Current public dialogue is full of questions about what kind of innovation or “revamping” the health system needs. In this context, as a physician, I am compelled to apply principles of evidence-based practice to the public vs. private debate: Will Brian Day’s plan to expand privately funded health care in BC shorten wait lists and improve the system?
Evidence indicates it will do the opposite. Of the Canadian provinces, BC has the most privately funded orthopedics services, and the longest waiting lists for this specialty. Evidence indicates that privately funded health services and long public wait times go hand in hand, and that growth in private payment will do nothing to alleviate it.
Let’s look at the evidence:
- Koehoorn et al. studied cost of care and return-to-work time for 1380 WCB patients in BC who received privately funded and public services for knee surgery, and found that expedited, privately funded care was more expensive and did not improve return to work times – patients receiving care in the public system did marginally better for a fraction of the cost.
- Australia expanded private insurance, and found that it did not decrease wait times; rather, in regions where private insurance was most often used, wait times in the public sector rose.
- In his CMAJ article Duckett specifically finds that while privately funded health services slowed the pace of growth of demand in the public sector, public service demand still continued to grow, but with diminishing access to resources to address the increased need.
- Tuohy et al, in a study of all OECD nations with parallel private insurance for health care, found that privately funded care produces longer wait times and draws resources out of the public system. They also note that shortening wait times in the pubic system is usually most successfully achieved by increasing the amount of public investment, not by increasing the amount of private investment.
- Beasly, studying patterns of private insurance in the UK, found that increased use of private payment is correlated with increased waiting lists, and that the two are causally related. As more patients and physicians use the private pay system, not only do the resources leave the publicly-funded system, but the pressure to restore public resources declines, as fewer people (and in particular fewer affluent people) apply political pressure to ensure that public wait lists are addressed.
- OECD comparisons by the Commonwealth Fund in 2014 ranked Canada 10 out of 11 countries on health system performance, with the USA ranking last. The clear message is that a two-tiered system without a public payer (the USA) is the worst performing system. Further comparisons with this data set – including the conclusion that Canada ranks below the 9 other Commonwealth countries because of its lack of privately funded health care – are fallacious for the following reasons:
- Data is not comparable between countries. Methodological problems and gross differences between national health systems (rural and remote composition, health delivery model, differing baskets of services) preclude further valid comparison or extrapolation from this data. For example, the data employs subjective rankings of health system features such as the use of Health Information Technology (HIT) for computerized alerts with drug doses or interactions; another rates doctors on routinely receiving and reviewing data on patient satisfaction and experiences with care; another asks respondents to rank frequency of denied insurance payments for health care services. Subjectivity of ratings aside, the data does not use appropriate measures for an apples-to-apples comparison of health systems.
- OECD rankings rely upon satisfaction and cost. Canada’s ranking has predictably declined due to annual decreases in public health spending (increases have not kept up with inflation and population growth) and a lack of federal and provincial leadership on health reform. Meanwhile, out-of-pocket spending for non-Medicare insured services in Canada are the greatest drivers of increasing health system costs, and may or may not be captured in this mixed dataset as outlined above. Billions of dollars of cost-savings can be achieved through measures that will also improve quality, including better after-hours primary care, pharmacare, and home care. However, without the leadership to achieve this, our satisfaction:cost ratio will predictably decline.
- Satisfaction, cost, and outcomes in the health system are determined more by social and economic conditions that contribute to health (contributing to 50% of health outcomes) than they are by access to health care (contributing to 25% of health outcomes). Poor populations suffer worse health outcomes and increased health system use than wealthy populations. The commonwealth nations with high (and increasing) income inequality are also the worst performing in this ranking: the US and Canada. Income inequality has grown in Canada as its health system performance ranking has declined.
And some mythbusters for further information:
 Koehoorn et al. “Do private clinics or expedited fees reduce disability duration for injured workers following knee surgery?” Healthcare Policy; 7(1) 2011: 55-70 http://www.longwoods.com/content/22528
 Duckett SJ. 2005. “Private care and public waiting.” Australian Health Review; 29(1): 87-93.
 Ducket, S. Living in the parallel universe in Australia:
public Medicare and private hospitals, CMAJ • SEPT. 27, 2005; 173 (7) 745
 Tuohy CH.,CM. Flood, and M. Stabile. 200. “How Does Private Finance Affect Public Health Care Systems? Marshalling the evidence from OECD Nations.” Journal of Health Politics, Policy and Law. Vol. 29, no. 3, June, pp. 37-375.Cardiac Care Network of Ontario. 2005. “About CCN.”http://www.ccn.on.ca/mission.html.
 Besley T et al. 1998. “Public and private health insurance in the UK.” European Economic Review; 42(3-5): 491-497.