New Canadian Medical Association President Brian Day says his plan will Cure the health care woes
By Cooper Langford
If Canada's health-care system showed as much snap in delivering services as Vancouver surgeon Brian Day does in returning messages, we'd be the envy of the world. He's fast, as if he sterilized his BlackBerry on the way into the operating room of his privately run Cambie Surgery Centre and dictates replies to an assistant in between incisions and sutures. These days, however, Day's claim to fame isn't his business etiquette. Nor his prowess as one of Canada's leading orthopedic surgeons, for that matter. He's in the public eye as the new president of the Canadian Medical Association (CMA) - representing this country's 60,000 physicians - because he intends to use his 12-month appointment to lobby for private-sector-style discipline in a public system that's crumbling under rising costs, increasing wait times and growing public expectations.
The fact that Day, a controversial dark-horse candidate, won the election indicates that he's not a lone ideologue, but rather a voice for a growing body of medical professionals. "Doctors in Canada understand this thing isn't working," he says, during an hour-long interview that he squeezes into a heavy schedule of clinical and administrative work. "There needs to be a major jolt. There's an insatiable appetite for health care among Canadians. And it's only going to get worse as our Baby Boomer population ages."
Few would disagree with that assessment. Day's prescription is another matter. To critics, he is "Dr. Profit," a bogeyman that's threatening free, universal medical care in Canada. Even as the ballots were being counted for the election in August 2006 (the association elects its presidents a year before their terms begin), Maude Barlow of the Council of Canadians helped lead a rally outside the conference centre where the vote was being held to protest the surgeon's views. It's true that the private sector plays a major role in Day's thinking about Canada's health-care future, but should Canadians really be as worried as his critics would like them to be? A closer listen to Day reveals that there's no need for panic.
His ideas have little in common with the creation of a two-tier medical system favouring the wealthy that his opponents fear most. Instead, he talks about the need to revise the 23-year-old Canada Health Act, which he says is out of date, given the progress medicine has made thanks to new and costly technologies, such as MRIs, high-performance drugs and "laser this and robotics that." He says Canadian hospitals lag behind other countries in terms of developing information systems to monitor and assess the quality of care they provide. And he argues that public funding for hospitals should be attached to patients - just as it is for family doctors - giving hospitals an incentive to treat more people. Not exactly nightmare stuff.
What makes his ideas a lightning rod is that he also says that privately run clinics - such as the Cambie Surgery Centre, which he helped found in 1996 - should be allowed to compete for the right to provide these services. Clinics would be built and maintained with private funds, saving government money, while the bill for the procedures would be paid by the public purse. Day says the only alternative to allowing more private clinics is cutting services or a massive rise in taxes. Indeed, health-care spending, at around $150 billion in 2006, has tripled in the past three decades, even after accounting for inflation, according to the Canadian Institute for Health Information (CIHI). And the increases show no signs of letting up.
During his one-year term at the CMA, Day doesn't expect to see the kind of major change in the health-care system that he talks about in conversation. Nor does he assume that, as a spokesman, he will advocate for all of his personal opinions.But there are two themes that will likely dominate his work in the months ahead: the need to eliminate wait times, and the value of moving hospital funding from annual grants to a fee-for-service system. On wait times, Day makes one simple point: When you tally it up, it costs more to have them than it does to clear them up. The longer it takes to get treatment, the more people's conditions deteriorate, and the cost of care goes up. So does the cost to the economy in terms of lost productivity and disability payments. "Our system," Day says, "would actually cost less if we spent money up front and had no waiting."
Day readily admits he has no idea what clearing the lists would ultimately cost. But he argues that having hospitals billing governments based on the services provided will foster rapid change. It will give incentives for hospitals to perform more procedures and clear up backlogs. "This is what's happening in Britain, right now," Day says. "It's doable simply by changing the funding system and introducing market principles into the way hospitals are run." Critics, however, charge that fee-for-service funding results in hospitals "creaming off" the market. It forces them to focus on procedures that create healthy revenues and margins, while steering away from complex or expensive cases.
Even those who see value in the concept in principle offer cautions. "There isn't a magic bullet," says Marc Rochon, CEO of the Toronto Rehabilitation Institute and a vice-president of the board at the Ontario Hospital Association. He worries about how hospitals would maintain their capacity to deliver less common, but no less important, procedures if resources are increasingly directed to common treatments. "Fee-for-service is a reasonable policy option," Rochon says. "But you have to be cautious to align the method of payment with your goals." Day acknowledges those concerns, saying that we can look to existing hybrid systems in place around the world and tailor a solution to meet our needs. Closer to home, government-funded, fee-for-service treatment is already available at a growing number of clinics around the country, and the CIHI reports that Canadians spent $44 billion on private health care in 2006.
According to Day, if we eliminated wait times and if Canadians embraced private delivery of public services, this could set the stage for sustainable growth in the national health-care industry. With backlogs cleared and a system that's open to private investment in public services, he says, Canada could become a destination for health care for fee-paying patients from around the world. That would create a whole new revenue stream for the health system entirely outside the tax system. "We could offer services to the so-called medical tourism industry," he says. "Right now, we have Canadians going to India. It could be the other way around. MRIs in hospitals close at seven o'clock at night, when they could be running 24 hours. We're stifling one of the potentially biggest industries that Canada could have." That opportunity, if it exists, may be some years off. Day notes that the current public health system is closely tied to national sentiments and that politicians, in his view, have been reluctant to execute real change in the past decade. On the other hand, Day believes increasing private opportunities in health care is an inevitable part of the future. More and more cases are coming before the courts from people seeking the right to get publicly funded treatment outside the current system. And as those cases are resolved, governments will come under increasing pressure to make fundamental change.
For Day, as president of the CMA and a practising doctor, that's a process he hopes to hasten in the coming months. "What can the CMA achieve in one year?" he asks. "I think it can plant the seed."