Monday, December 01, 2003

Liberals head for extra-billing fight with doctors

By Paul Willcocks
VICTORIA - Who would have thought the Liberals would be the ones to battle doctors over extra-billing and private health care?
The New Democrats pretended nothing was going on as doctors and clinics found more and more ways to charge patients directly. Jumping the waiting list, at a price, is routine for many procedures, from surgery to diagnostic tests, and the violations of the Canada Health Act are blatant.
But the Liberals seem to have put principle ahead of both pragmatism and politics, introducing a bill that will end much of the direct-billing that has fueled the growth of private clinics.
In the process they have opened another front in what will be a bitter war with doctors over the next six months.
The Liberals are due to pass the Medicare Protection Amendment Act in the next few days. Health Minister Colin Hansen introduced the bill modestly, promising only "greater clarity to both patients and private clinic operators about billing practices for medically necessary health care services."
In fact the bill outlaws most direct billing for medically necessary procedures. It specifically bans the most common abuse, in which patients get around the ban on direct billing by having a friend pay. And it sets up tough enforcement powers and maximum penalties of $20,000 per violation.
Mr. Hansen's position is that if clinics are operating in accord with the Canada Health Act, they shouldn't have a problem.
But they aren't, as the doctors' immediate reaction confirmed. The BC Medical Association called the act "Draconian," warning it was "basically setting up a medicare Gestapo.'' And doctors complained bitterly that they hadn't been consulted.
It's tough to say how many thousands of procedures would be banned under the new act. But Dr. Brian Day, medical director of the private Cambie Surgery Centre, predicted some of the province's 50 private clinics would have to close. They would just lose too much business.
Not all direct billing violates the Canada Health Act. If a procedure isn't medically necessary - if you're just curious and want a CAT scan, or opt for a facelift - you can pay. And the federal government has legalized queue-jumping by organizations like the WCB, which are allowed to pay for fats private treatment for clients. (The Liberals used to think that was unfair, but have changed their minds since the election.)
But doctors and clinics the act to have a big impact, and everyone will feel the shock wave.
Waiting lists will grow. Leaving aside the question of fairness, every operation done in a private clinic means one less name on the waiting lists for hospital treatment.
And despite Mr. Hansen's denial, the crackdown will cause big problems in already troubled negotiations with doctors. Doctors already complain that inadequate funding has forced hospitals to close operating rooms, meaning they can't work or get paid. Private facilities - and direct billing - allow them to perform more operations and add to their incomes.
Proposing to take that opportunity away - while at the same time refusing any increase in doctors' fees under the Medical Services Plan - will lead to a major confrontation as negotiations head towards an April deadline.
Mr. Hansen says B.C. is under pressure from Ottawa, which complains the province isn't enforcing the Canada Health Act. (B.C. was docked $5,000 in federal health transfer payments this year over two direct billing cases in 1999.) The Ontario government introduced similar legislation this week.
And he may have decided that it's worth a showdown with doctors to clear away a number of issues. This week the auditor general reported major problems with the $300-million alternate payments program to doctors, which is an alternative to fee-for-service. Planning is inadequate, spending is crisis-driven and results are unmeasured, said the report, done at the health ministry's request. But any changes risk another battle with doctors.
Mr. Hansen is doing the right thing. But his timing, and tactics, are ensuring a very tough New Year for B.C.'s health care system.

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