October 24, 2014
Dr. Ryan Meili, The Star Phoenix
Meili is a family physician in Saskatoon and vice-chair of Canadian Doctors for Medicare.
Premier Brad Wall took to Twitter last week to ask: "Is it time to allow people to pay for their own private MRIs in Saskatchewan like they can do in Alberta?" This came after a radio talk show during which he'd received a call from a patient who's been waiting three months for an MRI scan. This is one of many Saskatchewan patients who are, understandably, frustrated by long waits for essential imaging services.
It is a real problem. For that reason we should be very wary of false solutions and look first to evidence before rhetoric takes over. The best place to look for that evidence is the province Wall references as a model.
Many Saskatchewan residents have sought out care in Alberta's private MRI clinics, giving the impression that the experiment there has been a success. When we take a closer look, it turns out things are not so wildly rosy in the land of private MRIs.
Perhaps the most surprising fact is that the wait list for MRI scans in Alberta, rather than having been shortened by the presence of private imaging clinics, is actually the longest in Canada. According to the Canadian Institute for Health Information, patients in Alberta can wait from 87 days to 247 days for a scan, compared with 28 to 88 in Saskatchewan.
These waiting lists exist despite Alberta having the second highest number of scanners per capita in the country, suggesting overuse may be a problem. Excess capacity may actually exacerbate this phenomenon.
It may seem counterintuitive that the public wait list would lengthen in the context of having more MRI clinics and scanners. It appears that capacity, in the form of physicians and technologists, is siphoned off from the public system by parallel, patient-pay services, a pattern that has been seen in surgery as well as imaging.
Premier Wall has talked about creating a mechanism to prevent this drift of resources from the public system, but the experience of jurisdictions around the world suggests this promise should be viewed with considerable skepticism. Even more troubling is the question of equity. If an MRI scan is the limiting factor in getting a surgery and I can pay for my scan, I get to have my publicly-funded surgery before someone in as much need but less able to pay out of pocket.
This is the principle reason that the existence of patient-pay MRI clinics, as Wall pointed out in a 2008 StarPhoenix interview, is against the Canada Health Act.
They clearly violate the principle of universality by allowing certain patients to access care quicker than others based on finances rather than medical need.
While the reputation of Alberta suggests a preponderance of private imaging centres, the reality is that in recent years that province has moved away from the patient-pay model. Many of the private clinics charge the public system for the scan and also charge the patient a premium. Alberta was also forced to repay some patients who had paid for medically necessary scans.
With no financial savings and no increase in accessibility, there is actually little real impetus for provinces to promote patient-pay imaging centres. In fact, Alberta has moved in the opposite direction, increasing public capacity and ending the practice of contracting out services to private facilities.
As a result, there appear to have been no new private MRIs built in Alberta in the past decade as the business case for such operations is limited without public subsidy.
Along with failing to increase affordability and access, private MRIs pose a more insidious threat to publicly-funded health care. The more that Canadians
believe they have to pay out of pocket for necessary care, the more we will see confidence in and commitment to medicare eroded. We need strategies to improve access to diagnostic technologies that strengthen medicare rather than strategies that undermine it.
Premier Wall has expressed a real interest in leading innovation in health policy. There are ways to improve access to MRIs that don't undermine the principles of the public system or confidence in it. Imaging is one of the most overused elements of our health-care system. A 2013 study of MRI use showed that more than half of lower back MRI scans in an Alberta hospital were not appropriate.
Working to promote rational use of technology is one way to make sure it's available for those who need it most. Expanding hours of use, training programs for personnel and the number of machines in the public system is another.
Anyone can learn from their mistakes. A true leader learns from the mistakes of others. Saskatchewan should look closely at the experiences of other provinces before it chooses a path that, while seeming to offer solutions to our challenges in health care, could actually make them worse.
Source: The Star Phoenix