The Decibel - Are Alberta and BC good models for private surgery?

Episode Date: January 20, 2023

Ontario Premier Doug Ford announced this week his government is increasing the use of private clinics for procedures like cataracts, diagnostic imaging and eventually hip and knee replacements. The move sparked a lot of criticism – but Ford says he’s following the lead of other provinces like B.C., Alberta and Quebec that are already doing something similar.First, we’ll talk to The Globe’s provincial politics reporter Jeff Gray about Ontario’s plan. Then, we’ll talk to The Globe’s B.C. reporter Mike Hager about how that strategy is working in other provinces, and why B.C. is now moving away from private health care.Questions? Comments? Ideas? Email us at [e-mail]

The past several years also taught us when it comes to your health, the health of all Ontarians, the status quo is no longer acceptable. The Ontario government is planning to expand the use of private clinics to help reduce the backlog of surgeries. It sparked a lot of criticism, but Premier Doug Ford said he's taking his cue from provinces like BC, Alberta, and Quebec that already do something similar. We need to be bold. We need to be innovative. We need to be creative. We need to look to other provinces and countries to see what they do differently and borrow the best ideas. So today, we're going to talk to provincial politics reporter Jeff Gray about Ontario's plan. And then we'll talk to BC reporter Mike Hager about how that strategy is actually working in other provinces. I'm Maina Karaman-Wilms, and this is The Decibel from The Globe and Mail. Jeff, thanks so much for joining me again.

Thanks for having me. So what are the basic details of Doug Ford's plan? So the plan, as he announced just the other day, they describe it as having three steps. As a starter, the idea is to move more cataracts eye surgeries into private clinics. 14,000 more surgeries will go there to try and clear the backlog that has been made worse by COVID-19. There's 200,000 people waiting for various procedures, outpatient procedures like these, I think. It's a lot of people. It's a lot of people. As a second phase, they're going to expand more cataracts and they're going to expand the number of diagnostic procedures that you get in these places. So more colonoscopies and that kind of thing. MRIs, CT scans, that kind of thing. MRIs, yeah. And then the third phase,

which they need to change legislation to accomplish, will see them move more complicated surgery and open more of these clinics potentially or allow existing ones to expand. And that'll be for hips and knees and some foot surgeries. And so why focus on these kind of procedures then? There is a consensus, it seems, among people who run hospitals and doctors that the idea that you could move simple, less complicated surgeries out of big, busy hospitals that are dealing with all

sorts of very complicated and urgent surgeries, move them to these smaller facilities that are specialized, and you would get, well, A, it'd be nicer for patients. B, these facilities get better at doing these things and do them more quickly. So these clinics would still be billing OHIP, Ontario Health Insurance Plan, but they're not publicly funded. So can we just make sure we get, I guess, kind of clear that? They're not on the front end, they're not getting public money, but patients are not paying for these procedures. No, no. These would be standalone facilities that when they do a surgery, they send the bill to OHIP. And is that something that we already see in the province now?

Yes, we have. We've always had this. There's a bunch of different little institutions and rules and regimes that have been set up. We have private hospitals in Ontario, barely any of them. Only one of them does the kind of surgery that we're talking about now, outpatient surgery. And it's existed since before public health care came into being. Your family doctor is not an agent of the state at a public institution. It's a private sector entity, basically, when you go see your family doctor for most people. And we have these things called IHFs, Independent Health Facilities. And there's 900 of those, which sounds like a lot. Most of them are small. Most of

them do diagnostics. And only 10 are in the business of doing anything remotely related to what we're talking about surgeries and most of those do plastic surgery. Okay all right so let's get I guess to the the reason behind these these changes here. Do we need more more clinics like more places to have these operations? Are the facilities that we have right now in the province are they at their full capacity? Well here's where the critics of this whole plan kind of make a few points that I think that we haven't gotten clear answers on. So one is, obviously, we hear about the hospital system being strained every day. Mostly we're hearing about ERs, right? Not this wing of the hospital.

I mean, it's all related, but there are numbers that show that operating rooms are not actually being used to their full potential, to full capacity in the public system right now. So the ERs are overwhelmed, but the operating rooms actually are not being used to their full capacity. Yeah. Now, I think there's a whole bunch of complicated reasons for that. Well, one reason that's not that complicated, although we can't figure out, you know, it definitely raises questions for people, is that the number of surgeries is limited by the amount of funding, the amount of staff that you have. So the Auditor General had a report in 2021, where she said that a significant percentage of the Providence hospitals were not using their operating rooms at full capacity. So there's that factor. The other problem is what critics of this plan say is if you open up these little clinics or you expand the ones we've got, they need staff too.

And where are they going to get that staff? Nurses and other people. Surely those people will come from the hospital or from a pool of people that would otherwise work at a hospital. And all we hear about every day is how the hospital system is strained because it doesn't have enough staff. Right. Yeah. Why create these new clinics if the spaces we have right now aren't being able to run at full capacity? Wouldn't it make more sense to utilize those better? Yeah, no one's really answered that question. I think there's a couple of arguments where people, for instance, hospitals need to

handle a whole bunch of very urgent and complicated surgeries and need to have a whole bunch of staff on hand. The little clinics don't need to have all those people. So that brings your costs down, the number of staff, the type of staff you need. All those things are different. Where people get concerned is, we'll hold it a minute now, if these clinics are private companies that are trying to make money, they'll be taking staff away from the public system. And the argument that unions and the NDP and others make is that that over time will result in the degrading of the public system, which we need. Now, the government has said, oh, these new clinics, they will have to produce staffing plans

that would presumably show how they will staff their clinics without harming the public system. There's a lot of devil in the details of how that would really work. I still don't, I don't think anybody really understands exactly how that would protect the hospital staffing problem. I mean, one scenario would be that, well, it's a lower stress, easier place to work,

nine to five, no one's coding on the operating table, this is all, that you might get retired nurses who were stressed out, burned out in the system would come back and work there, but they wouldn't work in a hospital again. So we're not taking people away from the hospital. On the other hand, this is a government that's limited nurses wage increases with its wage suppression bill, as the opposition calls it, Bill 124, which limited everybody in the public sector to 1% wage increases. Although that's before the courts, it actually got struck down and doesn't exist at the moment. But regardless, there's a whole bunch of questions that haven't been answered about how that staffing question will get solved.

Yeah. I've also heard a lot about upselling at for-profit clinics. Can you help me understand why that's such an important issue? So at these clinics, you come in for your OHIP covered cataract surgery, as an example, and the eye doctor says, oh, well, I mean, you can get the OHIP lens in your eye, but I've got these much better lenses for you that cost $400, $1,000, $2,000. And I really think that would be a better choice for you. You should think about. And when they pay out of pocket, that would go to the clinic then, is that right?

Oh yeah, for the fancy lenses. Yes, yeah. So, and this has been raised over and over again. The government's response is basically, well, look, this is how it works. The other inconvenient fact about that for critics of these clinics is that that actually happens in hospitals.

I was just going to ask, wouldn't you get that option in a hospital too? You're already free to pay more. We have the option of getting private rooms. Many people would have insurance that would cover that, but you could also pay for that. This idea that upselling is unique to private clinics, whether or not it's a problem, how is it regulated, all that stuff. These are not new problems. How is it different doing this in a private for-profit clinic? Well, I think their argument would be, look, we're going to have more private clinics,

and they have more incentive to do this. The idea is that private clinics will make their money on the add-ons, on the upselling, and they have shareholders and they have a bottom line that they need to attend to. And so the argument will be that this will happen more. As the Auditor General has pointed out in a report recently that there are way more concerns about this kind of thing happening in private clinics. And the report also points out that the enforcement keeping track of this, the government has not been doing that.

Jeff, thank you so much for taking the time to talk to me today. Thanks, Manika. After the break, Globe reporter Mike Hager tells us why BC is moving away from private health care after giving it a try. Mike, thank you so much for joining me. It's great to talk to you. Yeah, no problem. Thanks so much for having me. So how often are surgeries in Alberta and BC, how often are they being done at private clinics? Well, the best data we have is from the last fiscal year, and it showed that in Alberta, about 20% of surgeries are happening in these private clinics. And in BC, it's just about 5%.

And to put that into context, Ontario currently, it's actually at 3%. That's right. And, you know, the majority of these appear to be cataract surgeries in BC and Alberta. So, you know, these private clinics, they have to, by law, do less complex surgeries that don't require an overnight stay in hospital typically. And so we're talking orthopedic like knee, hip replacements and cataract surgeries. So I guess then I want to get a sense of how this system is working. How does Ontario compare in terms of wait times to these other provinces? So the Canadian Institute for Health Information collects this data and compares each province as to how it's doing for the benchmark of people getting

different procedures. And Ontario is actually a front runner in many surgeries. It's actually only lagging behind Alberta, BC and Quebec in removing cataracts with just 60% of surgeries being done within 16 weeks. But otherwise, it has the shortest wait times for hip and knee replacements. So Ontario is doing quite well with wait times in other areas. And just because they're doing better than their counterparts in many of these surgeries, the wait times still are, you know, unacceptable. I want to ask you specifically about BC here, Mike, because BC has been changing things up recently. Can you tell me what has BC been doing recently with their private clinics? Yeah, we tried to get the health minister, Adrian Dix, this week. He's obviously very busy, but he just sent a statement when we asked about what Ontario is doing and how BC approaches the same problem of surgical backlogs. of the public health care system. And that included last year buying up two private surgical

clinics on Vancouver Island. In effect, they were kind of acting as extra operating rooms for local hospitals. But they were, again, just doing cataract surgeries and less complex surgeries. So they were kind of hamstrung by the law. And the province said that they were being underused and unused. So now once the province bought these two clinics for $11.5 million, they've argued that they've been able to complete thousands more surgeries a year than were happening when they were privately owned. So they've actually, like public money has bought them to bring them back under the public system then?

Oh yeah, yep. You know, BC was cited by Premier Ford, but it's running counter to kind of Ontario's approach. And of course you have a new Democrat government in power since 2017. And in 2018, shortly after forming government, they bought up two MRI clinics in suburbs of Vancouver to improve wait times for those types of imaging. What does the BC government say about why they're moving these clinics back under the public umbrella?

Well, their main argument appears to be efficiency. They think that, you know, the economy is a scale. They're able to, you know, shuffle patients among different facilities, I guess. And their staffing enables them to get through these wait lists faster if they increase the public capacity. I'm glad you brought up staffing there, because staffing is one of the main criticisms of Doug Ford's plan, that people will leave public jobs and move to private ones. So what have we seen in Alberta and BC on that issue? Yeah, I mean, that is of paramount concern, right? We have an HR crisis in healthcare across the country. And it is, you know, the main

point that critics in Alberta seized upon is that, you know, there's about 1000 vacancies for nurses in Alberta, the union told me. And they're worried that increasing these private surgical centers will drain more nurses from the public system and, you know, lead to worse outcomes everywhere. You know, their union vice president said, it's not about space, it's really the people. And she said that there's operating rooms across Alberta that are public that aren't being used because there just isn't enough staff right now. But you said they're worried about these staffing concerns, but has it actually happened? Like, have we actually seen this become an issue? In Alberta specifically, those surgeries remain mostly cataracts. And apparently the HR issues from those existing clinics haven't become a huge issue yet, but there's the existing crisis in the public system.

So any more ramping up of those private centers for more procedures, joint replacement procedures in particular, is worrying to the nurses union. So is Alberta planning on ramping up private procedures then? Yeah former premier Kenny was elected on a campaign to do just that and so there's a lot of requests out for centers to partner with the province for these publicly funded private surgeries and south of Calgary in particular is where they're ramping that up this year. As the NDP critic told us, you know,

the efforts to expand have been kind of hamstrung by the pandemic so far. And so now we, we will see these clinics begin to do many more surgeries and then, you know, the staff are, that are needed for the surgeries will be employed. So I guess it remains to be seen just how it will play out in Alberta. And what about in BC, Mike? Have we seen the similar kind of staffing worries in BC? Across the board, there's understaffing. People are just plain burnt out from this pandemic and all the different waves. But in BC, there is a much slighter percentage of the overall surgeries being done. And so these

surgical centers, there's only seven of them now operating, and they're less than a percent of the budget for BC's healthcare. But there was no data, of course, which is part of the problem on reporting on this. There is no real agency tracking how many people go back and forth between the two or leave the public sphere for a private job. In 2017, our colleagues here at The Globe found that there was, you know, really significant illegal extra billing by doctors across Canada in private clinics. But it was especially bad in BC and patients had to pay out of pocket for just the right to see their doctor or surgeon. Perhaps that's why we've seen a lot of auditing of these clinics in recent years. Exactly what are they looking for here?

What are these audits kind of after? Egregious billing, extra billing of people who are getting publicly paid for services and surgeries. They're looking for things like, you know, paying out of pocket to get even an appointment, to get before a doctor and to get surgeries done. And the Globe found that, you know, people were getting asked to pay after calling a public hospital to get info on their wait times. They were referred to a private clinic with the same surgeon who then asked for a referred to a private clinic with the same surgeon

who then asked for a fee to have an audience with the patient. I think this kind of relates to the next thing I want to ask you about, which is upselling patients, the concern around upselling patients in private clinics. How much of that do we see in BC and Alberta? Well, in BC at least, it's a constant worry of critics of these arrangements. And each year, the federal government kind of claws back health transfer money that they say was lost to overbilling. And in a Canada Health Act report, it showed that BC lost like 62 million of its health transfers from Ottawa over four years ending 2021 as a penalty for unlawful extra billing. They can claw those back after investigating. Mike, given all of the stuff

that we've just talked about then, I'm curious, what are people that you've talked to saying about this move that Ontario announced this week? How do people in BC and Alberta think about this? Everyone is grasping for solutions to these systemic problems plaguing healthcare across the country. Out West, critics I talked to were incredulous that Ontario was you know looking at subsidizing more private surgeries to the tune of millions of dollars given that they say this money comes at the expense of the public system and really the public system should be bolstered instead of these surgical clinics out West there's that extra concern of unlawful billing

and you know a health coalition of numerous groups the campaigner with them said that the same time that many of these private surgical clinics are are doing these surgeries there's there's documented cases of them unlawfully charging patients for medically necessary procedures that are covered under our version of OHIP. Mike, thank you so much for taking the time to talk to me today. Thank you. I really appreciate it. That's it for today. I'm Mainika Raman-Wilms. Our producers are Madeline White, Cheryl Sutherland, and Rachel Levy-McLaughlin.

David Crosby edits the show. Kasia Mihailovic is our senior producer, and Angela Pichenza is our executive editor. Thanks so much for listening, and I'll talk to you next week.