Shouldn’t We Have the Right to Choose?
Dr. Brian Day has a cure for Canada’s sick medicare system: private-sector surgery clinics
BY KAREN VAN KAMPEN
From National Post Business
It’s almost 8 a.m. on Vancouver’s Ash Street. As commuters rush to catch the bus at the corner, few notice a big, burly man struggling to lift himself out of a car. With one hand cradling his side and the other grasping the open passenger door, the man, a six-foot-two RCMP officer, slowly pulls himself up. Pain shoots through him.
To those unfamiliar with the Canada Health Act, what the Mountie will do next might appear to be illegal: He is about to enter a private hospital to undergo surgery. And the RCMP is going to pay for it.
The officer has been off duty for four months, but his sore hip has been plaguing him for years. Now he’s hobbling towards the Cambie Surgery Centre, a brash experiment in Canadian health care where, within an hour, he will jump the public queue and undergo surgery. The surgery will not only free him of pain but save his employer, health insurer and Canadian taxpayers tens of thousands of dollars.
If the RCMP had waited for the officer to be treated by medicare, here’s what it would have cost in time and dollars. Wait for an MRI: 19 weeks. Wait for surgery: 18 weeks. Cost to the RCMP and its insurer for long-term disability during the year the officer would be off work: $60,000 or more.
But when the RCMP compared these costs to what Cambie offered, the choice was easy. Wait for an MRI (at another private clinic): one week. Cost of the MRI: $700. Wait for surgery: a few days. Cost of surgery: $4,000. Total cost of private care: $4,700. Total time off the job postoperative: three weeks.
The three-storey Cambie Surgery Centre is a six-year-old facility offering orthopedic, cosmetic, eye and dental surgery. Inside waiting for the Mountie is orthopedic surgeon Dr. Brian Day, the centre’s founder. Day is a man with a big prescription: to save Canadian health care by complementing—not replacing—the public system he supports and in which he continues to practise.
Day’s prescription, however, calls for an ingredient the very mention of which disturbs many Canadians: private, for-profit medical facilities and services, including surgery, a concept that conjures up doomsday scenarios of the end of one-tier, universal-access health care. Those scenarios, Day believes, are based on a misunderstanding of what medicare is. Our system has always had exceptions that allow some people to jump the queue, often on the government’s dime, while others are forced to wait—and suffer.
The RCMP officer is a case in point. He’s allowed into Cambie only because his employer is allowed to use it. The RCMP is exempt from the strictures of the Canada Health Act so it can get officers back to work as fast as possible. It doesn’t matter whether it chooses public or private—whatever is most cost- and time-efficient. The same rules apply to a Workers’ Compensation Board client, members of the Armed Forces or a prisoner in a federal jail.
But the exemptions don’t end there. If the officer were a regular guy from another country, or even another Canadian province or territory, he could book a surgery at Cambie with no problem. But if he were an ordinary B.C. resident with a bad hip who tried to get treatment, he’d be refused. And if for some reason Day relented and did the surgery, he’d be breaking the law.
“Canadians don’t realize it,” says Day, “but the current health system is actually infringing on their rights.” If he has his way, Cambie and other centres like it will take over all elective surgery, allowing megahospitals to focus on trauma and critical care.
The surprising element of Day’s prescription lies in the funding. He and others like him would deliver the services—but the government would still pay for most of them. Yes, he’d make money for himself and his investors. But in return, he says, the Canadian health-care system would see an infusion of cash that would lead to more up-to-date buildings, equipment and technology, better access and faster service. For the government, it would lead to savings in expenditures because Cambie can operate more efficiently and inexpensively than big, all-purpose hospitals. Indeed, Day claims he can do most surgeries for a little more than half of what it costs public hospitals to do the same procedures.
At 8:05 a.m. the Mountie limps into Cambie’s first-floor waiting room. With its marble floors, leather couches and original works of art, it looks as if it’s ready for an elite clientele. But Day’s typical patients are far from wealthy. Most are unionized employees (sent to Cambie by their workplace medical-insurance providers) and children on social assistance (primarily kids in need of extensive dental work requiring general anesthetic).
Since many of these kids were being bumped by life-threatening cases in the public operating room (OR), the B.C. government now pays Day to do what the hospitals no longer can handle.
After riding the elevator up one floor, the RCMP officer takes a seat outside one of Cambie’s three ORs. A few months earlier, in the same OR, Day had performed surgery on a prisoner whose knee pain was so severe he couldn’t endure the one-year public wait usually associated with the procedure. So the prison sent him to Cambie, paying over $3,000 for the surgery. It brings up the question: How come a criminal can jump the queue while other needy Canadians have to wait?
A day earlier, Day had seen a professional snowboarder from Ontario. He had a torn knee ligament and didn’t want to waste his time off the slopes in Ontario’s medicare queue. So, with help from his sponsors, he raised over $3,000 and came here. The previous week, Day also treated patients from Japan, Australia and Jamaica.
While the Mountie is being prepared for surgery, Lorraine Varner, Cambie’s executive director, is holding a meeting in her office. One of the big items on her plate is overseeing the $4.5 million Cambie expansion next door.
By spring 2003, Cambie will more than double its size to 17,100 square feet, increasing its operating rooms to six, one more than the nearby UBC Hospital. And while UBC has about 200 postoperative and long-term care beds, Cambie will have only 14, because its low-risk, less-invasive surgeries have 95 percent of patients leaving only hours after their operations.
Cambie performs some 3,200 surgeries each year, the average costing about $2,500. A big part of Varner’s job is keeping track of Cambie’s $300,000 monthly operating expenses and making certain that its 182 full- and part-time staff (122 of whom are doctors) function as a team. If Varner worked at a public hospital, she would run only one segment of the business. “Layers and layers of management people in a facility such as this are not required,” she says.
Varner co-ordinates and oversees the daily operation. Right now, one of medicare’s big problems is the nursing shortage: 8.5 percent of nurses call in sick every day, one of the highest rates of absenteeism of any profession. But at Cambie, Varner has had no such problem. After all, she’s got terrific bait: flexibility of shifts, competitive starting salaries (nurses begin at $34 an hour, compared to salaries as low as $27 in the public system) and excellent benefits.
It’s 8:30 a.m. and Day, in emerald scrubs, steps onto a stool beside the operating table to gain height over his patient, who is now dozing under local anesthetic.
The hip arthroscopy the officer is about to undergo is an expensive procedure, primarily due to the cost of equipment. For this operation, Day will use a $12,000 distractor, a ministretcher that will keep the Mountie’s left leg raised at a 45-degree angle from his body so the X-ray probe, part of a $170,000 machine, will have a clear path to the hip’s interior. In addition, Day will use a $20,000 set of surgical instruments, an improvement over the standard $5,000 orthopedic sets that, in his experience, most public hospitals purchase.
Day would like to do this sophisticated version of hip arthroscopy at UBC Hospital, where he practises one day a week. But he can’t, he says, because the facility has no money to purchase the equipment for this and other types of specialty orthopedic procedures—which is why Day will often leave $20,000 worth of instrument sets at UBC. “When I do surgery there,” he says, “I’m using equipment that belongs to Cambie.”
Over a year ago, Day had a patient—a B.C. resident he saw through his public practice at UBC
—with a condition similar to the Mountie’s. Since the hospital didn’t have the equipment, Day offered to do the $4,000 procedure at Cambie, but he says B.C. Ministry of Health officials refused. So the patient was sent to a private surgical facility in San Francisco. Total cost, picked up by the B.C. government: $25,000.
By 9:55 a.m. his hip operation successfully completed, the police officer is taken to recovery. In half an hour he’ll awake, groggy, with a small bandage on his hip, and by noon he’ll be ready to go home.
Day rests up for his next surgery, a $2,000 knee-ligament transplant, and over a steaming cup of tea he tells how the Cambie Surgery Centre came to be.
About ten years ago, he says, the OR time of surgeons was significantly reduced as part of the B.C. government’s deficit-cutting measures. Angry, Day and a group of physicians looked into building a 35-bed private surgical facility, but the NDP government—in power at the time—decided the project was too “politically dicey.” Day quietly began planning a smaller venture.
By 1994 Day’s OR hours hadn’t improved. Frustrating him further, he claims, was UBC Hospital’s refusal to invest in the latest technology, which he worried would not allow him to stay at the forefront of his profession.
But, Day says, there was another factor that helped launch Cambie: Due to technological advances and mid-1990s government budget cuts, hospital stays had decreased by about 15 percent, and up to 70 percent of surgery in hospitals was now day surgery.
Deciding it was time to make his move, Day went out and secured 22 investors—14 of whom were doctors—each at $100,000. Next, he convinced a reluctant Royal Bank to give him a loan of $2.6 million. Pulling the remainder from his own pocket, he bought the land and built Cambie for $5 million.
In July 1996 the centre greeted its first patients. Initially business was slow, and for the first two years Cambie was in the red. “We’re now making a profit,” says Day. “And that’s a dirty word in health care.”
As governments struggle with soaring health-care costs, Day maintains, they have to decide what they can and cannot afford. “They’ve got to tell Canadians, ‘Look, we can’t give everything to everyone.’”
Contracting out elective procedures—such as hip and knee surgeries—to private clinics would reduce public waiting lists and prevent thousands of health-care dollars from going to available ORs south of the border. It would also free up public operating rooms and resources for trauma cases. But staunch defenders of the public system argue that once you give up yet another publicly funded service to the private sector, for-profit businesses will want—and take—more.
“One possibility is that we will carve out a U.S.-style private system in which costs, unconstrained by government, will explode,” says Dr. Gordon Guyatt, a spokesman for the Medical Reform Group, an advocacy lobby whose guiding principle is universal access for all. “In this scenario, the public system will become a second tier of care, more underfunded, and will languish.”
Wendy Armstrong, past president of the Alberta branch of the Consumers’ Association of Canada, agrees and adds that two delivery systems will never relieve the waiting list because both are dipping into the same pool of doctors.
The public-versus-private debate isn’t made easier by the fact that rules for what can be done by the private sector and what by the public vary from province to province. For example, private clinics in Alberta can perform complex hip, knee, shoulder and spinal surgeries that are restricted to public hospitals in most other provinces. And in British Columbia, adds Day, “if a child has an amputation for cancer, the operation is covered. But giving that child an artificial limb is not an insured service under medicare. Parents have to pay for that artificial limb. In Manitoba, they don’t.”
Day moves on to discuss the business acumen and money-managing skills of people who run public hospitals. In his experience, hospitals are top-heavy with managers, vice-presidents and presidents of boards who don’t have a proper financial background. Recently, one of Day’s colleagues ranted about one of his hospital committee meetings. “He walked out after an hour and a half, because 20 managers had been discussing what brand of soap to buy,” says Day. “These people are being paid between $80,000 and $150,000 to discuss that. At Cambie, one person makes that decision.”
But the public hospital’s biggest problem, Day believes, is that it can’t see as many patients as there are in line for treatment. “The patient is at the bottom of the pyramid because the patient uses up the budget,” he says. “A place like Cambie is the exact opposite. It works on supply and demand. If there aren’t patients—in other words, customers—revenue stops fuelling the business.”
If Day gets his way, the future will have cash-paying Americans coming north for bargain care. When Canadian surgeons have reached their weekly limit, he asks, why not offer Americans medical aid at a discount while subsidizing our system?
Day reflects on his role as a physician this way: In both his private and public practices, despite all the rules he must adhere to, his patients come first. “My duty really is to advise them of the best thing to do for their health,” he says. “If the best thing is to pay, jump the queue and break the law—it’s not my role to uphold it.”