Recent revelations about private surgical clinics in Vancouver offering quick service to patients willing to pay a "facility fee" have once again sparked debate about private clinics. Doctors who run these private surgical clinics argue their private services will decrease waiting times for others.
Experience and evidence from across Canada and around the world, however, does not support this claim.
All health systems manage access to services by establishing queues of one kind or another. In the US, access depends heavily on how much money one has. In BC, the job of managing wait lists falls mainly to physicians, and it appears most of them do a pretty good job. In May, the median waiting time for general surgery was 3.1 weeks, while for orthopedic surgery it was 7.0 weeks.
Compare this with some of the orthopedic surgeons who work in both public hospitals and private clinics, whose patients are waiting between 50 and 55 weeks for surgery. This may explain why these patients are willing to pay so much money to move up the line, but if they switched doctors they might find their waiting times drastically reduced, and their wallets a little better off as well.
A study of waiting times for cataract surgery by the Consumers Association of Canada found that Alberta patients whose eye doctors practice in both public hospitals and private clinics not only have the longest waiting times, but are also paying the highest user fees. The study looked at Calgary, where all cataract surgery is done in private clinics, Edmonton, which has a mix of public and private, and Lethbridge, where all cataract surgery is done in the city's public hospital.
The results showed that cataract patients in Calgary had the longest waiting times and paid the highest fees for surgery. Patients in Lethbridge paid nothing for the surgery, and waited the shortest length of time, while Edmonton fell in between the two.
Missing from the debate thus far is a clear reminder of why universal access is so important to sustaining a vibrant public system. First, private clinics serve only those able to pay, and thus erode equity. Second, universality eliminates class differences. Our public heath care system is cherished by virtually everyone, because currently all taxpayers benefit from it and have a stake in it. But when those who can afford to turn elsewhere, support and funding for our public system will wane, and waiting lists for public services will grow.
That has been the experience of Britain. When the Thatcher government moved to a two-tier model, professionals and funding were sucked from the public to the private system. The quality of the public system became a shell of what it once was, serving those without the economic capital to use private hospitals, and lacking the political capital to demand adequate funding.
Australia also operates with parallel public and private health care systems. There too resources have been diverted from the public to private system. Waiting lists at the public hospitals are now longer, and public money has not been saved, as private facilities have required billions in public subsidies to stay afloat.
When equity is eroded it is the middle class who pay the highest costs, while the poor get charity health care if they pass a means test. In the United States, for example, medical bills are the leading cause of personal bankruptcy. In 1996 one out of eight American families spent 10 percent of their incomes on insurance premiums (on top of what their employers paid), in addition to out-of-pocket expenses for services and supplies.
Studies have also raised questions about whether doctors should be able to practice in clinics in which they are also investors. A report published in New Zealand last December looked at doctors who practice in a mixed public and private delivery system. It showed that ophthalmologists (eye doctors) have a strong financial interest in maintaining long waiting lists for cataract surgery in the public sector, in order to fuel demand for more lucrative private sector care.
Some doctors offering private surgery insist they have a "moral duty" to do so. Such arguments, however, see our health care system in narrow and individualistic terms. Doctors have a moral duty to all patients in need--not just those willing and able to pay private fees of $1,400 to $2,400--and a duty to refer patients to other doctors they know to have shorter waiting lists. And we all have a moral duty to protect the universality and accessibility of our entire health care system.
The solution to lengthy wait times is not to turn to private clinics. Rather, it is for our federal and provincial health ministers to end extra billing and user fees, provide the health system with sufficient funding, ensure an adequate supply of specialists in under-serviced areas, and maximize the utilization of public operating rooms.