Will the first cut be the deepest? The debate on for-profit surgeries

Ontario’s doctors have been recommending a solution to the surgical backlog and communicating our issues with wait times to governments. Our patients have been waiting too long for care. Ontario’s doctors are very clear that we are for a publicly funded, single-payer health-care system ensures every medically necessary procedure continues to be funded by OHIP, as it is now. At the same time, the status quo is not meeting our patient-care needs. Bringing forward the solution of focused surgical centres to catch up on the cataract, hip and knee surgeries is something we’re committed to working with the government to implement.

The status quo is not meeting our patient-care needs.

I want to stress that Ontario’s doctors are strongly recommending immediately striking an implementation committee that we, along with external health-care stakeholders, would sit on to work with the government to ensure these models are implemented with these principles in mind. That includes integration with hospitals, public funding, assurance of high quality and safe care for patients and also help with a human-resource strategy to staff these clinics.

I think it’s a purposeful, slippery slope towards a two-tier health system. It is an open invitation to investors and profit-seekers, especially for procedures like hip and knee replacements. I wouldn’t be surprised if we also see renewed efforts to implement medical tourism. We already saw this years ago in Ontario under a different government; we urged the health minister then to stop and the government heard us. Will the current government hear us, too?

These are the ghosts of privatization, which come and go. When we stop them, they go dormant for a little bit, and then they come back again. The danger is that this time our own provincial government is the privatizer ghost.

It is dangerous for the public anytime profits drive surgical procedures that require a hospital stay. Hip and knee replacements are such procedures. We can see south of the border what happens when you deepen a two-tier system – it costs more, and it delivers less for everyone.

The biggest danger lies with investor-driven clinics.

The biggest danger lies with investor-driven clinics. The first legal obligation of the corporation is to make profits for its investors. Patients are, by law, secondary. They also don’t have the infrastructure to provide care for patients who become unstable, as it is not profitable to create such an infrastructure. If there is a serious adverse event, they will put that patient in an ambulance headed to the hospital. They skim the system of the profitable patients and leave public hospitals with higher acuity and fewer resources.

When you expand investor-driven care, you’re actively advancing the expansion of a two-tier system. Premier Ford and (Minister of Health Sylvia) Jones said it themselves: “for-profit clinics will take the less complex patients.” What they omitted to say is that Ontario’s hospitals will lose nurses and doctors to the clinics while staying with the more complex patients. We already have a health human resources crisis. How can public hospitals assure safe and quality care with increased acuity and a worsening nursing crisis? The investor-owned clinics will aggravate the exodus from the hospitals due to inadequate compensation and impossible workloads.

Nurses are gravely concerned about the expansion of for-profit surgical clinics. They provide lower quality of care, and they decrease safety and quality in our public hospitals. To make profits, they cut corners and they do so by taxing the already inadequate resources in public hospitals.

The for-profit motive is always problematic in health care. Evidence shows that for-profit clinics push for more expensive and at times unnecessary procedures. For example, you may be urged to get a knee replacement when losing weight and increasing exercise could prevent surgical action. In health care, getting more doesn’t necessarily mean getting better. When government funding goes to for-profit clinics, precious dollars are lost from a struggling public system. Wait times will increase, not improve – and patients will get less than what they need in the public sector. It’s a lose-lose.

Nurses are in huge demand. Nurses – RNs, NPs and RPNs – will always have an assured workplace. Whether it is in investor-driven care or the public sector, nurses will always have work. The public – persons who rely on our health-care system – are our primary concern. They are the real losers of these for-profit experiments.

I am not concerned about a slippery slope as long as there’s proper oversight and governance – which takes real work and commitment but is possible. There are private alternatives in virtually every other country. We are an anomalous health system in this dimension, and we are certainly not the highest performing health system in the world.

I think many people confuse or conflate private delivery and private payment. What is very important is that we are not talking about preferred access to care as a result of having more money in one’s pocket. We have a considerable amount of private delivery and support of health-care delivery already in the country.

This is not the first time we’ve seen this. Approximately 20 years ago in Ontario, we had an incredibly long waitlist for radiation oncology services. Patients in the GTA were forced to go to Thunder Bay, where they had extra capacity, and to Buffalo, where it was considerably more expensive.

What the government at the time did was create a contract for a private provider to provide radiation oncology services. These were paid for by OHIP at the prevailing reimbursement rate. In a year and a half, the waitlist was fully eliminated with high-quality care and no extra expense to the province. We don’t have to use the U.S. boogeyman as a comparator. We can look to the (U.K.s) National Health Service; we can look to Australia, Switzerland, Singapore and Israel. There are many other systems that have private delivery.

We don’t have to use the U.S. boogeyman as a comparator.

We absolutely have to ensure quality. That has to be monitored along with access to ensure that private providers are not simply cherry-picking and taking easier cases. If they take the easier cases, they have to be paid less. If they take the more complicated cases, they should be paid more. But we should have oversight around quality and access in both the public and private systems.

Another question is whether this will increase capacity in the system or if we’re just shifting capacity. Are we going to lose health human resources from the public system to the private system?

There is good reason to believe that we can increase capacity; people may choose to work more hours if they work in a private environment. In the U.K., the NHS never saw a major shift from the public system to the private. In fact, most clinicians who work privately spend the majority of their time in the public system to maintain their credibility. Most physicians in the private system in the NHS spend about 80 per cent of their time in the public system. Importantly, in the NHS, the private system does provide preferred access to those who can pay privately. That’s not what we are talking about in Ontario. OHIP will continue to pay, not patients, whether with publicly owned or privately owned providers.

Ideologically, many people are concerned about a capitalist system emerging. But if we were to find a shift, let’s say nurses moving from the public system to the private system – that tells us they’re not happy in the public system and prefer to work in the private system. Why in the world would we feel comfortable restricting the job mobility of nurses? Nurses should have better working conditions if they can be provided. The changes we are talking about provide the opportunity for better access to care, better working conditions and high quality – if done right. It can be; we see examples of that across the globe.

To be very direct, this is most certainly part of privatization and likely to lead to an entrenched private, investor-owned surgical sector and diagnostic-imaging sector. Based on the research evidence and experience, both across Canada and internationally, we know that investing in public-sector capacity and implementing system efficiencies like centralized waitlists and team-based triage are the kind of reforms that we need to support the public system.

The private sector is going to want to increase the number of contracts it has and continue to increase its role in publicly funded health care. What we have seen in B.C., for example, is the continued use of outsourcing to private surgical and diagnostic-imaging clinics continues to contribute to staffing shortages in hospitals. We know this to be the case in other jurisdictions as well. The same workforce can’t be in two places at once.

We are likely to hollow out our public-sector workforce at a time when we can least afford it.

What is of particular concern is that we know we have operating room (OR) capacity. We don’t necessarily have daytime capacity. But if we were to extend OR hours into evenings and weekends and do our best to expand and fully utilize the existing capacity in the system, while maintaining the existing workforce that’s already in place, that would be a much more beneficial strategy over the long term.

The concern is that we are likely to continue to hollow out our public-sector workforce at a time when we can least afford it.

Finally, around the issue of the slippery slope to privatization: One of the findings from the B.C. report that I published in August of last year is that out of clinics that have been contracted to perform publicly funded procedures, there were at least two that were found to have engaged in unlawful extra billing. This raises the very real concern that even when you are looking to outsource publicly funded procedures and say that they’re consistent with the Canada Health Act, we end up seeing a tendency to extra bill.

We know that within a business model, investors are looking to increase their returns and user fees are one primary way of doing that. We know that upselling is already an issue. While extra billing is a bit separate, these are still ways to maximize revenue among profit-motivated organizations. The case in B.C. shows that we have an ongoing problem with extra billing and unlawful activity in relation to the Canada Health Act, so this is a very real issue.

The announcement to reduce surgical backlogs will not reduce backlogs. Likely, it will contribute longer term to increased surgical wait times and is a slippery slope to privatization. Policies to move medical care into for-profit facilities can only be advocated for by those willfully ignoring the evidence of what happens when health care is privatized, introducing institutional for-profit motivations to its provision.

The health-care workforce is at this point mostly fixed and any solutions to increase health-care workers are a long way off as it takes many years of education to train people and even more to become experienced. The strategy of recruiting health-care workers from other countries needs to be viewed through the ethical lens of how such policies compromise the ability of other nations to care for their own populations. Opening of private facilities in the short term inevitably means draining the public facilities of their staff.

Australia, where I currently work, has gone down the road of two-tier health care for several decades. It has been definitively shown down here that two-tier systems do not reduce (but increase) wait times in the public system. It prioritizes care not based on those who have medical needs, but on those who can afford to have insurance or pay out-of-pocket for the private system.

It prioritizes care based on those who can afford to pay out-of-pocket for the private system.

Around 60 per cent of elective surgeries are now performed in private hospitals in Australia. Any extra capacity to deal with the large wait lists created by COVID or shutdowns has been stripped away. The poorer, often sicker and more complex patients are downloaded almost exclusively to the public hospital system as the private hospitals cherry-pick the easier more lucrative work.

The improved “efficiency” touted as being the reason for private, for-profit entities to run surgical care is the result of the selection of easy, high-volume (and sometimes questionable value) cases to be done privately. The public/private divide has made planning and managing surgical care impossible and created massive inequities in access to care. The underfunding of the health-care system and lack of leadership in moving away from funding models and business cases that reward volume is the real problem that needs to be addressed in the provision of surgical care.

Populist politics often provides what seem like simple, easy answers to complex problems and the introduction of private facilities to provide surgical care to Ontario is a good example. Once new hospitals are opened and privatization happens, it will be decades before people realize the harm that was done in the longer term. Other solutions to surgical waits such as centralized lists have not even been trialed yet, proving again this government’s priority to allow for-profit motivation into health care, which will inevitably lead to the further erosion of the public hospital system.