Globe columnist Margaret Wente’s July 8th column Heresy takes root in BC has holes in it that would fit a fast ferry. Wente omits facts, reports opinion as fact and makes claims that have no basis in fact. To see CUPE’s comments, click on the yellow-highlighted text.
Heresy takes root in BC
By MARGARET WENTE
Tuesday, Jul. 8, 2003
If you’re a weekend jock with a bum knee, don’t live in British Columbia. You might die of old age before you can get it fixed. The waiting lists for surgery are even longer than they are here in Toronto where SARS shut operating rooms for weeks and created enormous backlogs.Wente trivializes BC’s sweeping plans, which cover 200 types of surgeries, and will mean thousands of privatized procedures, from tonsillectomies, hysterectomies and mastectomies to pacemaker implants and toe and foot amputations. It’s not just about having a bum knee and wanting to jog again. Says who? There is no central system to objectively track and compare wait times for procedures between cities or provinces. According to the Canadian Health Services Research Foundation (visit www.chsrf.ca and go to their Mythbusters series), “waiting lists in Canada are haphazardly manage and inconsistently measured. […] individual physicians or hospital departments usually keep the lists and there is little coordination among the different keepers.” The foundation also notes that Canadian lists aren’t independently audited. Audits of wait lists in Britain found many names that shouldn’t be there – either their surgery had happened, or they didn’t need it (which, incidentally, doesn’t mean they died of old age, as Wente flippantly suggests). Finally, the CHSRF points to research suggesting well-managed and coordinated lists could cut wait times, based on a real-life public experience with heart surgeries in Ontario.
“I don’t know if it’s demographics or population growth, but the wait list for hip and knee replacements has grown 350 per cent over four years,” says Clay Adams, the spokesman for the Vancouver Coastal Health Authority.Is that your opinion, or is that based in fact, Mr. Adams? Wait list data is “capricious,” according to the Canadian Health Services Research Foundation. The CHSRF examined two wait list reports – one by the right-wing Fraser Institute, and one by the Manitoba Centre for Health Policy and Evaluation. The Fraser Institute report appeared to document lengthy wait times and steady increases in those times. But it was based on entirely subjective data: “a sample of physicians giving their opinions on how long a patient can expect to wait.” The more objective Manitoba study found wait times of about 30 days, or 4 weeks – not the 7.2 weeks reported by the Fraser Institute – and based its findings on “administrative data from hospitals and physicians to measure actual patient experience.”
Over the past decade, a succession of governments tried to fix all this. They reorganized the hospital system and poured billions more into it. The waiting lists just got longer.The reality is, from the federal government on down, there haven’t been a lot of efforts to “fix” public health care. Instead, the Liberals cut billions from health care, and over the past several years have made a show of “replacing” the funds, but only to old spending levels, and without any concrete or comprehensive plan to reform and expand public health care. Many key recommendations of the Romanow report have been completely ignored by the federal government and, following the Liberal’s lead, the provinces. This winter’s health accord was a major disappointment, with no new measures to enhance accountability or ensure that federal funding is being spent on care that’s 100 per cent public. New money has started to flow – but with no strings attached. In the same week BC announced its surgery privatization, the provincial government also passed on $132 million in new federal funding for patient care, including about $30 million for the Vancouver Coastal Health Authority. That increase in funding will now, in part, be siphoned into private sector pockets – and profits.
So now, B.C. is going to experiment with contracting out – but only when it saves money. This month, the province’s biggest health authority, based in Richmond, will begin asking private, for-profit clinics to bid on certain types of day surgeries. Want your knee done fast? Step right across the street. The doctor (possibly the same one who’d have treated you at the hospital) will see you now. The government picks up the tab, the taxpayer saves money, the doctor makes a buck, and you get to run the 10K again. Because no overnight stays are involved, it’s legal under the Canada Health Act. Everybody’s happy.Show us the evidence, please. CUPE’s Hospital Employees Union has filed several Freedom of Information requests seeking the information the Campbell government is basing its sweeping privatization schemes on. The FOI requests have turned up scant information. In response to a comprehensive freedom of information request filed last year by the Hospital Employees’ Union, the Ministry of Health Services disclosed that it has just 55 pages of documents in its possession to justify the government’s plans to privatize health services and facilities. But after the requested information was vetted by the Premier’s office, the ministry completely severed all but two pages of its thin privatization dossier before providing it to the union. Perhaps the files are so thin because there is no evidence privatization saves money, is more efficient or delivers higher-quality care. Better call your lawyer. Allegations of queue-jumping stemming from a Vancouver Coastal Health Authority eye surgery contract show there are many ways privatized surgeries could violate the Canada Health Act’s five principles of universality, accessibility, portability, public administration and comprehensiveness. The B.C. Health Coalition recently learned the provincial government was penalized by the federal government for two separate violations of the Canada Health Act in March 2003. The coalition is calling for an immediate investigation of private surgical clinic billing practices. In spite of this recent news, CUPE and other health activists are concerned the federal government isn’t doing it’s part to protect public health care. CUPE has launched a legal challenge to force the federal government to uphold the Canada Health Act and protect public health care from privatization. Find out more. Especially not the families of people who die. Recent, peer-reviewed studies published in the Canadian Medical Association Journal and the Journal of the American Medical Association have found patients are more likely to die in for-profit facilities than not-for-profit facilities. The JAMA study looked at American dialysis patients in for-profit and not-for-profit centres, and found an eight per cent higher chance of death, or about 2,500 premature deaths a year, in for-profit centres. The for-profit kidney clinics appear to find “efficiencies” by providing substandard care: patients were treated by less-qualified staff, had less dialysis time and got lower doses of drugs. Visit www.jama.ama-assn.org and www.cmaj.ca to access the full studies, co-authored by physician and McMaster University professor P.J. Devereaux. In another study cited by the CHSRF, Johns Hopkins University researchers found patients at not-for-profit kidney treatment centres were more likely to get referred for transplants than those at for-profit centres. While the researchers themselves wouldn’t speculate on why, others have argued this is because for-profit centres don’t want to see a patient cured, and thus not coming back as a steady “customer” for their service. It’s all about revenue streams, it seems.
“The news from Victoria is shocking, and should horrify everyone in Canada,” wrote Judy Darcy in these pages. Ms. Darcy is president of the Canadian Union of Public Employees. “The people who benefit most from private care are not the patients, but the privateers.” According to her, Premier Gordon Campbell has replaced Ralph Klein as public enemy No. 1.
Patients, however, appear eager to be exploited by the privateers. For the past four years, B.C.’s Lion’s Gate Hospital has contracted out 620 cataract surgeries a year to a private clinic. The contract cut the cataract waiting list by a third, freed up significant operating room time at the hospital, and cut other surgical waiting lists as well. Not a single patient has complained.Maybe that’s because they’re not really being given any options. Wente and Adams neglect to mention that the for-profit clinic doing the eye surgeries no longer has the contract, has closed and was impounded by bailiffs in June. The clinic’s contract with the Vancouver Coastal Health Authority apparently ended by mutual agreement on March 31, at least that’s according to the authority. A newspaper investigation has uncovered several people who say they paid extra to get faster treatment – a clear violation of the Canada Health Act. And other provinces have had vastly different experiences, so it would be nice to see the independent study that produced these statistics. Studies of Manitoba and Alberta’s experiences contracting out cataract surgeries show the move didn’t shorten wait times. The Consumers’ Association of Canada’s Alberta branch also found it cost more – fees were higher in private clinics, and the majority of patients were shelling out for upgraded lens implants. In Manitoba, where all cataract surgeries are now public, patients with a doctor working the public and private systems faced waits of up to 26 weeks, compared to a 10-week wait with a surgeon operating only in the public system.
“We’re more efficient,” says Gerard McKenzie, an orthopedic surgeon who, with about 20 other doctors, plans to open a private surgery centre in October. It will be located across the street from St. Paul’s hospital, where he also works. “The hospitals are excellent places to do cardiac care, cancer cases, and other care where you have sick patients. But to take somebody who has a minor problem and put them through exactly the same system with the same bureaucracy is not cost effective.”Not so fast. The CHSRF has done research busting the myth that for-profit facilities mean more efficient and cheaper health care, looking at studies from Canada and the US. Cost are higher, which drives up health spending. There’s wasteful duplication of administration services such as billing. And quality of care is poor in for-profit facilities. As the CHSRF found, “Despite charging patients higher prices, paying lower wages and incurring more administrative costs, the quality and access to care in for-profit hospitals isn’t better.”
But how can private clinics do things cheaper if they also have to build in a profit? Surely the patient has got to be shortchanged somehow. In fact, the opposite is frequently the case. Many private clinics are high-volume specialists that get very good at what they do. Their overheads are much lower than the hospitals’. They can do things hospitals can’t, such as motivate employees with incentive plans. And they aren’t constrained by union rules. “If I want to clean the room I can clean the room,” says Dr. McKenzie. “If I want to transport the patient, I can do it myself.”Easy: on the public’s dime. First of all, their staff are trained and have experience in the public system. That’s where they are hired from. In addition, some private hospitals are housed in publicly-built facilities they’ve bought or leased at fire sale prices, as is the case in Calgary. The Klein government mothballed several hospitals, which created bed shortages and wait lists. The Tories then stepped in with their convenient, ready-made “solution”: private, for-profit hospitals. If something goes wrong during surgery, patients are transferred to a publicly operated emergency room – they don’t have to fund their own backup plans. And surgeries are performed drawing on the public blood system. So count massive public subsidies as one way the private sector appears to be cheaper in some ways. The other ways are simple slicing: cutting corners on cleaning and other vital supports. Plans which are prone to abuse as corners are cut to speed delivery. With what training and equipment? It’s not like swabbing the deck of your yacht, or caddying your clubs around the course…
To compete, the private clinics pay nurses and other health professionals as much or more than the public sector does. But they don’t use high-priced union workers for services and maintenance. Even some of B.C.’s hospitals have now decided that paying someone $23 an hour to sweep the floor is probably not the best use of scarce health-care dollars.Poaching health care professionals will only undermine public health care. Since they can’t be in two places at once, those caregivers certainly won’t be working in public facilities to shorten line-ups. Given the limited pool of health care workers, a parallel private system may mean shortened wait times – but only for those who can pay for it privately, definitely not those left without doctors and nurses in the public system. Contracted out cataract experiences in Canada, as well as the British experience with a parallel private system, are the proof. Finally, Wente seems just fine with paying some health care workers “as much or more” than the public sector, yet criticizes (and misrepresents) the wages of public health support workers. Wente begrudges hospital cleaners a $23/hr wage – far higher than most earn – yet she suggests that doctors, at their inflated wages, should be free to sterilize rooms. Paying public sector workers to do the job well is a sound investment. In fact, the head of Taiwan’s disease control agency recently said contracted out hospital cleaning and laundry contributed to the spread of SARS. Contracting out these key infection control measures can cost lives. (See this news report about the Taiwan situation.) These tasks require a great deal of skill and training, as Simon Fraser economist and political scientist Marjorie Griffin Cohen documented in a recent study. She found health support workers often spend the most time with patients of any health care workers, and may be the first to spot a problem or tend to a need. Sterile operating rooms, nutritious food and clean laundry are all critical to care and must continue to be an integral and integrated part of the health care network. To access the full study, visit www.heu.org.
Across the country, private clinics already do a brisk business catering to third-party payers. The biggest of these are provincial workers’ compensation boards, for whom it only makes economic sense to get injured workers treated quickly and back on the job. Want to jump the queue and have your knee fixed in a hurry? Then make sure you twist it on the job.Workers don’t support queue-jumping. Nor do they believe that workers’ compensation plans should operate outside the public health care system. It is interesting to note that health care workers are among the most vulnerable to occupational health hazards, in part because they are overworked.
Here’s another perfectly logical question: Why do hospitals want to contract out surgeries when so many of their own operating rooms are dark? Why don’t they just turn the lights back on?
It’s simple. They can’t afford to.Not quite. They aren’t being properly funded to turn the lights back on, thanks to decades of government cuts. Quite simply, the lump sum Wente talks about has shrunk dramatically while costs have continued to grow. And let’s be clear what the biggest and fastest-growing health care cost is: prescription drugs. Their price tags continue to spiral out of control thanks to 20-year patent protection that blocks cheaper and equally effective generic drugs from making it onto the market and into hospital dispensaries. That protection now has the weight of globalization behind it, with the World Trade Organization’s recent demand that Canada keep on allowing this country’s biggest drug deal to go on unchecked.
Unlike doctors, hospitals aren’t funded according to how many procedures they perform. They get a lump sum to do everything. That isn’t enough to keep the ORs open and hire the nurses to staff them. So they ration – by closing operating rooms.
“All the incentive for the hospital is to not treat patients,” explains Dr. McKenzie. “But in the for-profit system, the incentive is to treat as many patients as you can.”Actually, the incentive is to skim the “easy” procedures that can be done quickly to rake in cash, leaving the more expensive and complicated surgeries for the public system.
Sweden and Germany, among other nations, contract out some health care services to private providers. But there’s no guarantee that this sensible idea will catch on. Here in Ontario, the government closed a private (more efficient) cancer radiation clinic because of the political heat.In Sweden, health privatization has recently gone sour in Stockholm. Last fall, voters rejected both the right-wing Stockholm County Council and its local privatization scheme. An update from the Canadian Centre for Policy Alternatives found “allegations that the private hospitals and clinics in Stockholm are pre-disposed to cream-skimming, making it more difficult for seriously ill patients to get care.” A leading Swedish cardiologist has said the lives of cardiac patients were at risk under the privatized system, because the private sector will not treat the critically ill, and funding has been diverted from the public system leading to a shortage of space. While there is still some private care in Sweden, it’s certainly not proving to be the miracle cure. And a flagship experiment has been defeated by the people. Voters chose a party that promised an end to any further privatization. Simon Fraser University political scientist Daniel Cohn says “the public has soundly rejected the notion of a health care system in which for-profit facilities play a leading role.” Read more on the CCPA site. That political heat had a very credible source: the provincial auditor. In a special audit, he found the privatized care cost $500 more per treatment than public care, and that government had not looked at public options before privatizing the after-hours centre. Conflict of interest – or the appearance of it – which so often accompanies parallel private care was another theme in the auditor’s findings. The auditor said Cancer Care Ontario, violated provincial competition and transparency policies, awarding the contract to a corporation headed by a key Cancer Care Ontario official. Get the full auditor’s report at www.gov.on.ca/opa/. For a more detailed examination of conflict of interest and privatized surgeries, see Gillian Steward’s research on the Calgary Health Authority, found at www.ualberta.ca/~parkland/ and reported on in CUPE’s 2002 Annual Report on Privatization, available on CUPE’s web site.
So long as we keep calling medicare a sacred trust, the word “profit” will always be a heresy, and therefore inadmissible. So here’s a thought. Maybe it’s not Gordon Campbell who’s public enemy No. 1. Maybe it’s Roy Romanow.