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.

CN the big winner in BC Rail deal

VICTORIA - First, count the BC Rail sale as a broken promise, and one that's being handled with a notable lack of honesty.
CN Rail is buying the railway -- a 90-year deal counts as a sale. And public ownership of the rails and land under them doesn't change that reality. The Liberals promised not to sell or privatize the Crown corporation. They broke their word.
That out of the way, is it a good deal?
It is for CN Rail, for certain. CN is paying $1 billion. But $250 million of that is buying BC Rail's past losses; CN hopes to reduce its own taxes by at least that much. If Revenue Canada turns down the plan, then the government has to give the money back.
That leaves $750 million for a debt-free railway and all its equipment and buildings, valued at more than $250 million. CN will put some extra cash in for new cars to serve the forest industry and improved container service. It will make some quick cash by selling some locomotives and 1,300 of BC Rail's existing cars.
But work with the $750 million as the investment.
The takeover will add something like $100 million a year to CN's profits. CN Rail expects to improve on that, in part by eliminating one-third of the remaining jobs and increasing the business.
So conservatively, figure that CN spent $750 million and can expects to earn about $130 million a year. That's a 17-per-cent return on the company's investment, a great deal even given the risk of buying a business that is largely dependent on volatile resource industries.
Why did they get such a good deal? Under the conditions the Liberals set for the sale, CN was the only potential buyer. If the government wanted to sell -- and they made it desperately clear that they did -- then CN was in a position to drive a very hard bargain.
The competitive bidding process was merely an exercise. The railway is integrated with CN's existing lines; CN has the infrastructure in the West that allows it cut the most jobs; CN has the chance to take control of the market and make the most money out of running BC Rail. It was always going to be able to pay the highest price.
That wouldn't have been true if the government had decided to consider a range of factors in deciding on a successful buyer, like job protection or guarantees against line closures.
But those weren't a significant part of the decision. CN gains the right to run the railway as it sees fit, abandoning lines or starting new services or selling equipment. (Line closures are barred for five years.)
And on a straight cash basis, CN was always going to be able to pay the highest price. (That may explain CP Rail's complaints that the process was unfair.)
Partly, the price just reflects market forces.
But the government weakened its bargaining position dramatically by making it clear from the outset that BC Rail was going to be sold. From the time the Liberals said they were not prepared to allow BC Rail any capital to finance improvements -- even if the corporation could make the payments out of its profits -- the sale was certain.
And knowing the government was desperate to sell quickly, CN was in a very strong position to cut a good deal.
The benefits for northern communities -- some $156 million -- will be welcome and useful. There's a significant economic development fund, and spending on the Port of Prince Rupert and a Prince George airport expansion.
But northerners will rightly wonder why they had to wait for the sale of BC Rail to see this spending.
If investing in Prince Rupert's port makes sense, it should not require the sale of a Crown corporation before the money is available.
The bottom line? A broken promise, for sure.
And a deal that achieves the Liberals' goal of getting taxpayers out of the railway business.
Footnote: The NDP was denied their usual chance to examine the deal in Question Period hours after the premier's glitzy announcement. Speaker Claude Richmond, apparently miffed at heckling from Joy MacPhail and Jenny Kwan, refused to recognize MacPhail and instead allowed a string of softball questions from Liberal backbenchers.

James should hit the road to rebuild NDP
VICTORIA - New NDP leader Carole James is a mighty popular woman around the Capital Region. Even after a dozen difficult years on the school board, through cuts and labour disputes, she emerged with what looks like a huge pool of goodwill.
Not a bad start for a new leader. Earned respect is a valuable currency.
Overall, James looks like a sensible choice for the party. She falls -- apparently -- into the middle of the NDP policy spectrum. Ex-MLA Leonard Krog was seen as more loyal to the party's traditional positions (too hard, in the language of Goldilocks); newcomer Nils Jensen as more eager to move the party to the middle (too soft); and James fell somewhere in between.
One of the big questions is just what that means. The James' campaign was long on good intentions and short on specifics. She's opposed to offshore oil development, a position that will cost the NDP votes in many coastal communities, but play well in Vancouver. She apparently believes in the need to balance budgets, while having a strong economy and healthy communities.
But it's all rather sketchy. I've yet to hear of a candidate from any party opposed to healthy communities.
The mushiness clearly wasn't a bad strategy for the leadership campaign, and will likely play well in the election campaign now barely a year away. No matter what the NDP says, they will be running in 2005 for the chance to form a larger opposition. That means voters will accept some policy vagueness.
But they will be looking for competence, credibility and the ability to reflect their interests and concerns. James' challenge is to demonstrate, in short order, that under her leadership the party can live up to those expectations.
She already has one big advantage.
She's not personally lugging the tawdry baggage of the last NDP government. The Liberals' favorite comeback to any attack on their record has been a ritualistic reference to the fast ferries.
It's a rebuke that has long grown tired; it will seem even more stale directed at James.
But the Liberals keep using the line because it still resonates.
As the polls show, it takes more than a couple of years for people to forget the bungling of a government as inept as the former NDP administration.
That's the challenge for James.
She has to explain how the NDP is now different than it was through the late-90s. How has the party's structure been changed? How has it become more broadly based, and less a party with a bias towards representing the interests of public sector unions? (James had strong support from both CUPE and the BC Government Employees' Union; the party's newly elected president is from the BCGEU.)
She has to explain how her policies differ from the past NDP regime.
And she has to show that she can bring competence and effectiveness to government.
James can do that more readily without a seat.
While the house is sitting, Joy MacPhail and Jenny Kwan can continue to question the government, with James just hitting the big issues.
That gives her the chance to travel the province and make the case for the party. (And it also avoids a highly public baptism by fire in the legislature.)
It also gives James a chance to start recruiting credible candidates, which may be the most important task in the time before the election. Even people who don't trust the NDP may be prepared to send the party's candidate to Victoria -- if they know and respect the local nominee.
That doesn't mean James will get a free policy ride, especially if the Liberals succeed in their attempts to pin her down. But it does mean voters will accept vagueness on specific issues, if they are satisfied that, overall, the party recognizes their concerns.
Footnote: James starts with a couple of other advantages. She's lived and worked mainly in Victoria, but has spent the last two years in Prince George. She's well positioned to tackle the Liberals' on their failure to make significant improvements for people living outside Victoria and Vancouver. She has inside knowledge of the children and families ministry, one of the Liberals' most mismanaged files.