During the 1990s, the corporate health sector urged hospitals to focus on clinical patient care and to contract out non-clinical support to companies whose core business it was to provide such services (no conflict of interest there, of course). Provincial governments, too, encouraged hospitals to redefine their “core missions” in narrower and narrower terms. As administrators whittled away, Canadians saw laundry, food services, laboratory and many outpatient rehab services re-defined as non-essential, non-clinical supports that could be contracted out without compromising patient safety or quality. The mainly female hospital workforce who followed these jobs in to the private sector saw their wages slashed and their job security disappear.

What did Canadians get in return for this strategy? Here are a few enlightening statistics from a well-researched and documented booklet published by CUPE in January called Healthcare Associated Infections: A Backgrounder. The human and financial costs associated with contracting out are tremendous.

• Between 1995 and 2006 the Canadian Nosocomial Infection Surveillance Program found that rates of MRSA in Canadian hospitals had increased 17-fold.
• The rate of patients contracting C. difficile infections, the chief cause of health care diarrhea, increased almost five-fold between 1991 and 2003.
• The Norovirus, which affects mainly seniors in long term care facilities, doubled in B.C. between 2002 and 2007.
• Every year in Canada one in 9 hospital patients contracts Health Associated Infections (HAIs) which have been linked to between 8500 and 12,000 deaths per year. HAIs are now the fourth leading cause of death in Canada.
• In BC, 7% of all patients infected with C. difficile are readmitted to hospital for an additional 13.6 days at an additional cost of at least $18,000 per patient.
• In the Vancouver Coastal Health region alone, more than $3 million was spent by the health authority to treat 2,526 patients with C. difficule in one year (2002/03).

Are HAIs only a problem because services are provided by greedy multinationals? The answer is that infections are linked to understaffing, increased workload, high turnover and poor training of staff. The way that these companies earn the big bucks is by…hmmm… let’s see: reducing staff, increasing the workload, foregoing training of the workforce and maintaining poor wages and working conditions that lead to low morale and high staff turnovers.

On the other hand, studies have shown that when hospitals increase the number of cleaning and infection control staff, when they invest in training and education, and when stability in the workforce is maintained and encouraged, infections decrease.

The track record of increasing infections and related deaths in BC hospitals is the legacy of contracting out that started during the 1990s and continues to this day. Both the Liberals and the NDP should be challenged during the election to outline what steps they’re going to take to bring these services back in to the hospital system. But that won’t be enough: as CUPE’s excellent backgrounder emphasizes, we need evidence-based policies that protect patients from hospital acquired illness and death. That means ending and reversing contracting out. But that’s not all: we need reduced occupancy rates, trained staff, better wages for more workers in the hospital system, mandatory standards and increased transparency.

Read the booklet — it’s an eye-opener. If ever there was an overlap between the interests of health care workers and the public, this is it. And think about surgical services trotting down the same road.

A couple of weeks ago I wrote that Brian Day and his followers had launched a lawsuit against the province, alleging that, “in contravention of the value of individual choice,” the Medicare Protection Act restricts or prohibits patients from “accessing the private health care of their choice”. Day & Co. brazenly admit in their Statement of Claim that “Independent surgical facilities receive facility fees for the use of their facilities for the pupose of operations and other procedures”. The fees, according to the Statement, come from all and sundry — health authorities, the workers’ compensation system, other third party payers and patients.

And here I thought that Diane Marleau, a federal health minister from the long ago 1990s said plainly that facility fees “are objectionable because they impede access to medically necessary services” and therefore “violate the [Canada Health] Act“. Silly me.

Now, I’m sure many of you read about the lawsuit in the Vancouver Sun, the Globe and Mail and other media outlets. But I’m equally sure that, for reasons I cannot fathom, you didn’t read about the Government’s response, filed on February 20, in any of these same investigative outlets. I wonder if that’s because, as a Vancouver Sun editorial put it in 2007, when it comes to whether or not a facility might violate the Canada Health Act, “what matters in all of this is no longer the law”, but whether anyone in government cares. “It’s time to focus on what is really important here,” the editorial continued. “Two tier health care is here to stay.”

But I digress.

In its Statement, the government dismisses most of the points raised by Day & Co., and asserts that “there is no freestanding constitutional right to health care”. Heaven forbid. But the most interesting thing about the Statement is not the government’s defence of medicare, but rather the Counterclaims against the five Plaintiff Clinics and the Specialist Referral Centre (collectively dubbed the “Extra Billing Clinics”). The SRC expedites access to specialists (for a fee, of course). Here, in handy point form, are the key allegations in the Counterclaim:

1. That Cambie Surgery (Day’s outfit) and the SRC have refused to provide information or allow audit inspectors on the premises so that the Medical Services Commission can determine whether these two companies have violated the Medicare Protection Act. The goverment has asked for an injunction “restraining Cambie and SRC from hindering, molesting or interfering” with inspectors who are trying to carry out the audit.

2. That Cambie and the SRC charged patients for services listed on invoices as “surgery”, “overnight”, “administration fee surgery”, “facility fee”, “consultation/assessment”, “surgeon’s fee”, “anaesthetic fee”, “escort services” (escort services?), and “prepayment for surgery”. These services are either fully covered under MSP or, if charges are allowed, the charges exeeded the amount permitted. The government has asked for interim and permanent injunctions restraining Cambie and the SRC from violating medicare laws.

3. That the Extra Billing Clinics, jointly and individually, “have themselves been engaged in unlawful billing practices…and also have aided, abetted, assisted, and facilitated the unlawful billing practices of others who practised in the Exra Billing Clinics or who arranged payment through or with the participation of those facilities”.

4. The government also alleges that patients were required to sign “Acknowledgement Forms” which falsely informed patients that the services for which they were being charged were not covered under the Medical Services Plan and committed patients to forego reimbursement from MSP or any other public agency. The waivers also forced patients to agree not to file any complaint with any government body regarding the circumstances of the benefits provided by the Extra Billing Clinics. Patients also undertook” not to disclose any information to any government regarding the particulars of the beneficiary’s surgery”, including costs. If the patient does disclose, the waiver “purports to require the beneficiaries to indemnify the Extra Billing Clihic for damages and costs arising from [the] disclosure”.

Wow, if all of this is true — and if, contrary to the editorial assertion in the Sun, the law does indeed matter, these folks have really got themselves in deep doo-doo.

We’ve had a lot of budgets like this in B.C., so this one is in keeping with its right wing predecessors. During the 1980s, for example, the never-ending Social Credit government used to table budgets that gave the boot to working people in general, unions in particular, the poor, women, youth and, their favourite target, public sector workers. While they slashed services Socred ministers reassured everyone that the public would never notice the difference despite the fact that fewer people would be there to deliver them and that those who remained looked increasingly haggard and exhausted.

The Liberals are continuing this tacky boondoggle. This week’s budget boosted health care more than any other sector, which gives you some idea of how poorly everything else fared. Finance minister Colin Hansen claimed that the $4.8 billion for the health sector over the next three years constitutes 90% of all “new spending”. But as Marc Lee pointed out in his excellent post, very little of what’s gone to health actually is new money — last year’s allocation was brought forward to this year’s budget, with a dash of $25 million on top.

But this budget’s spending reflects a more general malaise in the provincial government when it comes to health care. As with many of the policies it pursues, all of the evidence should have pointed to a decidedly different direction in regard to the budget.

Take, for example, evidence about the social determinants of health, those factors that can prevent things like cardiovascular disease and Type 2 diabetes, the latter of which is now described as an epidemic. These social determinants play a greater role in preventing disease than biomedical or lifestyle behaviour modification. A 2006 paper by Dennis Raphael identified 11 key social determinants of health: Aboriginal status, early life, education, employment and working conditions, food security, health care services, housing, income and its distribution, social safety net, social exclusion, and unemployment and employment security.

David Gordon’s sensible Ten Tips for Better Health put these in language we can all understand:

THE SOCIAL DETERMINANTS TEN TIPS FOR BETTER HEALTH

1. Don’t be poor. If you can, stop. If you can’t, try not to be poor for long.
2. Don’t have poor parents.
3. Own a car.
4. Don’t work in a stressful, low paid manual job.
5. Don’t live in damp, low quality housing.
6. Be able to afford to go on a foreign holiday and sunbathe.
7. Practice not losing your job and don’t become unemployed.
8. Take up all benefits you are entitled to, if you are unemployed, retired or sick or disabled.
9. Don’t live next to a busy major road or near a polluting factory.
10. Learn how to fill in the complex housing benefit/ asylum application forms before you become homeless and destitute.

Gordon, D., Posting (April, 1999) Spirit of 1848 listserv.

The increase in the incidence of Type 2 diabetes in Canada — 69% between 1997 and 2007 — can be linked to the rising number of people who aren’t able to act on these good suggestions. People who are poor are not only more likely to get Type 2 diabetes than their wealthier counterparts, but they are also more likely to hospitalized with complications related to the disease. This has been shown to be the case by Canadian and international researchers, including those associated with the World Health Organization and the Pan-American Health Organization.

According to a 2007 study published by Ontario’s Institute for Clinical Evaluative Sciences,for example, Toronto neighbourhoods where poor people live also have much higher rates of Type 2 diabetes and obesity. “Areas with lower socioeconomic status (SES),” the report said, “had…higher diabetes rates. These neighbourhoods clustered in the northwest and eastern parts of the city. Conversely, neighbourhoods with a more advantaged SES profile tended to be clustered in the centre of the city and had lower diabetes rates.” In January 2006, the New York Times reported that in East Harlem, where incomes average $20,000 a year and the poverty rate is 38.2%, between 16 and 20 percent of residents have Type 2 diabetes. That compares to the Upper East Side, where the average income is $75,000, the poverty rate is about 6.2% and an estimated 1% of residents have the chronic condition. Like Clyde Hertzman (UBC) and others in Canada and internationally, Raphael has argued that the most important policy options for governments are ones aimed at reducing poverty. Poverty reduction is not just a human right, not just a moral and ethical obligation of government, but strategies to achieve that goal would reduce the strain on our health care system as well.

Does the budget have anything to do with the growing mountain of evidence about what people need to be healthy?

Hmmm… let’s see. The $8 minimum wage is frozen at $8 an hour, well below the “living wage” of $16.74 an hour. Wages in the public sector are to be frozen for the next couple of years and there is no strategy to raise wages in the private sector. The budget projects unemployment at 6.2% but by last month it had already reached 6.1% and the “up to” 88,000 new jobs it projects are clearly inadequate. The social safety net? The only reference to safety that I could find was in reference to policing and roads. Housing? The housing budget has been cut and market housing prices are 55% above the average family’s ability to pay. Those on income assistance will see an increase of one-half of one percent, while the ministry of Children & Families got only a one percent boost in the budget.

I would say the budget failed to ensure that the determinants of health are more accessible in these looming tough times — a 100% percent failure rate, in fact. But don’t worry! While the budget fails on health determinants side, the government has engaged the pharmaceutical industry in public-private partnerships to deliver chronic disease management (CDM) programs. So British Columbians with Type 2 diabetes and other chronic conditions — if they can afford to do so — will be able to dip in to the medicine chest to heal the wounds inflicted by this budget.

Mark Godley is the founder and head honcho of False Creek Surgical Clinic, one of the largest companies in BC providing a range of surgical and medical services, including women’s health and gynecology, plastic surgery, pain management, cardiology, colonoscopies, general surgery, you name it, they’ve got it. Like Copeman, Godley wants to sell his stuff through a national network of facilities operating in “a competitive, free marketplace”.

Godley is a complicated investor, associated with a number of entities. One of them is Surgical Spaces, Inc., a management company that oversees two surgical facilities in which he is the medical director. The CEO of SS Inc., is one Anna Stylianides, whose interests appear to cover both surgical services and mining, a natural fit some might say. Stylianides, who sits on the board of directors of Callinan Mining, Ltd., brings her expertise in mergers and acquisitions, financial restructuring and — oh look, national expansion strategies! 

But then there’s National Surgery, Inc., another Godley linked company whose website greets you with this sizzling enticement: “Choose your destination”. Here you are linked to the two surgical facilities managed by Surgical Spaces: Vancouver’s False Creek (“The Face of Things to Come”) and Winnipeg’s Maples (“We Accept US Patients”). Click on one and you are transported (mind-wise) to either location. If you want False Creek’s staff to book a hotel (the Westin Grand Hotel, say) they can do so “using our corporate discount rate”.

But wait! What if you need URGENT care, not just slow-poke old surgery? Well, now there is the False Creek Urgent Care Centre — FCUCC (rhymes with hiccuck) — set up in 2006 by Godley as an extension of False Creek Surgical and ostensibly for people (like, uh, everyone) who don’t want to wait in the hospital ER of their choice.

FCUCC’s four owners — Godley, Rael Klein, Tony Massolin and Stylianides who is also the CEO — caused quite a stir when they opened. That’s because they were charging outrageous prices to cross FCUCC’s threshhold — $199 instead of the standard MSC payment to hospitals of $60-$80. To get around the laws (remember those?) that require opted out physicians to bill only the amount in the Medical Services Plan’s fee schedule, FCUCC said its physicians were from out-of-province and were unenrolled (as opposed to opted out) and therefore could charge pretty much what they liked. In fact, they had to charge that amount because, according to a spokesperson for the company, the higher fees were necessary to get the return on investment that the owners were expecting. They are, after all, entitled — why would they set up a business that didn’t return a profit?

So what exactly is “urgent care”? According to trusty Wikipedia, it’s ambulatory care provided in a facility outside of a hospital emergency department, “usually on an unscheduled, walk-in basis”. Surrey North’s then-MP, Penny Priddy (NDP), called FCUCC the “American-like clinic” and that’s not far off the mark. According to Omni Health Care, a US company with a similarly named “Urgent Care Centre”, these services are for people who, like Omni, understand that “minor emergencies don’t wait for a convenient time to visit your doctor”. (Whoa, dude, that is so true.) And FCUCC “can offer a referral to our extensive specialist consultation and surgical services”, a convenient urgent care launch pad into a profitable pool of providers.

Hmmm…what does our health minister say about all this? George Abbott’s statement was so dry you wanted to cough as soon as you read it. “It would appear,” he said, “we would have no basis for any legal action against the clinic.” Hack, hack.

What should he be saying? Well, first of all, no doctor should be able to practice on both sides of the medicare fence. All that would be required is a simple amendment to the Medicare Protection Act.

Secondly, Abbott could be pushing his own government to fund 24/7 multi-disclipinary health care centres throughout the province. (Duh.) According to the Canadian Institute for Health Information (CIHI), Canada had the highest percentage of respondents to an international poll who said they could have received their emergency care from a regular physician in a non-emergency setting (like a 24/7 multidisciplinary community health centre). While FCUCC says it’s providing “urgent care”, most of Canada’s emergency department visits are for less- or non-urgent care, and it’s likely Godley’s outfit offers services that fall under that heading. The only difference is the arm-and-a-leg character of FCUCC’s fees. But these services could and should be provided in publicly-funded settings that are accessible without point-of-service charges.

British Columbians should be entitled to these services without having to fork over cash in an emergency (urgency?). But what should we be doing in preparation for the election in May to ensure the government is on the road most British Columbians have suggested they want?

Wow, life is tough.

Let’s look at this culture of entitlement and some of the stars who have struggled to beat it back. In fact, let’s start with the Copeman Healthcare company.

Copeman Healthcare Inc. charges $3900 to join, plus $2900 each year. Some might argue that these fees are way too high — even illegal, as the BC Health Coalition has asserted. But membership has its privileges, as American Express says. For this hefty fee you are entitled to, among other things, a “therapeutic lifestyle change” overseen by the company’s medical staff, access one of six doctors, a nutritional counselling, nurses, kinesiologists. Of course, Copeman & Co. argue that they are entitled to charge such fees, and to earn a profit by providing primary health care to the 3600 patients who have signed up.

Now, the REACH Community Health Centre, located on Commercial Drive in east Vancouver, also charges a membership fee — if you pay between $1 and $25 you can join the non-profit society, vote and run for the board of directors and participate on one of its committees. (Conflict of Interest declaration: I’m on the board.) But in this case, membership doesn’t have its privileges: you don’t have to sign up if you are among the 10 000 patients who access one of REACH’s six doctors, or its pharmacist, or its dental clinic, or one of the counsellors, nurse practitioners, or if you participate in the Multicultural Family Centre or the diabetes program.

A letter from REACH to the Parksville paper said that multi-disclipinary, non-profit clinics should be funded by the government. “Health care providers should not be entitled to high membership fees, high annual dues, or high profits from treating patients,” the letter concluded.