine Fleming Whitemud Citizens for Public Health says:

      Carlos, Susan indicated she went to a fee-charging Concierge Clinic because there were no family doctors in Calgary taking on new patients at that time. Some companies, as well, are paying for their employees to have their care at these places, and in fact, Concierge Clinics market heavily for this, calling it an “Executive” health program. Unfortunately, (and that is why we have Medicare) most people are not in the situation to afford the $3,000-$10,000 per person/year membership fees. These clinics also keep their patient numbers lower than regular medical clinics, and this, plus other factors like General Practitioners going into cosmetics for instance, affect physician “manpower”. This certainly is not helping Albertans get access to family doctors. One of the other problems is that the fee-charging clinics are also billing the Alberta Health Insurance Plan for services to their patients- “double-dipping” in fact. The leaked document about the Alberta Health Act the government was proposing before the last election indicated that legislation was going to be changed to officially sanction this. The other fee-charging clinics like private MRI clinics represent institutionalized queue jumping, and this has been acknowledged by the feds for years but of course, nothing has been done about it either. See section “G” Privatization after the Tables on Uninsured Services. http://www.parl.gc.ca/content/lop/researchpublications/944-e.htm

    • Carlos, with respect to my decision to join a concierge clinic; as Elaine pointed out, when we returned to Calgary we could not find a GP who was taking new patients. An utterly ridiculous situation, but there it was. We used walk-in clinics occasionally but walk-in clinic doctors could not refer us to specialists. Given that we required a specialist’s care we joined the clinic because it was the only way to get a GP who could make the referral. Also as Elaine points out, my company had its own executive medical program which led us to this particular clinic. We were lucky we could afford to take this step, but would have mortgaged the house if that’s what it took to get the right care. Others are not as fortunate as we were. That’s why I strongly support our public healthcare system and am working with people like Elaine and Wendy to ensure that it isn’t undermined by concierge clinics.

      The GP shortage in Calgary is easing a bit, however two of my colleagues are still going out of town to access a GP. One drives to Canmore; the other drives to Edmonton. As I said…utterly ridiculous. To make matters worse, the cut to the post secondary budget imposed by Mr Lukaszuk means that the U of C medical school will cut 15 medical student positions out of its program this fall. This will make a dicey situation even worse.

  6. Carlos Beca says:

    Susan you did what you had to do and it is simply none of my business but I understand what you mean. I was just surprised but I got it now. I learned something new in the process – I did not know that walk-in clinic doctors could not refer people to especialists. That is bogus and of course probably to protect family doctors more.

    I am quite sure that concierge clinics are going to undermine the system and that is why the govenment does nothing about it. At Federal and Provincial level, it is their objective to set a two tiered system. Alison Redford has said over and over that she supports the public system but who can believe her. So far she has done almost everything that she said she would not do,

    Not surprised with the situation of medical students in Calgary. I have never been so frustrated with how this province is not being managed at all.

    Lukaszuk is very low key these days and I am sure the spin doctors must have warned him that he is severely damaging the government’s image.

    • Thanks Carlos. I’m with you–I don’t think I’ve ever been as frustrated with the government (both provincially and federally) as I am now. Their lack of vision and compassion for all citizens not just those who vote for them is truly breathtaking.

  7. carlosbeca says:

    Breathtaking is the right word. I have many times wondered if our Canadian culture has actually changed to a more agressive, less compassionate way. That is not what I feel from people around me but I have learned that in Alberta people always agree with you to avoid discussion. In reality they believe in something completely different.

    I am sorry Elaine I forgot to acknowledge your reply and explanation on the concierge clinic. Thank you.

  8. Elaine Fleming, Whitemud Citizens for Public Health says:

    Thanks for this Carlos. I have posted the article to the Whitemud Citizens for Public Health Facebook. This is an issue we have been concerned about for awhile and have discussed at length with our MLA’s, different health ministers, politicians from the other political parties and even the Premier. We are definitely going in the opposite direction vis a vis privatization of the delivery of health services. Opposite, and backwards.

  9. J Anne says:

    Hi. I think the big question is that the health care has to bring in more doctors, and to acknowledge the problem of lack of care, due to doctors being limited to getting paid for a limited time with patients. I’ve been in the regular health care system since I was young, and almost died due to lack of time, attention and basic neglect. As well, neglect in receiving proper diagnostic imaging when needed. I do agree that there is always a bad apple where ever you look, including private health, but not all are like that. I am in survival mode, and want to do the best I can with the disease I have in seeking the best care possible, which I have found in naturopathic private care, and concierge medical care. I’ve been in triage limbo since spring of this year, still waiting to see a specialist, and told probably won’t get to see one until next year. No jumping the que happening in Alberta in my doctor’s private clinic. But I am going to the US to see specialist instead. A family member just paid to get private MRI done (they are not rich) as the wait would have been 8 months for health care paid one. It was a good thing, because problems showed up, and gave them a piece of mind that they can now focus on the further care needed. Yes, system is flawed, but when your sick, it is nice to have options. To not have options, in my opinion, is a country or province impeding on basic rights. I believe in combination of private and public care. I do understand potential concerns with the concierge private clinics, but reality is there are people like myself who are willing to pay to get the help they need, and the last thing you think about when you’re ill and frustrated with the health care system, is the fairness of these clinics being around. I do hope these clinics are not taken away.

    • J Anne the point you make is a good one—we’re all human and we will do whatever it takes to ensure that we get the treatment we need. That’s why despite my strong support for the public healthcare system I finally gave up and took my daughter to the Mayo clinic for assessment. It was very expensive but we were getting absolutely nowhere here in Alberta and were at our wits’ end.

      There is a major disconnect between how we say universal healthcare should operate and how it actually operates in a province that is continually touted as the richest province in the country. Where does all the money go? Why don’t we have more doctors, particularly family medicine doctors who, according to the literature, are the “connectors” who ensure that we get the right care where and when we need it. Why don’t we have enough facilities to treat our ever increasing population? And most importantly, where is the strategy that will see us through this difficult issue?

      I do hope that you will find relief soon. The struggle must be very stressful for you.
      All the best.
      Susan

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