Fast & Curious: Short Takes on Random Things

For-Profit Healthcare

I have to admit to not having fully understood how for-profit clinics had succeeded in infiltrating the Canadian healthcare system in the first place, having forgotten that the price of single-payer healthcare is eternal vigilance.

A drawing of a gold caduceusMy understanding was that the Canada Health Act (CHA), which parliament passed unanimously in 1984, prohibited private clinics but the truth, as usual, is more nuanced.

The CHA prohibits physicians from “billing medicare systems while simultaneously providing services, and charging patients, for medically necessary services provided at a private clinic.” This effectively makes doctors choose between working in the public system and working in the for-profit system and the for-profit system, in Canada, is not sufficiently lucrative to tempt them away from the public.

But doctors determined to undermine universal healthcare (and they exist) have found workarounds. The trick is that Canadians are only insured for things like hip or knee replacement or cataract surgery in their home provinces—cross the border into another province and, hey presto! They are able to pay for their own operations (as can anyone traveling to Canada from another country).

The advent of virtual care, which allows doctors to treat patients in other provinces without the need for patients to travel, has basically opened the door to for-profit clinics and invited them to come on in, although Federal Health Minister Jean-Yves Duclos has announced plans to crack down on them.

Provincial governments, of course, can simply flout the CHA and allow private clinics to do work paid for by the public system—Doug Ford’s plan to expand the use of private clinics in Ontario is just a more ambitious version of what’s been happening in this province with private surgical clinics since the Dexter government.

The feds will claw-back some of a province’s health transfer in response, as they did last week, but the total clawed back—$82 million—represents such a drop in the bucket when it comes to the health transfer, worth $45 billion in 2021-2022, that it remains to be seen if it will cause provinces like our own to take the steps necessary for reimbursement. (For the record, though, British Columbia got $15.6 million back this year as a “partial” reimbursement of deductions in 2021, 2022 and 2023.)

A list of Canada Health Transfer deductions by province, March 2023.

Source: Health Canada


Chair rental

Proponents of for-profit health care will say, “If the patient doesn’t have to pay, what does it matter if the surgery is done in a private clinic?” and the answer is that it gives the private clinics exactly what they need to embed themselves in our system—the ability to operate in both the private and public sectors—and to profit from the provision of health care, which shouldn’t be allowed.

This open letter to the Ontario NDP from J. Richard Wright explains how, even when treatment is paid for by Ontario’s health care insurer (OHIP), private clinics still manage to squeeze out a little something extra for themselves:

…my brother-in-law recently required an iron infusion. He was told by his doctor that if he took the iron supplements orally, it would take several months for his iron numbers to reach a therapeutic level.

Or, he could be infused and cut that time down substantially. He chose the latter method and was referred to a clinic (obviously private) in the doctor’s building.

Of course, when it came time to settle up, he paid for the infusion with his OHIP card. But then he was presented with an additional invoice for $75.

When he asked what it was for, he was told it was for the rental of the chair in which he was infused and the services of the nurse who administered the infusion.

The chair rental charge, needless to say, was not covered by OHIP. (I wonder what would happen if you brought your own chair?)

That nurse administering the infusion is a nurse not working in the public system. She might have good reason for choosing to work in a private clinic, she’s probably paid better and has better hours, but that’s a problem that needs to be solved by improving working conditions in the public system, not by expanding the use of private clinics.

Likewise with nurses working for agencies. The CBC reported last August that Toronto’s University Health Network (UHN) had spent “just over $1 million to hire nurses from various agencies in 2018 — but that increased to more than $6.7 million in 2022 alone, more than $4 million of which was tied to hiring private nurses to work in its ICUs.”

Dr. Michael Warner, critical care medical director at Toronto’s Michael Garron Hospital, told the broadcaster:

What we’ve seen during COVID is that these agencies are charging much more, and I’m not sure where their money is coming from, but hospitals are paying much higher hourly rates. What they’ve done during the pandemic has been predatory and exploitative.

I saw a separate CBC interview with Warner in which he explained that some of these agencies employ “surge” pricing, like Uber, so the more in-demand their nurses’ services are, the higher the hourly rate they charge—and the rate the hospitals pay the agencies is not, it must be remembered, the rate the nurses are paid.

Bottom line: agency nurses cost the system more, and this is not the only example of for-profit care adding to, rather than reducing, the cost of healthcare.


Saving money, cutting wait times?

In a recent piece for the CBC, reporters Marcy Cuttler and Christine Birak cite data from the Canadian Institute for Health Information (CIHI) that show that:

knee replacement surgery in a public hospital, paid by the province, costs about $10,000. The same surgery in a private clinic can reportedly cost patients up to $28,000.

They admit they can’t say for sure how much provinces pay for knee replacement surgery in a for-profit clinic because the amount is often “kept secret, due to confidentiality agreements,” but they can point to cases where provinces have given up using for-profit clinics because they’ve proved too expensive:

In 2011, the Vancouver Island Health Authority dropped plans to outsource MRI scans because they were more expensive in the private, for-profit sector. More recently, Fraser Health, one of B.C.’s health authorities, purchased two private MRI outpatient clinics, bringing them back into the public system as part of the strategy to cut health-care wait times.

In 2014, Quebec ended contracts with two private surgical centres for cataract and other surgeries because the costs per case were lower in the public system.

Cuttler and Birak also largely debunk another talking point in favor of for-profits, that they reduce wait times. They take the example of Ontario, where the province’s health minister has cited cutting wait times as one of its goals in turning to the for-profit sector. CIHI data, they say, show that Ontario:

…actually had the shortest waiting times in Canada for hip and knee replacement surgeries in 2021/2022 — 73 per cent of Ontario patients received knee replacement surgery within six months.

By comparison, patients in provinces outsourcing surgeries to for-profit clinics waited longer. In British Columbia, only 70 per cent of patients received knee replacements within six months, while in Alberta, it was 53 per cent and in Quebec, 48 per cent.

Only in cataract surgery did Ontario lag behind, with 60 per cent of surgeries being done within the 16-week benchmark.

It’s pretty damning evidence that the push to expand for-profit medicine is for the benefit of for-profit providers, not the general public.

And that leads me to my final thought which I’m going to hold off on until the end of the next item, because while I thought I was being truly random this week, it turns out there’s a clear link between my two items.


Renters, unite!

In a CBC story about the future of Nova Scotia’s rent cap, reporter Michael Gorman spoke with Minister of Service Nova Scotia and Internal Services Colton LeBlanc who said:

When we’re talking about the Residential Tenancies Program itself, it does have broad-reaching impacts on the lives of Nova Scotians. We’re talking 300,000 tenants, 6,000 landlords across Nova Scotia. So we continue to take that feedback from those Nova Scotians and … [are] continuously striving to strike a balance.

Those strikingly unbalanced numbers became an immediate subject of discussion on Twitter, where Adam Boyd (@BoydMath) said:

The NS government says they’re striking a balance between the interests of 300000 tenants & 6000 landlords. Seems like that balance should be 50:1 in favour of tenants. Maybe renters feel powerless but with about 1/3 the population renting that could be a lot of political clout.

scale with "human rights" on one side and "economic driver" on the other

Inadvertently accurate graphic from the Nova Scotia Affordable Housing Commission report, “Charting a new course to affordable housing in Nova Scotia.”

Reporter Robert Fisher at the St Croix Courier (@RF_Journo) chimed in with:

Problem: money. Landlords have it, tenants don’t. That’s the political clout that matters today. Politicians count on voters’ short attention spans & money. Case in point: Ontario where a despised gov’t was handed an even bigger majority in the last elxn.

My reaction, besides agreeing that if tenants could form some sort of province-wide association they really would have some political clout, is to note how many units some of those landlords must own to achieve that wildly out-of-whack 300,000 to 6,000 ratio.

REITs like Killam, for example, are landlords to thousands of tenants in this province, because we treat housing as a commodity ripe for the exploiting and nobody is better at exploitation than the finance industry.

No surprise, then, that hedge funds like Kensington Capital Partners are investing in for-profit healthcare (their portfolio includes Clearpoint Health Network, a chain of Canadian surgical clinics).

Which means the day has come when the financial industry has crept its way into pretty much every corner of your life: owning the roof over your head, the clinic where you get your knee replacement, the animal hospital where your pet is treated, the newspaper that gives you your information about the world—improving none of these things while extracting as much profit as humanly (or algorithmically) possible.

NDP leader Jagmeet Singh, who has been speaking out about the creeping privatization of healthcare, was asked by then-CBC Power & Politics host Vassy Kapelos back in August 2022 whether trying to keep for-profit clinics at bay wasn’t “too Utopian” (her actual words) a goal given how much for-profit medicine already exists in the Canadian system.

Boil that down to its deeply depressing essence and what she’s saying is it is not possible to imagine anything being done differently from the way it’s being done today.

But if that were true, then Vassy Kapelos would still be hosting CBC’s Power & Politics because it would be “too Utopian” to imagine a better gig and in reality, she left three months later for CTV.

A photo of Vassy Kapelos host of CTV's Power Play

Because things CAN change.

And on that unexpectedly upbeat note—I’m outta here!