Friday, April 13, 2007

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.

Tuesday, April 10, 2007

A simple way to save lives on our roads

Another year, another 50 unnecessary deaths in B.C., victims of the government's unwillingness to put politics and ideology ahead of public safety.
Governments like to talk about keeping our streets safe. So why do the Liberals steadfastly refuse to introduce a simple, cheap measure that could save so many lives and keep thousands of people from hospital every year?
I'm referring to photo radar, reminded of the lost opportunity by a British report assessing the effectiveness of the "speed cameras," as they call them. The Department for Transportation report found that in 1996, before photo radar was introduced, only 28 per cent of drivers in England were obeying the 30-mph speed limit in built-up areas. By last year, more than 50 per cent of drivers were obeying the law.
The number of drivers going more than 35 mph - the point at which tickets are issued based on photo radar - was cut almost in half, from 37 per cent to 19 per cent. (The study looked at a wide sample of roads, not just at areas where photo radar was installed.)
Speeding down residential streets and through business districts is still a big problem. And photo radar has had made only a slight impact on highway violations. But the reduction in speeding is still huge. And so is the reduction in deaths.
The study found pedestrian deaths had fallen from 997 in 1996 to 671 in 2005. That's more than 300 people a year going home to their families instead of the morgue.
There's nothing surprising in the study. The reviews of B.C.'s photo-radar experiment found similar reductions in speeding, crashes, deaths and injuries. Drivers don't speed when they think they might get caught. So offenders slowed down.
Despite the arguments of people who believe that speed limits are unnecessary - that every driver should be able to drive at the speed he decides is safe - all the evidence shows speed limit enforcement saves lives.
A major Australian review last year analyzed data from 26 photo-radar studies from around the world. The results were striking. The number of crashes was reduced by 14 per cent to 72 per cent once photo radar was installed. Fatalities were reduced by an even more dramatic 40 per cent to 46 per cent.
Or look at the evidence here.
The B.C. government introduced photo radar in 1996. In the preceding five years an average 510 people had died annually in crashes. During photo radar's almost six years of operation the annual death rate fell to 412 - almost two fewer deaths each week.
The Liberals killed photo radar after the 2001 election.
In the first three years after it was gone the average number of deaths was 449, an increase of 37 a year from the photo-radar era. In 2005, 459 people died in crashes.
A study done on the first year of photo radar in B.C. found "a dramatic reduction of speed" at deployment sites, accompanied by a decrease in collisions, injuries and deaths.
"The analysis found a 25-per-cent reduction in daytime unsafe-speed-related collisions, an 11-per-cent reduction in daytime traffic collision victims carried by ambulances and a 17-per-cent reduction in daytime traffic collision fatalities," the study reported.
A lot of British Columbians didn't like photo radar. They thought - wrongly - that it was a cash grab. The implementation was unnecessarily costly and labour intensive.
So the Liberals said during the 2001 election campaign that they would kill the cameras.
But the evidence shows that was a bad decision. It has cost hundreds of lives and thousands of injuries, shattered families and put needless pressure on the health care system.
Fixing the 2001 mistake would be as simple as using the red-light cameras already in place at intersections around the province to catch speeders.
Other high-risk areas - neighbourhoods used as shortcuts by commuters, high-accident streets, school zones - could also be targeted.
It's hard to see why the government won't act. Solicitor General John Les says he doesn't think photo radar saves lives, but he can't really believe that in the face of all the clear evidence.
And given the ease with which the Liberals shed other campaign promises, that can't be the issue.
Photo radar would save lives, reduce injuries and help ease the health-care crunch.
What's the government waiting for?