From Hippocrates to Hypocrisy
By Steven Lewis
Winnipeg Free Press
August 21, 2005
The official voice of Canadian doctors has had it with single-tier medicare. Why? Because patients are suffering and dying waiting for care, according to the ineffable Dr. Victor Dirnfeld of British Columbia, with rhetoric unsupported by evidence.
Governments just don’t give Canada’s altruistic doctors the resources to do right by their patients. The solution: Give Canadians a choice to buy their way out of the public lineup.
Last Tuesday, CMA delegates timidly endorsed a private, parallel system by resorting to the convoluted vehicle of the double-negative (voting against a resolution that was against private medicine).
By Wednesday, they were braver. Sixty-four per cent voted in favour of this resolution: “The Canadian Medical Association supports the principle that when timely access to care cannot be provided in the public health-care system the patient should be able to utilize private health insurance to reimburse the cost of care obtained in the private sector.”
Good for the CMA. On Tuesday, the debate was muted, the proceedings oddly preoccupied with wording. No passion, no ringing discussions of principle. Not with a bang, but a whimper. The next day, more spirited to-and-fro. In the end, forced to take a stand, the 200 delegates took one.
It’s folly to blame an interest-group for pursuing its interests. The CMA does not exist to advance the public interest — it is the doctors’ lobby, pure and simple. And, like all sophisticated interest groups, it insists that it is solely preoccupied with the well-being of the public.
Ergo: When a bunch of us doctors set up private clinics for the well-to-do, all Canadians will get better and more timely care. That’s why we’re doing it — nothing to do with money. We deeply admire the public system; we just can’t pass a resolution that declares it to be the best option. We share its values, only it isn’t getting the job done.
Government’s fault — always is.
The CMA has traded the Hippocratic for the Hypocritic with a capital H. But it could show the public just a little respect. We’re quite prepared for your pursuit of self-interest.
You don’t have to pretend you’re doing it for us — you’ve been ambivalent about medicare since the beginning. It’s not about us having a choice, since, by the CMA’s own reckoning, most Canadians won’t be able to buy private insurance. It’s about you having a choice. We’re just fodder for the argument, and collateral damage when you get what you want.
So come clean. Celebrate the lucrative private options for doctors who want to make more money and restrict their practices to those in their own class. Tell us candidly that you favour a minimalist set of core services for the masses, reserving the high-quality diagnostics and fast access to care for successful people like you. That way, you’ll make more money. And, with a stripped-down public system, you’ll pay less tax, too.
And don’t be afraid to chide the thousands of physicians who are naïve enough to commit to the public system. Tell them that their labours are in vain, their system is second-rate, their Toyotas an embarrassment in the hospital parking lot.
Let’s assume that many doctors will want out, and the public system will be under more strain with its capacity temporarily reduced. What can governments and the public do to strengthen the public system and shore it up against further erosion?
There’s a lot that can be done. First, let’s get all the talent in the public system working at full capacity. Get other professionals involved more centrally in primary care. A team of nurses, rehabilitation therapists, psychologists and pharmacists is capable of providing excellent front-line care. If my physician clinic went private and I had the option of seeing a nurse practitioner in a comprehensive clinic, I’d go in a minute. I might go anyway.
Second, if the CMA and its followers want a private and parallel system, make sure it is truly private and parallel. Don’t subsidize it by training its personnel at huge public expense — charge them full tuition ($60,000 a year for physicians). Make them build their own hospitals so the complications from their surgical centres don’t end up taking our space in the public system.
Students at the swish private schools — you know, the ones that the CMA likes to refer to as benign analogies to private medicine — don’t get to use public-school facilities whenever it’s convenient. Let them and their investors put billions of dollars on the table and see if they can make a go of it. You want to be entrepreneurs? Go for it — assemble the capital, take the risk.
Third, regulate profiteering and over-servicing. Provinces can pass laws that opted-out physicians can charge no more per service than the rate in the public system. Some do so already. Require private clinics to undergo regular quality and utilization audits. The U.S. is full of horror stories of investor-driven excess. Examples: A northern California hospital was cracking open chests to perform unnecessary by-pass surgery in response to pressure from the head office to increase profit margins. A southern California outfit was flying in healthy patients from the East Coast to undergo a few days of diagnostic investigations to generate higher revenues.
Impossible here, you say? Think Enron. Think Vioxx. Hell, think Krispy Kreme. Profit is a harsh taskmaster.
Fourth, and importantly, make doctors choose — in or out. No hybrid public and private practices. Take away the safety net: You don’t get to maintain a part-time public practice, where the state pays your fees, while building up your private and parallel business.
You’re entitled to move out — and we’re entitled to change the locks.
But it’s not just governments that have to respond vigorously to the privatization challenge. It’s all of us. Citizens have to make medicare a political issue at both the provincial and federal level. Make parties declare where they stand. If governments get a democratic warrant to preside over the development of a private and parallel system, let it blossom. Canadians deserve a chance to vote on it, one way or the other.
Not everything has to be overtly political. Legions of doctors are philosophically committed to the values of public health care and do their best to make it work. We should support them, honour them, and let the world know who they are. Launch a sticker campaign that certifies medical offices and clinics as medicare-friendly. Voting with one’s feet is always a healthy signal to those who earn their living by serving us. Ask the embarrassing question when making an appointment: “Are you a medicare-friendly clinic? If not, why not?”
And every once in awhile, hit the streets. As the CMA drafts its report on how the public and private systems ought to interact, serenade it with the chants of tens of thousands of citizens in front of their Ottawa head office in support of single-tier health care. Demonstrations in front of provincial medical association offices would be similarly invigorating.
We owe a debt to the CMA for letting us know where it stands. Let’s reciprocate the favour by letting it know, loudly, where we stand. If, in the end, the public sides with the CMA, applaud them one more time.
All that is clear right now is that if medicare is to improve and thrive, it will be in spite of — not because of — the efforts of organized medicine.
Steven Lewis is president of Access Consulting Ltd. in Saskatoon and adjunct professor of health policy at the University of Calgary.