Health Minister Adrian Dix is planning to fine doctors and private clinics that extra-bill their patients. Extra-billing occurs when patients are charged by their physician for services that are already insured through the Medical Services Plan.
The Canada Health Act of 1984 was the first in a series of attempts to put an end of this practice. It authorized the federal government to withhold transfer payments from provinces that permitted it.
But the act had two serious deficiencies. It placed all of the responsibility on the provinces, some of which had no desire to be drawn into a fight with physicians.
And because the legislation was easily circumvented, successive federal governments failed to follow through on the threat to withhold transfer payments, either in part, or in whole. This was the policy of the Stephen Harper administration.
In 2003, the B.C. Liberal government tried a different approach. Premier Gordon Campbell’s administration introduced legislation — the Medicare Protection Amendment Act — that made it an offence to extra-bill. But here, too, the legislation was never fully implemented.
Now, though, times have changed: A different federal government in Ottawa is determined to act.
Health Canada has audited three private clinics in B.C., and estimates that patients have been illegally billed to the tune of $15.9 million. Transfer funds to the province in that amount will be withheld.
So Dix has bitten the bullet. He says the B.C. government will fine physicians who extra-bill up to $10,000 for a first offence, and $20,000 for a second.
This is at once a courageous and politically dangerous decision. The primary reason patients in B.C. visit private clinics is that they cannot get timely care in the public system.
Long wait times for surgical operations, and for some diagnostic procedures such as MRIs, are endemic. Patients have become accustomed to using the private system as an escape hatch when faced with unacceptable delays.
This is not a defence of private medicine, nor of extra-billing. Rather it is an indictment of the public system for failing to meet demands. Nevertheless, it is a present reality.
If Dix succeeds in ending extra-billing, and the fines he has in mind will almost certainly do that, private clinics will have only two choices. They can stop charging patients for insured services, which might wreck their business model.
Or their physicians can de-enrol from the Medical Services Plan, which means they may no longer work in public facilities.
But that is a significant risk, financially and professionally, because many doctors who practise in private clinics also see patients in public facilities.
It is important to draw a distinction here. Several health authorities, including Island Health, contract with private clinics to deliver surgical or diagnostic procedures for an agreed cost.
But in these cases, the patient is not billed. The province picks up the full tab.
The problem is that health authorities have never been given enough money to deliver all the procedures required.
Dix has, to an extent, addressed this issue. He recently announced funding for an additional 9,400 surgeries and 37,000 more MRI scans by 2019.
This will certainly reduce wait times. But will it do so sufficiently?
More than 500,000 surgeries are conducted each year, provincewide. It’s difficult to say how far an extra 9,400 will go in cutting wait times.
And B.C. lags behind the rest of the country by a considerable margin in the number of MRIs performed. Here, too, it’s unclear how much impact on waitlists the additional scans will have. If some patients find they still face long delays, particularly where pain or mobility issues are involved, there will be blowback if the private option is no longer available.
If the province is prepared to rebuild surgical and diagnostic capacity to the point where reasonable wait times are established, the debate is essentially over. Why would anyone pay for a private procedure if there is timely access in the public system?
But Dix has not yet demonstrated that the public system can pick up the slack and achieve wait times that are within acceptable guidelines.
The fault for this is not his. Health services have been starved for a decade and more. There is a huge unmet demand that, realistically speaking, will take years to satisfy.
And there is also an important legal matter to consider. The provincial government is suing a private clinic in Vancouver for extra-billing. The clinic’s defence (in part) is that patients wait too long in the public system.
It might have been safer for Dix, politically and legally speaking, to hold his hand until the elimination of over-long waitlists was either achieved, or at least in sight. Instead, he is betting that voters (and the courts) will recognize the moral intent behind his decision, even if some patients suffer.
Whatever the case, we are about to experience the health-care system that its inventors dreamed of, but that in practice has proved elusive. This is an enormous political gamble.