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OP-ED: Private delivery acceptable when key criteria are met

January 25, 2013

The Medical Post

Opinion Editorial by Dr. Danielle Martin

Canadian Doctors for Medicare says it opposed Shouldice Hospital sale but not all private delivery of health care

In a recent editorial about the Shouldice Hernia Hospital, Medical Post editor Colin Leslie asks the “thoughtful left” whether there “are any situations where standards and oversight can make the private delivery of publicly paid, publicly administered complex health care acceptable.”

I would like to answer this question on behalf of Canadian Doctors for Medicare. Although we are non-partisan, we try to be thoughtful, and we are committed to improving health care for all Canadians.

“Are our criteria impossible for private providers to satisfy? We don’t think so. The Kensington Eye Institute in Toronto is a good example of a new model of care that provides high quality care to everyone.”

Our big concern is not about labelling public “good” and private “bad”—it’s about determining how various models of health delivery affect the health care that Canadians receive. That’s how we arrived at the conclusionthat, for example, the proposed sale of the Shouldice Hospital to a large corporation traded on the Toronto Stock Exchange and controlled by U.S. shareholders would not be in the public interest.

Canadian Doctors for Medicare has a systematic approach to assessing any proposed clinic, hospital or surgical centre, whether it’s private or public. It’s our Health Care Delivery Assessment Tool, and it’s available on our website.

The tool assesses the impact a new or proposed delivery model will have in four areas: equitable access, quality, appropriateness and integration.

The vast majority of Canadians—including physicians—believes that access to health care should be based on need, not wealth. So when a new model of care is being proposed, we would ask: Will the model allow for queue jumping? Will it place new financial burdens on patients by asking them to pay fees? Will the new model worsen access to care for most Canadians by using physicians, nurses or other health-care resources for a select few rather than for everyone?

Increasingly, the public is recognizing that not all health-care providers are the same, and that there is substantial variation in the quality of care. Physicians have always known this—we have our favourite surgeons who we recommend to friends and family, for example.

So when a new model is being proposed, we would ask: Will the quality of care be measured? Will the new model support capacity development by offering educational opportunities for medical students and residents? What will happen if the interests of investors conflict with the interests of patients? What safeguards will be put into place so quality doesn’t suffer?

For-profit providers in other countries and here at home sometimes increase their profits by encouraging unnecessary care. Many studies have shown that in the United States, for example, physician-owned diagnostic facilities promote unnecessary tests. This is not simply a waste of money. Unnecessary tests can cause harm—for example, it is now understood that CT scans in young people increase the lifetime risk of cancer by one in 1,000. This is a small risk at the individual level, but not trivial when we consider whole populations.

Finally, a health-care system that works well for patients needs to be integrated. Would the new care provider be willing to share clinical data with existing providers? Would public accountability be maintained by providing anonymized data to researchers?

Put simply, we have no objection to private care when quality, access and value can be maintained or improved.

Selling the Shouldice Hospital to a large corporation controlled by American shareholders would have been unlikely to improve access, quality or value for the Canadian public. We opposed the sale on those grounds, based on transparent and evidence-informed criteria.

Are our criteria impossible for private providers to satisfy? We don’t think so. The Kensington Eye Institute in Toronto is a good example of a new model of care that provides high quality care to everyone. Many physicians, of course, also run their own businesses and provide excellent, efficient care to all comers.

Other private providers obviously fail. For example, private diagnostic imaging centres in Quebec only serve patients who can afford their fees. Is it just a coincidence that wait times in the public system in Quebec are longer than elsewhere in Canada?

The point of our Health Delivery Assessment Tool is to provide people with a framework for thinking about whether proposals like the Shouldice- Centric Health deal are good for patients and the public. If governments and private interests used transparent, explicit criteria like these, we think the world of health-care policy would be better off.

It’s a tall order perhaps, but a thoughtful one nonetheless.

Danielle Martin is a family physician in Toronto and chairwoman of Canadian Doctors for Medicare.

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