Front Burner - Ontario mulls private solutions for public health-care crises

Episode Date: August 23, 2022

It's a perennial debate: what role should the private sector have in Canada's public health-care system? The fact is, it's already part of the ecosystem. Now, Doug Ford's government in Ontario is mulling the use of more private surgery clinics to alleviate pressures facing the public system. The move is receiving praise by some, while others raise concerns over how an expanded role of for-profit health care could have negative effects downstream. Today, Dr. Danyaal Raza explains those concerns. He's the former board chair of Canadian Doctors for Medicare, an assistant professor with the department of family and community medicine at the University of Toronto and a family physician.

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hi, I'm Jamie Poisson. Hi, I'm Jamie Poisson. You've probably heard this. It's coming from the health sector. Holy Christ.

I just swallowed a bee. Ontario Premier Doug Ford swallowing a bee. Okay, I can't even remember what we're talking about. I'll be rushing to the hospital to get this bee out of here. But it's possible you didn't catch what that press conference was actually all about. The bee thing was pretty distracting. Ford was answering questions about health care staffing shortages and the possibility of privatization. He said he was a strong believer in the public system. He also noted his government would get creative with health care delivery

and that everything is on the table. A few days later, his health minister announced plans to publicly fund more surgeries at private clinics as a means of chipping away at the backlog and alleviating pressures facing the system. Ford says the costs will not be passed on to patients ever, but it's reignited a longstanding debate over privatization in Canada's health care system. And it concerns our guest today, Dr. Daniel Reza. He's the former board chair of Canadian Doctors for Medicare, an assistant professor with

the Department of Family Community Medicine at the University of Toronto, and a family physician. Hi, Daniel. It's so nice to have you. Thank you so much for coming on to the show. Thanks for having me on, Jamie. I feel like the whole idea of privatizing healthcare in Canada, it's so loaded. Hey, it's so polarizing, but also quite confusing. How does private healthcare already factor into our public system? I just wonder if you could kind of paint a picture for me. Yeah. And, you know, I think it also helps to understand a little bit about what we mean when we say privatization, because it can typically mean two different things. So sometimes when people say privatization, they're referring to the way we pay our finance health care.

Right. Is it government funded or are people paying out of pocket or through private insurance? government funded or are people paying out of pocket or through private insurance. And so when we think of hospitals and doctors, you know, services that are covered under Medicare, these are predominantly publicly financed. But then we have other things like dental care and prescription drugs that are predominantly, in some cases, overwhelmingly paid for privately and where we have more of a U.S. style health care system. So in some parts of health care in Canada, we already have significant privatization when it comes to financing. But then the other piece people may also be referring to is delivery. And that's not necessarily who pays for the services, but on what basis are they delivered? Are they delivered on a

not-for-profit basis or for-profit basis? So is the hospital, for example, you know, not-for-profit or for-profit? Is the lab where you're getting your blood work for-profit, not-for-profit? And in that sense, you can pay with public money for these services, but there may be, you know, investors or shareholders involved, or maybe even a community board of directors if it's a not-for-profit. All right. So this new Ford government announcement, the surgeries at private clinics that they're talking about, how does that fit into the landscape that you just described there? So it looks like what the Ford government is proposing is an expansion of publicly funded money or contracting out towards for-profit facilities. So more on the

delivery side as opposed to the financing. Mr. Speaker, no one in this province, as long as our government is here, no one will have to pay with their credit card. They'll be paying with their OHIP card, not their credit card, OHIP. We see the value of having some of those independent health facilities that have existed in the province of Ontario for literally decades to take some of the pressure off of independent health facilities. And in Ontario, according to the latest figures, 98% of those sorts of facilities are operated on a for-profit or for-profit. But if you follow current trends, you know, unless there's a deliberate attempt made to actually invest in a not-for-profit system, invest in expanding hospital capacity, then we're most likely going to see an expansion of for-profit care. And can you give me some examples of what these facilities do? Like what kind of stuff do they do? Yeah, so, you know, most people might encounter them in, you know, strip malls or medical buildings where you'll have, you know, x-ray and ultrasound lab integrated where you might get your x-ray. Or if you go get your blood work done outside of hospitals, in many places, they're operated by for-profit corporations. So that's where we typically see them most often.

We also sometimes are starting to see them in like eye surgeries. And if this announcement goes forward the way I think many folks are expecting, then that experience will become a more common one in Ontario. And I just want to clarify one more thing, too, so that we're all on the same page here. Like this still won't be something that patients have to pay for out of pocket, right? Even though these are for profit entities? care more broadly. But sometimes in these for-profit centers, there are these uninsured services that may kind of be rolled in or included with the base payment for the services. But for-profit centers, because they're really seeking to maximize revenue, they're more likely to charge patients for things that might otherwise be covered in not-for-profit centers or hospitals. So they're kind of

operating really strictly to the letter of the law as opposed to the spirit of the law. So maybe an example of that would be like meals or an extra night or the kind of room you're in. Is that what we're talking about? Or is it other stuff too? Yeah, it's also sometimes, you know, some people describe it as upselling. So, you know, let's say you're going to go buy your car and, you know, you're talking to the salesperson and then they're, you know, selling you on the merits of the rust proofing or an undercoating. And maybe you don't really need it, but you're kind of talked into it. So sometimes, you know, we've heard anecdotal stories of people going into, for example, to get particular surgeries and they might be up sold on the cataract lens that, you know, maybe in some instances, you know, the upsell might be appropriate.

But sometimes patients might describe feeling pressured into the upsell. Okay, so now that we have a better sense of what we know so far about that announcement, I want to talk about all the concerns swirling around it. know so far about that announcement. I want to talk about all the concerns swirling around it. But I wonder if before we spend time talking about the for-profit side, if we could talk a little bit more about the non-profit side, like expanding non-profit clinics, you know, what do you think about that move? Could it reduce some of the wait times that we're seeing? Well, so there's absolutely no doubt that we need more capacity in the system, right? We need more elect, especially elective surgeries done. We need more spaces for folks in long term care, we need more home care. So there's no question that we need to create more capacity in the system. But the question, of course, is,

is how do we want to do that? So again, if we're just speaking about delivery on a not-for-profit versus a for-profit basis, if you actually look at the evidence, there's studies in the US that have compared for-profit versus not-for-profit hospitals and dialysis centers. The not-for-profit ones perform better. They have lower mortality rates and better outcomes. In the UK, about 10 years ago in 2012, they engaged in a large contracting out initiative through the NHS, which is their healthcare system. And they actually found that as they contracted out to for-profit facilities, mortality actually went up. So that reinforced the importance of investing in not

for profit facilities. And then even here in Canada, right over the past couple of years, we've seen what's happened in long term care. So if our starting question is, you know, what is the best way forward, you know, to deliver the highest quality care, then the evidence points towards investing in delivery that's operated on a not-for-profit basis. Okay. But like you said earlier, 98% of the ecosystem right now in Ontario, at least, is for profits. What would it take to invest more in a non-profit system to kind of ease some of these, well, some of the crisis that we find ourselves in right now? So this is really where the government needs to reject the status quo and show some innovative

thinking and actually make some purposeful attempts to invest in not-for-profit systems. In particular, you know, one area that people often point to is the development of community surgical centers that are affiliated with hospitals that actually really helps coordinate you know what we call case mix the mix between complex and less complex patients a lot of the referrals are already going to hospitals emergency cases are coming through hospitals so hospitals can coordinate both their staff and the cases between you know the in hospital cases versus these specialized community surgical centers. And it's been shown to work in many hospitals in Ontario, but it's something that

I think we need a bit more of. Would these facilities have the same kind of oversight that like a hospital would? Yeah, so increasingly hospitals are already doing this. So they're doing things like operating dialysis centers in the community, but using hospital infection control protocols, you know, hospital staff, hospital procedures. Many hospitals in urban centers are also partnering with hospitals in smaller communities to use their operating rooms during off hours. And in that way, they're also kind of bringing their own protocols, making sure things are up to standard, making sure the staff who are working there are being paid an equivalent wage. So these sorts of satellite clinics would very much operate under the same protocols as the hospitals that they would stem from. Okay. Now compare those to the for-profit clinics for me.

those to the for-profit clinics for me. So this is a challenge because one of the problems with our system is it's so fragmented as it already exists. And you're essentially creating these new standalone clinics that are not integrated with the system more broadly. And it becomes increasingly challenging to make sure that patients are getting the right type of care at the right time. You're creating new referral pathways. And you're also pulling staff away from, you know, not-for-profit systems where maybe the cases are more complex. There's higher rates of burnout. And, you know, we're living in an environment right now where healthcare workers are already burning out. And if you're pulling healthcare workers away from, you know, trauma centers, emergency departments, because burnout is so high there, then you're really doing a disservice to the system as a whole.

What about the argument that by pulling patients away, it alleviates some of the burden on the healthcare professionals right now, they can concentrate on those more complex cases. Like if these for-profit clinics are just taking cataracts, for example, then a hospital doesn't need to worry about that. with excess supply of nurses, of doctors, of paramedics, then, you know, that argument would be a lot easier to entertain. But unfortunately, that's not the case. So if you're creating, you know, a separate stream of care where the case mix is more straightforward patients, you're not integrating it with hospitals and other centers where there's higher levels of complexity, then you're really creating, you know, not necessarily a pressure relief valve for the system, but you're basically creating a profit center for these clinics that really, you know, if you're looking to make a buck, you want to take the easy patients,

patients who are less complex, who typically, you know, are wealthier because wealthier patients are healthier. They're more likely to speak English. You can put them through faster and you're going to pull whatever staff you need in order to maximize that revenue. In an environment where staff are already in short supply, then you have healthcare workers who are burnt out, who need a break. If someone says, hey, you know what, you can work the same or fewer hours. It's going to be less demanding. You'll get home on time more quickly.

Then you can't really blame people for taking those opportunities. then you can't really blame people for taking those opportunities. So you're creating this environment where you're actually pulling staff away from overtaxed hospitals towards, you know, quote unquote, easier care that is also good for the investors and the owners in for-profit care. And while it may be better for them overall, on the whole, it's actually a detriment to the system. In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem.

Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. Hi, it's Ramit Sethi here. You may have seen my money show on Netflix. I've been talking about money for 20 years. I've talked to millions of people and I have some startling numbers to share with you. Did you know that of the people I speak to, 50% of them do not know their own household income? That's not a typo, 50%. That's because money is confusing. In my new book and podcast, Money for Couples, I help you and your partner

create a financial vision together. To listen to this podcast, just search for Money for Couples. I help you and your partner create a financial vision together. To listen to this podcast, just search for Money for Couples. We've been talking a lot about Ontario today, but I wonder if you could tell me more about how we've seen increased privatization play out in other provinces in Canada. So if we go back to the different ways privatization operationalizes, either through, you know, the financing piece or the delivery piece, we've seen attempts at it. So a few years ago, there was a Supreme Court case launched in B.C. by a for-profit surgical center to basically undo some of the laws that uphold Medicare. For the province at the BC Court of Appeal, but a loss for Dr. Brian Day, owner of the Canby Surgery Centre, a private clinic in Vancouver. Day has been arguing in court for years that it is a violation of constitutional rights,

that the province will not allow extra billing and private insurance for services his clinic provides. He hasn't commented publicly. And that was defeated in the Supreme Court and then again on appeal. So that was a legal attempt on the financing side. So this was, you know, quite a comprehensive court challenge. Folks will remember, you know, the last legal challenge before this can be challenge was the Shugley challenge in Quebec. And so this this was a bigger challenge than that initial one in Quebec. What is that? What's like, what does that all tell you? Like,

put that into maybe you could try and put that in perspective for me. So that case actually came to conclusion, the judge issued an 880 page ruling, they had experts from around the world come and testify. And the judge found that moving towards this sort of private system that the plaintiffs were asking for would actually make care worse for everyone. The plaintiffs appealed it. And then in the appeal, they again lost based on the same arguments. So, you know, I think people need to be aware of the fact that these sorts of initiatives, these sorts of efforts to expand, whether it's privately financed care or for profit delivery can happen both through the legal system, but also through the political system. I actually find that quite frustrating because, you know, the evidence is very clear about how to build a better system, one that works for everyone. And whenever we get bogged down in these sorts of legal challenges or, you know, these political tangents, it actually sucks away the energy from investing in things that actually work.

So, for example, I'm a family doctor. I work in a low income community. I'm working on health system reform that includes things like talking on this podcast. But every time we're forced to basically uphold the principles and defend the principles of Medicare, that's less time that we can spend actually fighting for the things that will make the system better. I know this is a thread that you've been pulling throughout this conversation but I wonder if we could end this conversation with some more of your reflections on what you think actually needs to happen uh in order to make the system better? Because the status quo clearly is not working right now. Yeah, well, I think number one, you know, a hospital bed without a nurse is just furniture.

We added 3,500 beds. And with a historic $40 billion investment with 52 regions around Ontario that are either getting a new hospital or a new addition. We're adding another 3,000 beds, Mr. Speaker. We're working with the College of Nurses. So we're seeing unprecedented levels of burnout. We need to treat health care workers, including nurses, with the respect they deserve. That includes lifting wage caps that have been

instituted in many jurisdictions, including Ontario. For ICU nurse Hala Ayyub, a glaring piece missing in the plan, wage increases for nurses and repealing a law that allows the province to cap them. I love my profession, but I also have a rent to pay. I have other expenses. So that is, you know, without health care workers, we have no health care system. And then we also have to invest in some of the infrastructure we've been talking about. So not for profit surgical capacity, but also things like home care and long term care, because many seniors are being cared for in hospitals because there's nowhere else for them to go, but hospitals don't provide the highest quality care for patients who can be cared for either at home or long-term care. And then we

also have to think outside of doctors, hospitals, and we also have to think about initiatives we've been pushing for for a long time, things like pharmacare and dental care, because increasingly these are the sorts of services that keep people out of hospital and keep people healthy. And Daniel, like, I think what is probably very cute for people right now is, you know, the issues with the ERs closing, the very long waits for surgeries. And, you know, what kind of confidence do you have that governments will move in the direction that you think is the right way to go, right? Investing in not-for-profit facilities. Look, governments are 100% capable of doing this.

Nothing demonstrated that more clearly than, you know, the first few waves of the pandemic where governments were nimble, they were quick, they responded to a crisis in lightning speed faster than we've seen them respond to crises, you know, that preceded it. So we know it's possible. But what we're missing is the political will and leaders to actually do it. Now, I'm not so naive to think that there's quick fixes to this. You know, I've been working and practice long enough to know that these problems have been here for a while, and they're going to take a while to fix. But what we need to see is we need to start to see those efforts, right? There's a lot of, I think, morale is pretty low right now in the system. No one expects change overnight, but we need to see some positive changes

that we can look forward to, right? So we can hold our heads just a little bit higher. Thank you. Thank you so much for this. Thanks, Jamie. All right, that is all for today. I'm Jamie Poisson. Thanks so much for listening.

Talk to you tomorrow.