THE PROVINCE COLUMN: “Extra-billing” may not mean what you think

Stethoscope prescribing treatment to patient for doctor with pen writing recipe on clipboard in hospital.

British Columbians have probably heard the term “extra-billing” several times over the past few years as the provincial government has sparred with private health care clinics in court and in the media.

At face value, “extra-billing” doesn’t sound very pleasant. Who would want to be billed “extra” for something?

But if you scratch below the surface, you may find the provincial government’s definition of “extra-billing” is not what you think. Not only does it differ from Ottawa’s definition, what the government is opposing is actually an important feature of health care systems that deliver better results for patients.

To understand how this issue affects British Columbians, consider Bruce MacDonald’s story.

Several years ago, Bruce had a serious mould infection in his body and required sinus surgery. The infection made it hard for Bruce to concentrate; the discomfort he felt was “torture” and his relationships with friends and family suffered.

Incredibly, Bruce was told he would have to wait 2-3 years for surgery in B.C.’s public system. He broke down in his doctor’s office when he heard the wait time estimate and worried the infection could spread and overtake his body.

Thankfully, there was a private option. Bruce borrowed some money and paid to have sinus surgery at a private clinic in Vancouver four months later. In fact, Bruce credits the private clinic with saving his life after the government placed him on a long waiting list.

Fast forward to today, and the provincial government now considers stories like Bruce’s to be “extra-billing” – and illegal. Why? Because Bruce used his own money to pay for a procedure instead of waiting 2-3 years for the government to provide it.

Even if a patient is the only one who pays for a procedure (and the clinic doesn’t bill the government), the provincial government still refers to it as “extra-billing.”

Currently, the B.C. government is in court fighting the Cambie Surgery Centre and the Canadian Constitution Foundation on the matter of so-called extra-billing. If the B.C. government is successful, patients like Bruce will no longer have such private options in B.C. They’ll either have to leave the country for faster care or cross their fingers and hope the government provides surgery more quickly.

The federal government’s Canada Health Act, however, defines “extra-billing” differently.

Ottawa describes extra-billing as when a patient pays for a procedure and the provincial government pays for the same procedure. Ottawa’s definition more accurately describes cases where billing twice actually occurs.

Other countries with world-leading health care systems allow patients to pay for their own health care if they don’t want to use the public system.

If you review the progressive Commonwealth Fund’s 2017 analysis of health care systems in other developed nations, you’ll see that Canada ranked 9th out of the 11 countries studied.

Countries that led the pack – the United Kingdom, Australia, New Zealand, Norway, Sweden and others – all give patients a choice: use their public health care system or pay out of pocket at a private facility.

The Fraser Institute has noted that allowing private clinics to operate alongside the public system won’t solve all of our nation’s chronic health care problems. However, such clinics serve as a pressure valve that reduce the strain on the public system.

Simply put: when patients like Bruce are able to leave the government health care system, and pay for procedures in a private health facility, that’s one less patient waiting in front of those who are using the government system and are unable to afford other options.

One thing is clear, patients should know what the B.C. government means when it refers to “extra-billing.” It’s actually a feature of health care systems that provide better outcomes for patients.

Colin Craig is the President of SecondStreet.org, a new Canadian think tank

This column was published by The Province newspaper on March 29, 2019

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Prevention – reduce demand in the first place

If Canadians lived healthier lives, we could reduce demand for emergency services, orthopaedic surgeries, primary care and more. 

For instance, if you visit the Canadian Cancer Society’s website, you’ll read that “about four in ten” cancer cases are preventable. The Heart and Stroke Foundation notes that “almost 80 percent of premature heart disease and stroke can be prevented through healthy behaviours.” A similar number of Diabetes cases are also preventable. 

Many joint replacements and visits to ERs and walk-in clinics could also be avoided through healthy living. 

To be sure, not all health problems can be avoided through healthy living – everyday the system treats Canadians with genetic conditions, helps those injured in unavoidable accidents and more.  

But there is an opportunity to reduce pressure on the health care system through Canadians shifting to healthier lifestyles – better diets, more exercise, etc. 

To learn more, watch our Health Reform Now documentary (scroll up) or see this column. 

Partner with non-profits and for-profit clinics

European countries will partner with anyone who can help patients. 

It doesn’t matter if it’s a non-profit, a government entity or a private clinic. What matters is that patients receive quality treatment, in a timely manner and for a competitive price.  

In Canada, governments often delivery services using government-run hospitals instead of seeing if non-profit or private clinics could deliver the services more effectively. 

When governments have partnered with non-profit and private clinics, the results have often been quite good – Saskatchewan, Ontario and British Columbia are just a few examples of where partnerships have worked well. 

Canada should pursue more of these partnerships to reduce wait times and increase the volume of services provided to patients.  

To learn more, watch our Health Reform Now documentary (scroll up) or see the links above. 

Make cross border care more accessible

In Canada, citizens pay high taxes each year and we’re promised universal health care services in return. The problem is, wait times are often extremely long in our health system – sometimes patients have to wait years to see a specialist or receive surgery. 

If patients don’t want to wait long periods, they often have to reach into their own pocket and pay for treatment outside the province or country. 

Throughout the European Union, we also find universal health care systems. But a key difference is that EU patients have the right to go to other EU countries, pay for surgery and then be reimbursed by their home government. Reimbursements cover up to what the patient’s home government would have spent to provide the treatment locally. 

If Canada copied this approach, a patient waiting a year to get their hip operation could instead receive treatment next week in one of thousands of surgical clinics throughout the developed world. 

Governments benefit too as the patient is now back on their feet and avoiding complications that sometimes come with long wait times – meaning the government doesn’t have to treat those complications on top of the initial health problem. 

To learn more, watch our Health Reform Now documentary (scroll up) or this shorter video. 

Legalize access to non-government providers

Canada is the only country in the world that puts up barriers, or outright bans patients from paying for health services locally. 

For instance, a patient in Toronto cannot pay for a hip operation at a private clinic in Toronto. Their only option is to wait for the government to eventually provide treatment or leave the province and pay elsewhere. 

Countries with better-performing universal health care systems do not have such bans. They allow patients a choice – use the public system or pay privately for treatment. Sweden, France, Australia and more – they all allow choice. 

Why? One reason is that allowing choice means some patients will decide to pay privately. This takes pressure off the public system. For instance, in Sweden, 87% of patients use the public system, but 13% purchase private health insurance. 

Ultimately, more choice improves access for patients. 

To learn more, watch our Health Reform Now documentary (scroll up) or watch this short clip on this topic. 

Shift to funding services for patients, not bureaucracies

In Canada, most hospitals receive a cheque from the government each year and are then asked to do their best to help patients. This approach is known as “block funding”. 

Under this model, a patient walking in the door represents a drain on the hospital’s budget. Over the course of a year, hospital administrators have to make sure the budget stretches out so services are rationed. This is why you might have to wait until next year or the year after for a hip operation, knee operation, etc. 

In better-performing universal health systems, they take the opposite approach – hospitals receive money from the government each time they help a patient. If a hospital completes a knee operation, it might receive, say, $10,000. If it completes a knee operation on another patient, it receives another $10,000. 

This model incentivizes hospitals to help more patients – to help more patients with knee operations, cataract surgery, etc. This approach also incentivizes hospitals to spend money on expenses that help patients (e.g. more doctors, nurses, equipment, etc.) rather than using the money on expenses that don’t help patients (e.g. more admin staff). 

To learn more about this policy option, please watch our Health Reform Now documentary (scroll up) or see this post by MEI.