Private ER worrying, but no big threat

It's not good that a private emergency room in Vancouver will offer a promise of better care for people with the cash to pay for preferential treatment.
But it's also not a catastrophe for public health care, or near the threat to the basic principles of Canadian society posed by other private care initiatives.
The private "urgent care clinic" is the latest business launched by the people behind the False Creek Surgical Centre. The clinic's first attempt to open in December was an obvious violation of the B.C. law and the Canada Health Act. The operators proposed to claim payments from the public system and charge patients an extra fee for the service.
That's clearly prohibited. The basic principle of the Canada Health Act and B.C.'s medicare protection legislation is that people with money can't pay a little extra for preferential treatment.
Health Minister George Abbott has so far followed the lead of his predecessors - both Liberal and NDP - in ignoring the spread of two-tier care.
But this case was so obvious that he warned the clinic the government would take action if it stayed open.
The centre shut its doors to rethink its business plan. Now it's back, with a new business model that Abbott says is within the B.C. rules.
The clinic now says it won't double dip. Doctors won't collect money from the Medical Services Plan; they'll bill patients directly for the entire cost of their services. The clinic has recruited doctors from outside B.C. who aren't enrolled in the public plan.
That's legal under the Canada Health Act, which doesn't bar provinces from allowing private health-care providers - doctors or institutions - from operating entirely outside the public system and being paid directly by patients.
But so far, only a few doctors have made that choice. Practically, it's a lot easier and more secure to operate within the public plan. The patient shows up, the doctor does the work and the plan pays. No worries about billing or deadbeat.
And until now there hasn't been a market. Not enough people will choose to pay directly for a service that now comes with no incremental cost.
While hospital emergency rooms are often overcrowded and chaotic, it's hard to see many people opting for a private urgent care clinic and the extra costs. The False Creek clinic plans to charge a basic $200 fee to examine patients, with extra charges for any treatment.
For minor ailments, most people would opt for a free visit to a drop-in clinic. People with problems that are more serious will likely still head to a hospital emergency room rather than face a steep bill.
It will be interesting, and perhaps useful, to see how the business model and price structure evolves.
For one thing, the clinic might offer an interesting test of the efficiency of the public system. The Vancouver Island Health Authority, for example, charges people from outside Canada who need emergency room services. They're hit with a $400 tab for using the ER and another $200 if they see a doctor, plus treatment charges.
If those rates reflect real costs in the public system, it would be cheaper to send some patients to the private clinic and have the public system pick up the bill.
The urgent care clinic doesn't pose the serious threat to medicare created by private surgical centres and extra-billing based doctors' groups like the Copeman Clinic. They sell faster, better treatment to people who can pay. A sick child's care becomes based on how much money her parents have, not on the treatment she needs to get better
But there are still worries about the clinic. The business needs to make a profit and the owners will be pressed to find ways to tap the public system. Its opening means fewer doctors and nurses are available.
And while proponents of two-tier care argue it can relieve pressure on the public system, that can be a bad thing. If those with money decide to opt out, then they no longer have an interest in maintaining the quality of the public system. Those are the people who are most effective in shaping government's priorities.
There's no need to panic over the opening of this private, sort-of emergency room.
But there's good reason to be concerned about the steady erosion of universal care, and governments' reluctance to do anything more than talk about it.