Wednesday, May 31, 2006

Government leaps blindly, without a net, into private surgeries

VICTORIA - There’s no reason to set your hair on fire about the principles behind the drive to shift hundreds of thousands of surgeries to private companies.
But you should be nervous about a plan that rests too heavily on hope and ideology.
The Vancouver Island Health Authority (VIHA) is taking the lead on this effort. The authority has just asked clinics to bid on contracts to provide some 20,000 operations a year that are now being done in the public system. The provincial government expects the other health authorities to follow the same approach wherever there are enough private clinics to do the work.
Patients shouldn’t really care who owns the operating room, or hires the nurses. As long as the work is done well, access remains fair and the taxpayer isn ‘t being gouged there’s no threat to the public interest or violation of the Canada Health Act.
The health authorities even hope they can save money and reduce wait times. The private clinics, VIHA say, will be able to do more minor day surgery. That should free hospital operating rooms for additional major surgeries. The authorities are spared the capital expense of adding operating rooms.
And the authority promises that the patients will be protected. Waiting lists will continue to function as they now do. (That is to say badly, but with relatively fair access.) The private companies will be asked to explain how they will limit the poaching of public sector health care staff they ramp up for this business boom.
The big benefit should be the introduction of useful competition into the health care system.
Competition is a good thing. Grocery stores compete for your business, so they spend time looking for improvements that will win your loyalty - better service, lower prices, local produce. Good ideas are rewarded; bad ideas abandoned. Consumers benefit. And that’s just as true for health care consumers as it is for grocery shoppers. (Some people balk at the idea of health care consumers. But that’s our role - we pay money in taxes and MSP premiums and get service in return.)
Competition is almost entirely absent from the world of health care. If one team runs a great hospital, and another a mediocre one, they’re treated in pretty much the same way. Figure out a better way to run an emergency room and your reward is more people showing up for care, not more money or better equipment.
But there are some big, legitimate concerns with the contracting-out push.
For starters, the government has no idea whether this change will save money or cost more. Health Minister George Abbott acknowledges that no one really knows what it costs to do these operations in the public system. Without that, it’s impossible to make a rational decision about contracting out.
The simple and obvious solution is to have the health authority set up its own day clinic and compare its costs and outcomes with private clinics. The government has not taken that basic step.
It also hasn’t prepared a business plan for this enormous shift. How will public hospitals function without the minor surgeries that allowed them to make maximum use of operating rooms? What will happen if nurses or doctors decide the private clinics are better places to work?
There is a real risk that critical major surgeries will be cancelled because the needed staff will be down the road doing minor surgery for a private clinic. Health authorities can now set surgical priorities; once these contracts are in place that won’t be possible.
Many of these same clinics are already charging user fees for faster access to surgery, in practice many would argue is a violation of the Canada Health Act. Health authorities may be subsidizing the expansion of two-tier care
A major experiment with private delivery would be valuable. This looks much more like a poorly planned and blind leap into the unknown.
Footnote: One of government’s most baffling and destructive tendencies is its enthusiasm for wholesale change. Prudent managers test new ideas or approaches on a regional basis and assess results before expanding the initiative. Government - as we see again in this case - too often leaps imprudently toward the next great solution.


Gaye Males said...

how will this "free up" operating rooms?...How?...are there more doctors and nurses out there than we have been lead to believe?...My understanding is there is a shortages of these workers and has been for some time. Oh maybe the operating rooms will be freeed up, because they will be "empty". Like the food aisle of a grocerie store that has not been stocked. What a foolish comparison...wouldn't you agree.

Anonymous said...

I haven't heard whether the cost of these private surgery contracts will be financed with new money, or whether the money will be taken out of the existing VIHA budget, thereby reducing services elsewhere.

If it is new money why not put it where it belongs-into improving the public system.

In either case this move by government appears more like an effort to persuade you and me that "private" means "better". Of course that's the same as saying "public" means "worse", and we will all be clamouring for more corporate health care. I hope we don't fall for it.

Life in Victorola said...

One of the gating factors for surgeries is the absence of qualified anaesthetists. If they are drawn away from the public sector by private clinics then the public system loses. It is a zero sum game. Efficiencies must be found within the public system and not without. Greater interprovincial cooperation would also be useful. Also, the middle management feather-bedding at VIHA should be addressed. Send all those paper pushers to the primary care front. It helps clear the mind.

There are some economies of scale, like the Shouldice clinic, but I say ship people off to Toronto if there's extra-provincial capacity.

The pirate sector is doing very well, mostly due to the low cost of healthcare for its employees. Compare that with the American experience.

Dave Macmurchie said...

I'm a little surprised to see Paul fall for the "wonders of competition" argument. It's OK when applied to grocery stores, but health care is a very different situation: I buy groceries a couple of times a week, and this gives me lots of opportunity to compare cost, quality, service and so on, but I only have two hips, so my opportunity to comparison shop is a lot more limited. When it comes to health care, we are almost entirely reliant on word of mouth evaluations, as often as not from our GP if we're "choosing" a surgeon or other specialist, and the consequence of making a bad choice is much more severe than in choosing a bad grocer, or even a contractor.

If competition among clinics or hospitals is going to deliver any benefit to health care “consumers” (if that’s what we’re to be) there has to be some useful way, other than direct personal experience, of arriving at an informed opinion when exercising our consumers’ prerogatives. Maybe the Fraser Institute could produce an annual report card on surgeons – that would be fun.

Troy said...

The grocery store is not only Paul's idea of best private comparison relating to our health care, many of the BC Liberal's have this very mantra. I wounder then if there will be coupons and specials, get one knee done and the other at 1/2 price (non trasnferable and can't not be combined with any other promotional offer). We should all be very worried that the elected thinkers of this province and the libera; media honestly believe this is a realistic approach to what BC's health care "consumers" need.