Do doctors have the “democratic” right to charge whatever the market will bear for “uninsured” medical services? Or do the principles of universality and accessibility under the Canada Health Act still apply to the practice of medicine in Alberta?
Apparently some physicians feel they’re underpaid (join the club) and want to get on the “uninsured services” gravy train to supplement their income. The government assists them in this endeavor by arbitrarily delisting various “insured services”. This shrinks the basket of “insured services” and dumps the now “uninsured services” into the laps of enterprising medical professionals who charge market prices for services that once were free—well not entirely free, you paid for them with your tax dollars.
The Doctor, by Sir Luke Fildes (1891)
Recently, the College of Physicians and Surgeons (College) asked for feedback on amendments to its Standards of Practice. The purpose of the amendments was to ensure that access to medical care was based on medical need, not the ability to pay. Um…isn’t that the law?
Consultation 0005 quickly blew up into a debate about shutting down private MRI and CT services, the need for a two tier healthcare system and a how-dare-you attack on the College on all fronts.
Standard 18 “Charging for Uninsured Services”
“Insured services” are services the government pays for with your tax dollars. “Uninsured services” are everything else–from writing an absence note so your child can return to school after a bout of measles to “boutique” services like on-site physiotherapists, dieticians, kinesiologists, personal trainers and life coaches.
Nothing in Standard 18 prevents a doctor from charging for uninsured services.
What it does do is require a greater degree of transparency with respect to fees for “uninsured services”. Doctors would have to tell their patients the cost of an uninsured service in advance. They’d have to give their patients a choice between paying an annual fee for uninsured services upfront or paying as they go. In both cases doctors would be required to provide a schedule of fees for each uninsured service. Sounds reasonable, rather like asking your mechanic to check with you before he makes off-warranty repairs to your car.
Doctors would no longer be allowed to charge a fee for “being available” or for providing preferential access (oh good, because that’s illegal). Moreover, doctors could not refuse to accept a patient who wants basic “insured services” but doesn’t want to buy any of the “uninsured” bells and whistles (in the business world that would be anti-competitive tying and bundling—it’s illegal).
Promoting transparency or putting the brakes on two-tier healthcare?
Surely no self-respecting doctor would have an issue with greater clarity and transparency, so what’s the issue?
The Standard says the fee for uninsured services must “reasonably reflect the physician’s professional costs, administration costs and the patient’s ability to pay”.
A physician’s “professional costs” are not the same as a market-based fee so the size of the uninsured pie just got a whole lot smaller. Also, the reference to “the patient’s ability to pay” implies that the fee can be based on a sliding scale—a higher fee for a Daddy Warbucks and a lower fee for Little Orphan Annie.
That makes sense given the financial barriers to accessing private MRIs/CTs.
Physicians respond
The response from the medical profession and a smattering of civilians* was brutal. Comments condemning the amendments outnumbered comments in favour by a margin of four to one; 45% of the comments were made anonymously! Is there a pro-privatization secret society out there?
The barrage of criticism started with the mistaken premise that the College was surreptitiously trying to ban access to private MRIs/CTs and boutique clinics, when in fact it was trying to introduce greater transparency and an “ability to pay” limit on uninsured fees.
Commentators castigated the College for attempting to protect a failing public health system, meddling with the physician’s right to decide his own “financial destiny” (this guy should be in advertising), interfering with a patient’s right to choose his treatment, unfairly preventing the rich from accessing private medical services and…wait for it….going over to the undemocratic, socialistic and/or communistic dark side.
The underlying issue
The Anti-Commentators framed the issue like this: A physician’s ability to deliver reasonable access to medical service is hamstrung by our inept government’s budgetary constraints, consequently public healthcare is failing and it’s time to embrace a two-tiered health system. In the words of Anonymous, “Restricting the natural evolution of privatised medicine in this country will be socialistic at best”.
Health Minister Fred Horne & his boss
Fair enough–a failing public health system is a legitimate concern, however it is not within the College’s power to redress.
All the College can do, says Dr Matthew Rose, is ensure that Albertans have equitable access to necessary care and that inappropriate billing for “uninsured” services does not become a barrier to appropriate care or a means to privileged care. Hear, hear!
Allowing physicians to offer uninsured services with no regulatory oversight not only violates the College’s mandate to protect the public; it allows Alberta to slip deeper into a two-tiered health system without first engaging the public in a fulsome dialogue about whether this is necessary or desirable.
The move to a two-tiered health system should be made with thoughtful public consultation. It can’t be the unintended consequence of a physician’s desire to control his “financial destiny” or a well-heeled patient’s desire to get to the head of the queue.
*Ms Soapbox offered a comment under her real name, not behind the mask of “Anonymous”.
Susan on the Soapbox 
Very interesting post this week Susan. Thank you as always.
I am not at all surprised with the reaction you called brutal. I honestly believe that the balance of opinion is quiclky shifting to the privatization of the system. Total neglect of the existing system along with the obvious ‘let it happen’ atittude of the provincial government and the usual non-existing position of the Harper government and the growing public concern with the falling care quality is definitely going to cause the expected.
In a way I do not blame the doctors for their desperate hope to get on the consumer bandwagon. Citizenship is on the decline, consumerism is king and we will have to all pay the results of this race to no where. We call young kids ‘consumers’ over and over. We brain wash them with an hyper comercialized society. We expose them to everything imaginable including our most corrupt atittudes of take as much as you can especially when no one is watching and to political scandal once thought to be non-existent. Amazingly we expect these kids to become great people and in the case of this post, great caring doctors more concerned with patients then the the boat on the list for a Christmas purchase.
It is not going to happen and privatization is well on its way to full implementation very soon.
I will end this with a simple question – How would you feel about the existingsystem if you were a young doctor starting your career today?
Great question Carlos. I imagine that young doctors are very concerned about practicing medicine in Alberta. It would be extremely trying to deal with the constant upheaval in AHS (not surprisingly the new CEO of AHS captioned his first memo to AHS staff as “Moving to Calmer Waters), the antagonism between the profession and the government (which disappeared temporarily when they settled their contract dispute) and the government’s stealth attack on public healthcare that benefits their benefactors and leaves the rest of the profession out in the cold.
Nevertheless there are still some wonderful doctors out there, like Dr Noel Corser who made this comment in Consultation 0005: “We need to remember that the central goal of our profession is caring for patients, and that “running a business” is merely supportive of that.”
I have no doubts there are great doctors out there. I have no doubts there are many Albertans that are concerned with what is going on, but power always wins unless there is a David somewhere with unlimited courage and those are hard to find in normal times never mind in current times. It was just on the news this afternoon that our eminence Lukashuk just spent 11 thousand dollars in redecorating his ministerial office. The meeting table alone cost 4500 dollars. Now I know this is very silly to say but I am going to say it anyway – where is the baseball bat?
For clarity, Susan, people need to understand that there are doctors who are charging from $3000-$10,000 a person for membership in their clinics, and for this money they are promising access 24/7 to their medical services. The fact of the matter is, that our medicare system, and the laws that uphold it, are based on people having access to doctors regardless of their ability to pay. Period.
These “concierge” or “private” clinics as they call themselves, also promise “special” more in-depth medicals, lab work and diagnostics tests (which they bill the public insurance plan for as well- known as double-billing). There are some people who are concerned about whether all this testing is appropriate and whether these patients being taken advantage of. The whole area of expedited access to specialist care (queue-jumping) comes into play as well, and how these individuals will have access to, say, surgery in our public hospitals.
These exclusive clinics also offer access to other services, “uninsured” services that you mention such as massage therapy, exercise counselling and so on, some clinics including these things as part of their membership and others charging for them a la carte. Some people say there is considerable “upselling” of these extras by the staff in the private clinics.
It is important that you (and the College of Physicians of Alberta) are bringing these issues into the public domain for discussion, because so much is changing under the radar, so to speak, and the average citizen is completely unaware. Our governments, provincial and federal, have turned a blind eye to these events over the last several years, so it is up to us to remind them that they have the responsibility, and the authority to protect Albertans and their access to adequate health care.
Well said Elaine. Just an anecdotal story with respect to concierge clinics offering “in-depth” medicals and “base line” diagnostic tests. An acquaintance belongs to a concierge clinic here in Calgary. His doctor advised him to get a CT scan. There was no medical reason for the scan, it’s purpose was purely to get a “base line” of god knows what. The fellow underwent the CT scan and later applied to his insurance company for additional insurance coverage. The insurance company rejected his application, apparently because it was convinced that no one undergoes a CT scan unless they have a good medical reason to do so. They simply didn’t believe that he’d get one for no reason at all. To make things even worse, the fellow will never be able to apply for additional insurance again because he’d have to disclose that he’s been denied by this company or risk invalidating his policy. Probably not the outcome he or his doctor expected.
Good blog Susan.
At the very least, a more costly tier of access should not be subsidized by those in a lower tier which is what occurs now with physicians working in membership-based concierge clinics billing the public plan for a number of services provided to enrolled patients as well as receiving a generous salary or hourly fee from the concierge company through membership fees. Even the former Bush Senior government in the US has taken these practices to court.
Bottom line: Private markets are not free-for-alls where there are no rules and you can do whatever you want. For markets to work to the benefit of a community and society, they need to be “fair markets”. This holding someone hostage and demanding fees for other services or products to gain access to the originally desired service, as you point out, is considered anti-competitive in the real world and often outright illegal, an unfair trade practice like bait and switch or a Ponzi scheme.
Plus no small business people I know other than physicians who opt into provincial medicare plans have a billing number that gives them the right to invoice the public purse for a whole range of services provided to any Canadian who walks in the door and also have their legal fees/malpractice insurance largely subsidized by all taxpayers.
Its not only the up-front fees for concierge clinics that are creating illegal barriers for public plan members to access insured services (as well as other problems), there are places like Caleo Spine in Calgary which reportedly charges $200 for a required physio assessment prior to getting in line for a publicly insured spine surgeon assessment. I have also heard of cases where a doctor in the ER of an Alberta hospital demanded an upfront cash payment $600 at 10 o’clock at night to see a very sick person who just got off a plane – in one case, a young Canadian woman who no longer had medicare coverage because she was teaching in Asia to pay off her student loans.
It all sounds like extortion to me.
Uninsured people – i.e., visitors and Canadians living outside the country who come home for a visit, are also a good example of someone urgently needing uninsured services where discretion and ability to pay really does need to be considered. Interestingly when my daughter in Thailand ran out of health insurance and was injured in minor accident, she was seen and treated in the ER in Bangkok for free.
There are other hidden costs and harms associated with concierge and executive health check companies (often one and the same) including their referrals for private pay CT/MRI scans for “no good medical reason” – as your friend found out. So did Brian Mulroney when he became extremely ill with complications from lung surgery for an “incidentaloma” that turned out to be nothing but was identified in a “preventative” CT scan as part of an executive health check. See http://www.policyalternatives.ca/publications/commentary/beware-sales-pitch-unnecessary-ct-scans
and http://www.edmontonjournal.com/news/Opinion+Lengthy+waits+need+diagnosis/8994875/story.html
Given the experience in some other countries, I also suspect that many doctors who eagerly embrace these new practices today and rationalize taking unfair advantage of captive markets will wake up one day and find themselves wearing golden handcuffs with less autonomy than they could ever imagine. . . and in court without taxpayer subsidized legal counsel.
While the College of Physicians and Surgeons has the delegated authority to bring in standards and guidelines to govern the behaviour of individual physicians, it does not have the authority to deal with the companies and investors with whom they work or the conflicts of interest that are the root of many of our current problems, so they are doing what they can.
Their current proposed new standards related to the legal and moral management of insured and uninsured services and doctors leaving or closing a practice have come forward at this time in part due to disturbing testimony and examples that came out during the recent Preferential Access Inquiry. (I had a front row seat as a representative of the Consumers’ Association of Alberta, an official intervenor). We should not forget these stories and examples like Helios.
So, let’s support the many less vocal doctors and the College who, despite all the upheavals in their lives and ours, still think that fair treatment of one’s fellow man and some rules to protect the public and the credibility of the profession aren’t too much to ask. The last thing any of us want to worry about is whether a physician is recommending a course of testing or treatment for our good or for the good of investors in a company he works for or his own pocketbook.
Wendy
AKA Little Red Riding Hood
Wendy, thank you for this thorough and insightful comment. I especially liked your comment that the private market is not a no holds barred free for all. I worry that some doctors are trying to get the best of both worlds, guaranteed payment from the public purse for “insured services” topped up (doubled or tripled more likely) by the unregulated “uninsured services” income stream. If this comes to pass there is nothing to prevent the scenario you describe–physicians recommending testing/treatment for the good of his own bank account. Even the US instituted laws to prevent this self-serving predatory behavior.
Lynette Reid (the bioethicist who testified at the Preferential Access Inquiry) makes some interesting observations about the CPSA consultation process in her blog, Biocitizen. Here’s the http://biocitizen.ca/cpsa-public-consultation-on-concierge-clinics-coming-to-a-close/
Wendy, one more thing, I thought you with your delightful sense of humour would have commented on the startling resemblance between the photo of Little Orphan Annie/Daddy Warbucks and the one of Alison Redford/Fred Horne!