Critics say privatization of health care in Canada could cause a polarization of services, dividing medical care between premium 'wealth care' service for those able to pay and below standard care for those who cannot.
Tom Koch, 57, is a Vancouver-based ethicist and the author of a score of books about medical and journalistic issues of a moral nature. He describes himself as a democratic socialist. And when it comes to B.C.’s health-care system, he says, “It remains my belief that nobody should receive what everybody can’t.”This placed him in an exquisite dilemma when the private Copeman Health care Centre – Canada’s first private, primary health-care centre – opened in downtown Vancouver last November. His GP of several years, Peter House, announced he was leaving the Seymour Medical Centre to become medical director at this new, private clinic. Koch, who has arthritis, has been very vocal in his opposition to the privatization of health care. But, he admits, “That opposition paled before the need to have a physician who I knew thought like I did about things like pain control. The relationship I had with my personal physician whom I respect outweighed my concerns about private health care.” Koch felt House was much more proactive than his previous doctor. He was informative, a good diagnostician and sympathetic. It took Koch nine months to decide what to do, but in the end he paid his $3,500 and joined the clinic. “I’m not happy about it, quite frankly,” he concedes. Koch’s doctor didn’t have the same qualms when he was asked to join the business as medical director. “I was given the opportunity to work in a low-volume, high-quality primary care model,” House says. “I could never find a business model that would allow that to happen. I wanted to provide more quality in care. I didn’t want to rush everybody all the time, which I’d done most of my career.”In the eyes of some, the Copeman Healthcare Centre is a long-awaited chance for doctors and patients alike to get off the public health-care treadmill and focus on the individual needs of the consumer (i.e., patient), particularly in the areas of disease prevention and promotion of healthier lifestyles. In the eyes of others, it’s a disaster – a free-enterprise money-grab that threatens the foundation of Canada’s health system, dividing medical care into two separate, unequal entities: premium care for those who can pay, and standard or below-standard care for those who cannot. But with an eye to the business opportunity, some research estimates the yearly market in Canada for private medical clinics like Copeman’s could reach $11.5 billion. So what’s really going on here? A May visit to the clinic, on the fourth floor of an office building on Hornby Street, is revealing, not to mention pleasant. Stepping out of the elevator, one enters a large room that looks like the lobby of a fine hotel, with original oil paintings on the walls, a vase filled with stargazer lilies on a sideboard and another with lilacs on a glass coffee table. Neatly arranged along a shelf below the coffee table, the magazines – including a recent issue of Wallpaper – are all current and only lightly thumbed-through. In the spa-like washroom, there’s a shower and complimentary terry cloth robes – no backless paper gowns here. Lavender and bergamot-scented soaps sit beside the wash basin. The Copeman Healthcare Centre is staffed by family doctors as well as other health professionals such as nurses, physiologists and dieticians. All clients pay the same fees, whether they use the clinic a lot or a little. It costs $3,500 in the first year and $2,300 every year after that. No one who can afford to pay is turned away, even those with serious,pre-existing medical conditions. Designed to accommodate 4,000 clients, the clinic is not yet full. When it is, nine GPs will be available, keeping the ratio of patients to doctors about 440 to one, much lower than in most B.C. family practices where a GP typically has between 1,800 and 2,000 patients on file.Don Copeman, 48, is a tall and friendly fast-talker. “I don’t like to call this a waiting room,” he tells me, gesturing around the airy, elegant space with its suede-covered lounge chairs, “because our patients don’t wait. I like to call it areception area.”Copeman, the centre’s sole owner, expects to meet his target of 4,000 signed-up clients bynext spring. How close is he now? He won’t say. “When we open another centre,” heexplains smiling, “you’ll know that we’ve reached capacity.” MSP: PROGNOSIS NEGATIVE Don Copeman wanted to be a doctor. He was in the pre-med program at McGill and Queen’s universities. When he graduated from the latter with a science degree in 1978, he was broke, so he took a job selling medical supplies and instruments. He intended to go back to university, but never did. Instead, Copeman quickly developed a successful business career. “It was very rewarding intellectually, financially and otherwise. I came from a relatively poor family,” he says. “There wasn’t enough to attract me back to medical school, particularly because I was in the medical industry and feeling good about what I was doing. ”In 1997, Copeman became a partner in Vancouver’s False Creek Surgical Centre. He was the CEO for several years, managing the business side of the centre. (This summer, he divested himself completely of his holdings in that clinic in order to devote himself to his own.) Copeman says his years with the False Creek Surgical Centre opened his eyes to our “deteriorating medical system.” But it was his own family’s health problems that galvanized him into action. Copeman has a six-year-old boy, Max, who is autistic. When, as a toddler, the boy stopped speaking, Copeman had to wait several months before he could see a pediatrician. Even worse, the physician did not recognize the symptoms of autism. Max was put on a waiting list for further assessment. Two years later, Copeman received a call telling him that the boy could come in. By then, Max was already receiving private care in the form of behavioural and cognitive therapy known to help with autism. Copeman believes that if he had waited two years to seek treatment, Max “would have lost any chance of recovery. He would be extremely developmentally impaired.” Copeman’s concerns about the health-care system were exacerbated when his brother almost died from a post-operative infection Copeman says was not properly dealt with. And he lost his father, who was in his late 70s, to a rare form of cancer. Copeman maintains there were issues about waiting for an MRI, though he doesn’t say that a faster diagnosis would have changed the outcome. [pagebreak] “You pay all your life into the public insurance scheme,” he notes, “and then when you go to use it, it’s not available. That’s just ridiculous.” Copeman began thinking about how to make things better. Like many experts across the political and ideological spectrum, he concluded that the problem lies with family doctors. In B.C., after expenses, full-time family docs take home an average of $107,000 a year. Specialists can earn twice that. The Medical Services Plan pays them set fees for different services and out of this, doctors have to cover staff salaries, equipment, supplies, rent, continuing education, insurance, licences and other costs of running a business. After their long, income-dry years in medical school burdened by skyrocketing tuition fees, newly qualified GPs enter the workforce with punishing student debt loads, often in the $50,000 to $100,000 range, according toa 2004 BC Medical Association survey. Copeman and private clinic supporters say the only way for them to pay off this debt – and cover their office expenses – is to see large numbers of patients. A 2004 survey by the College of Family Physicians of Canada, the Canadian Medical Association and the Royal College of Physicians and Surgeons found that B.C. GPs average 117 patients per week, with some topping out at 500. Copeman thinks high patient loads increase the likelihood of mistakes (such as the missed diagnosis of his son’s autism). They also mean GPs don’t have time to conduct complex investigations, so they often refer patients to specialists. As a result, the specialists’ offices fill up with patients who have relatively minor ailments, which means longer waits for people with serious problems. Copeman argues that the majority of the problems handed over to specialists could be solved by family doctors if they had more time with patients and a little more expertise. So, he employs what he calls “expert” GPs, family physicians who have more knowledge than regular family doctors in certain areas: cancer care, sports medicine, women’s health, heart disease. Copeman’s doctors make very good money and see as few as 10 or 12 patients a day, about half the number parading through the average GP’s office. “If a client comes in with a sore throat, that might be easy to sort out and the visit might last three minutes, but if they need more time, if they need 45 minutes, they get it,” he explains. “This is not about extravagance. This is not about a doctor sitting down with fluffy towels and super comfy chairs, listening to nice music, sipping on a cappuccino. We’re hardcore medicine. We give people the exact amount of time they need. ”Copeman pays his doctors a healthy $225,000 a year. He can afford to be generous because of the yearly fees he charges; when the clinic is filled to capacity, gross revenues will top $9 million. The salary he provides is already twice what the average family doctor makes in B.C., but to sweeten the deal even further, his doctors’ incomes are boosted by their MSP billings. The Copeman physicians have not opted out of the provincial health-care system – they still bill MSP for their services and are compensated for treating patients just as they always were, except they see far fewer of them. According to Copeman, they should expect to make roughly $50,000 from these billings, bringingtheir total compensation to about $275,000. FEE ENTERPRISE As a business model, private clinics are gaining acceptance, particularly in Ontario, where 129 doctors have opted out of the public system, in Quebec where 97 have gone and in B.C. where six have left. But when the Copeman Healthcare Centre opened in Vancouver last fall, it created a firestorm of controversy. From coast to coast, headline writers lambasted the clinic for being an elitist, pricey, members-only club and warned about the arrival of two-tier health care in Canada. Debra McPherson, president of the B.C. Nurses’ Union, accused the centre of violating the Canada Health Act. And for weeks, George Abbott, B.C.’s Minister of Health, and David Cubberly, the NDP health critic, sparred in the legislature over it. In a country that once prided itself on its citizens’ universal access to free medical care, should for-profit health services be allowed? Copeman sees himself as a crusader and seems bewildered by the relentless attacks. “There’s a tremendous percentage of the population where it’s not the end of the world to spend $2,300 on your health if you’re at high risk of disease, if you have a bad family history. It’s really good value to be observed, cared for and nurtured. Sometimes it’s very hard for me to understand the criticism.”(It’s worth noting that if you are at high risk for a disease, the public system will also provide appropriate supervision and testing. However, if you have no symptoms or family history but you want a colonoscopy at age 40 just for peace of mind, the public system isn’t likely to cover that, but then neither would the $2,300 yearly fee at the Copeman clinic.) By late summer or early fall of this year, Copeman plans to open clinics in Toronto and Calgary, which he would also solely own. Eventually he expects to roll out 40 Healthcare Centres across the country. Having spent 18 months conferring with lawyers about his business model, he is confident that he is on solid legal ground. “The challenge is beating off detractors who are bent on confusing people,” he says. “It’s a tough battle, but you can tell the pendulum is swinging. There’s a handful of us in Canada who are arguing in favour of the pursuit of private options from a charter-of-rights perspective and from a free-enterprise perspective. ”The B.C. government, however, is not sure. In March, Health Minister George Abbott asked the Medical Services Commission, a nine-person independent body, to rule on the legality of Copeman’s business. In a phone interview, Abbott said, “There are real concerns about the structure and enough questions about it that it’s important that an independent authority like the Medical Services Commission either take action or provide me with advice. ”The Canada Health Act is supposed to guarantee that citizens have access to medically necessary doctor and hospital services without paying for them. Doctors at the Copeman clinic order tests, make diagnoses, prescribe treatments and drugs and referpatients to specialists, just as any GP would do. And Copeman’s patients don’t pay for these medical services – the government does. “The public piece is paid for by the public,” Copeman says. “Our feeling was that our clients have paid into health insurance just like everybody else. Why should they be denied insured services?” The government money goes to the doctors, and not to the clinic. Copeman adds emphatically, “We don’t get a nickel of that money. ”There is, of course, that private-clinic membership fee. Copeman says this buys members access to such non-insured services as nutrition, lifestyle and exercise advice not covered by MSP. “We drive people to make incremental lifestyle changes in a painless way to mitigate the risk of disease. We’re all about prevention, and if people already have diseases, we provide disease management. ”Non-insured services already amount to about 30 per cent of what Canadians spend on health care. They include optometry, physiotherapy, massage therapy and dentistry. Canadians also pay chiropractors, psychologists and naturopaths and they spend billions on prescription drugs. When it comes to these non-insured services and products, you can buy what you like and providers can charge whatever the market will bear. Private insurance companies such as B.C.’s Pacific Blue Cross can offer whatever level of coverage or reimbursement they choose for these services. (About 22 million Canadians have extended health-care insurance and 15 million have dental insurance, many as part of their employee benefit packages.)The Copeman clinic appears to be adhering to the Canada Health Act because patients aren’t paying their doctors; they’re paying the clinic, ostensibly just to cover those non-insured services. On the other hand, unless they pay upfront for those non-insured services in the form of an annual fee, they probably won’t get access to Copeman’s doctors. “It’s just such a confusing area,” Copeman says, noting that he altered his fee structure once in response to Ministry of Health concerns. Originally, he was planning to charge an initial $1,200 enrollment fee on top of the yearly fees. But this made it look as though people had to pay to access the insured as well the non-insured services at the clinic, a no-no under the Canada Health Act. To improve the optics, Copeman rolled the $1,200 fee into the first-year fees. “There’s a lot of politics around it,” he says. “If the government had given this private health-care clinic a blessing, there would have been political backlash, even though we’re not doing anything wrong. It’s just the public perception that we are.” Copeman didn’t need the B.C. government’s permission to set up shop, but the flip side is that he had to make the investment and hire staff before the Medical Services Commission reports to government. [pagebreak] MONEY TALKS Copeman has become a lightning rod for critics worried about the impact private clinics will have on the public system. Bob Evans, an economist at UBC who specializes in health care, says Copeman’s clinic will contribute to the shortage of family doctors. “If you take doctors out of the public system and give them lower patient loads, elementary arithmetic says you’re making the situation worse. ”David Cubberly, health critic for the NDP, objects to the way Copeman mixes insured with uninsured medical services. He thinks what’s attracting clients is more face time with doctors. And because these doctors are billing the system, the taxpayer ends up subsidizing a premier health-care experience for some people. “He’s creating two classes of users, those who pay the fee and those who can’t, the rest of us,” Cubberly said in a phone interview from Victoria. He says if clinics like Copeman’s are allowed to multiply, there’d be nothing to prevent any family doctor from charging his or her patients a fee to simply get their names on a roster, plus an extra fee if they want faster access 24 hours a day. “People will wind up paying money to see their doctor if this goes ahead in the form it’s in.” Already, B.C. is home to a variety of private clinics. There are 65 privately owned surgical facilities that mostly perform non-insured services such as laser eye surgery, cosmetic enhancements and dental procedures. But in the past 10 years, more than a dozen have popped up that, in addition to private work, are doing medically essential surgeries that used to be the exclusive domain of the public system. In 2004/2005, the B.C. government paid $4 million to these clinics to help clear backlogs and reduce waiting lists. Patients didn’t pay the bills, but the procedures were done in private settings. Another type of work done by the clinics seemsto contravene the spirit of medicare – if not the letter of it. The Canada Health Act allows organizations such as the WCB, the RCMP and the Armed Forces to pay for surgeries in private clinics. In 2005, the WCB paid for 3,798procedures in private clinics. One of the guiding principles of the Canada Health Act is that everyone is supposed to be treated equally, but as Tom Koch pointed out, the special treatment of certain individuals – police officers, firefighters, members of the military – seems to contradict that principle. Again, likely because the patient doesn’t pay directly, the arrangement has passed without much comment. There is a third type of work done by some of these clinics that seems to breach the spirit of the Canada Health Act even more: treating people who simply get fed up waiting and opt to pay a private clinic to fix, say, their knee. Brian Day, director of the Cambie Surgery Centre, explained that the government has benchmarks, times by which a surgery is supposed to take place. So if a knee is supposed to be replaced within six months of diagnosis, you may have to wait a full six, agonizing months to get your free surgery. If you want to do it within a month, that’s not medically necessary. Expediting the operation is a frill, like laser eye surgery, and you can choose to pay for it. Day says under 10 per cent of the 6,000 surgeries done every year at the Cambie Surgery Centre fall into this category. The cost of a private-pay partial knee replacement? Between $14,000 and $15,000. A PRIVATE MATTER During phone interviews, the only clinic willing to disclose gross revenues was the Cambie Surgery Centre. With six beds, it is the largest private clinic in B.C. According to Day, a renowned orthopaedic surgeon, total revenues at the clinic for doing medically necessary as well as cosmetic procedures were between $8 million and $11 million last year. In 2005, the WCB purchased $10 million in surgeries from private clinics and $31million from public hospitals. The same year, regional health authorities bought $4 million worth of day surgeries, totalling 5,535 procedures, or about two per cent of the all day surgeries performed in B.C. Compared to the more than $10 billion spent annually by the provincial health ministry, the money flowing through private clinics is a small trickle. But it’s likely to grow. According to George Abbott, this year five out of B.C.’s six regional health authorities (the exception is Northern Health)have issued requests for proposal to private clinics for day surgeries. These surgeries will be paid for by MSP. What’s new here is that the contracts will be for five-year terms; in the past, such contracts were always for a year or less. Abbott said, “This will allow us to assess what opportunities are in the marketplace for getting timely and cost-effective day surgery. There is the potential for tens of thousands of surgeries if the economics of the RFPs point in that direction. ”Day is confident that in the next five years, British Columbians will see a full-service private hospital equipped to perform the more complex surgeries such as open- heart or brain surgery that so far are off-limits for the private clinics. (How many of us will choose to pay privately for such complicated, expensive procedures asan aortic valve replacement remains tobe seen.) The province is clearly interested in outsourcing medical procedures, but so far that doesn’t involve giving the green light to patients paying for their own medical care. So Copeman has a fall-back position if the Medical Services Commission rules against him based on the yearly fees he charges. “We can change the business model and get the same clinical outcomes, with no government issues, if our physician sopt out of medicare.” In every province, doctors can opt out of the public sector and, as their services are no longer insured, they can charge patients or private insurers. However, in B.C., patients whose doctors have opted out cannot be reimbursed by the public plan. In other words, patients or their private insurers must pay the full cost of the health services they receive.Is the genie out of the bottle? Completely, and Copeman plans to cash in. “Our plan is to build five centres in the Lower Mainland over time. But that won’t service a fraction of what appears to be the national market. The study would indicate an $11.5-billion industry. ”He’s referring to a Decima poll conducted in June of last year that found five per cent of Canadians would be likely and 18 per cent would be somewhat likely to subscribe to a service such as Copeman’s. But will they actually sign the cheques, especially if they have to pay for medically necessary procedures in addition to annual fees? Copeman knows it’s a risk, but one worth taking. “Private health care will always be a certain fixed percentage of health-care expenditures,” he says, “because the public system will get better through competition.” That’s what ethicist Tom Koch wishes for, even as he forks over cash to see the same doctor he used to visit for free. “My hope is that Copeman will make itself redundant by showing that this is a better way to do medicine,” he says. “I believe everybody should have the same standard of care that I get. If this does provide better health care with better health outcomes, then we should all be getting that.”