Dr. Brian Day @DrBrianDay Twitter

  • Past President Canadian Medical Association
  • Past President Arthroscopy Association of North America
  • Honourary Associate Professor University of British Columbia
  • 2014 Doctors of BC Don Rix Leadership Award

Brian Day's Evidence before the Senate Committee in Ottawa

Oct 18, 2001

Published by the Government of Canada
The Chairman: I would thank you all for being here today.

Senators, our next witness is Dr. Brian Day, founder of the Cambie Surgery Centre, which is a private surgery clinic in Vancouver.

Dr. Day, thank you for coming. What we need to hear from you is not so much the argument of why private clinics are good, from your point of view, but how you fit into the system, what kind of patients you have, and what the overall reaction to your clinic is. Four days ago, when we were in Manitoba, we found out that there were a number of private clinics there which we did not know existed. We want to know how your clinic works in relation to the overall system, and we would like to get into a discussion with you about the evolution in this area.

Dr. Brian Day, Founder, Cambie Surgery Centre: I have prepared something for you which is taken from a talk that I give every now and then on private health care to people who want to listen. I will not read that, but I hope you take the time to go through it. You will need glasses to read it.

I will briefly tell you how we got into this. I am an orthopaedic surgeon. I have one of the biggest practices in British Columbia and I am a clinician. I am also what one would call an academic orthopaedic surgeon. I give lots of lectures and I teach. I am out of the country about three months a year lecturing and teaching. I am not just a private, for-profit entrepreneur.

About six or seven years ago we decided to build a private facility. It is actually a hospital. We call it a private clinic for political reasons. It is a hospital. It provides overnight stays; it is licensed by the City of Vancouver as a hospital, and it is a post-disaster facility for the province. We built it in the middle of the tenure of perhaps the most left-wing government that Canada ever saw. We have had 10 years of an NDP government. We did that for one reason and one reason alone. That is we, as physicians, were being deprived access to the public system. There was a choice: either we left the country to do our work; or we stayed and did something about it.

I will give you my own personal statistics. Ten years ago I had 17 hours of operating room time a week at the University Hospital. Six or seven years ago that was down to five and a half hours a week, and yet my practice, by volume of patients, stayed the same. I had, at one time, 360 patients waiting for surgery at that hospital, which was not accessible. This led to many problems. It led to a lot of doctors leaving. I had previously been the chairman of the Royal College of Surgeons of Canada's test committee in orthopaedics in charge of setting exams and graduating residents in orthopaedics. Of the last 16 residents that we trained in British Columbia, five are still in Canada. This is a real problem for specialists. We built this clinic because we had a choice of having nowhere to work or build a private facility. A poll of the 100 specialists who work at our facility indicates that between 35 and 40 would not be in British Columbia if it were not for our facility. I will explain why.

We have been able to go out and develop contracts with secondary paying agencies like the Workers Compensation Board, the RCMP and many other secondary insurers. In B.C. tourism is a very big industry. We treat a lot of Germans, American and Japanese tourists who ski here. We treat a lot of people off the cruise ships in the summer. We have a ludicrous situation here and it is that, if you are a Canadian skiing at Whistler and you hurt yourself and need a knee operation, you will wait between six and 18 months to see one of the doctors who specialize in that area. Then you will wait another six to 12 months to be admitted to hospital for treatment. If you are from Japan or Germany or the States, you can see a doctor and be treated within a few days. This, to me, is the legacy of the Canada Health Act.

If you look through what I have given you to read, you will realize that I am no great fan of the Canada Health Act.

The Chairman: I gathered that from flipping through your overview.

Dr. Day: I am sorry I missed Mr. Dave Barrett's presentation but I know exactly what he said. The Canada Health Act achieves the reverse of what it was set out to do. In fact, the people from lower social economic groups, people who do not have the ability to pick up the telephone and make a phone call, people who do not know how to wheel their way around the system are the ones who suffer in a system like this. I have read your recent report, so I know you are aware of this. It is the kind of system that existed in the former Soviet Union where, if you were on the Central Party Commission, you were treated and, if you were a peasant, you did not. I hate to put it in those terms, but it is almost that bad now. The people who are suffering the most are those who have the least ability to work their way around the system that we have as a legacy of the Canada Health Act.

I think that many of the people who make presentations to this group will also appear before the Romanow commission. Some of them are trying to influence public policy for their own end. For instance, I know that that CUPE spent many millions of dollars on a propaganda campaign with respect to Bill 11 in Alberta, and it succeeded. Bill 11, contrary to what many people think, has essentially stopped the development of any private facilities in Alberta. It has done the opposite of what it was originally set out to achieve. We, for instance, would consider expansion into any province in this country except Alberta because of Bill 11. That is because Klein gave into a propaganda campaign that was heavily financed.

Our budget for advertising and promotion last year in our facility was $500. We are not out there lobbying and trying to persuade people that private health care is the best. I think that, like most doctors in Canada, if the public system could provide patient care in the way that it should, or promises to do so, then there would be no need for a private system.

This is now an economic reality. We used to debate the politics of health care, the legal aspects of the Canada Health Act. Incidentally, we have had three legal opinions, including one from a lawyer I regard as Canada's top constitutional lawyer, that the Canada Health Act, in the circumstances of today, is unconstitu tional. It is very important that people accept that this is now an act that is based on principles that were formulated in 1964, a time when there were no MRIs, no CT scans, no transplants and so on and so on. It is just not realistic for today.

We are the only country in the world that has no other system. A place like our centre cannot cure the ills of even the British Columbia health system. A place like ours, though, will show accountability, and I think that is where the public system can learn from us, that is, by applying some of those principles that we have applied in the way we run our centre in an efficient, fiscally responsible way without the massive, overbloated bureaucracy that exists in the public system.

I do not want to give a speech, so I will be happy to answer specific questions. I think most of them are answered in this document that you can take away with you.

The Chairman: They are.

When you were talking about your clinic you kept saying "we." Does "we" mean a group of doctors?

Dr. Day: Yes. About 14 doctors invested in this clinic, as well as some businessmen. Of those 14 doctors, 12 have still not paid back any of the loan that they took out six or seven years ago to buy their share in the clinic. It is largely physician-owned.

The Chairman: I know about the Workmens Compensation Board contracts. However, I was surprised to hear you say that you had a contract with the RCMP.

Dr. Day: We do not have a contract with the RCMP.

Various groups are exempt in the Canada Health Act. Those include federal employees such as the RCMP, the Canadian Armed Forces, and people in the federal penal institutions, criminals. We have been approached by the prisons to ask if we can take prisoners because they are on wait lists for surgery.

The Chairman: We are well aware of the exemption for WCB, but I must check and see who the others are. I am not disagreeing with you; I am just saying that I did not know that.

In your remarks regarding Bill 11, you blew me away when you said that you would go to any province in the country other than Alberta. What is it about Bill 11 that would make you say that?

Dr. Day: The evidence is there. When the time came and the offering went out from the various regions in Alberta - I am talking about a year after Bill 11 - there were no applications by any organization or facility to undertake any private health care in Alberta. Largely as a result of lobbying by CUPE, the restrictions and the penalties in the regulations were so severe that nobody bothered to apply.

Contrary to what you may have heard from other people, this is not a big money-making business. I am the largest single shareholder in our centre, and I still drive my 1994 jeep. I am not wealthy. I still have a big mortgage on my house. The facilities that were built, at least in this province, were built because the doctors had a choice. They have skills, they have talent, they have international reputations, but they have nowhere to do their work. That is the simple explanation. The choice was to go south, as many of our young people are doing, or do something about it. The government had been not able to fix it, so we fixed it. We are now operating and making a profit. I know that is considered a nasty word, but I think that people who criticize that forget that there are 25,000 private, for-profit clinics in this country. Those are your doctors' offices that you go to. The private office where you visit your family doctor is run as a business in a private, for-profit system, exactly the same as we run our facility. We already have, as I know you will know, a private system. Our family practitioners are mostly private; our specialists are mostly private. A surgeon with nowhere to operate is not a viable entity.

Senator St. Germain: Former Premier Dave Barrett and another gentleman appeared before our committee to speak on behalf of the Tommy Douglas Foundation. I asked them why they are so opposed to these particular facilities and yet they are of the opinion that it is all right to take your money and go to the U.S. and spend it on a clinic there. Their response I believe, if I am correct - and if any of the senators find that I am wrong in my statement I am sure they will correct me - was that a private clinic siphons the doctors off from the public system. Do you agree with that?

Dr. Day: It is exactly the opposite. If it were not for our facility, 35 doctors would have left this province. I am referring to top specialists. Imagine a mechanic with thousands of cars to fix and the staff to do it, but the government owns the garage and it will not allow the mechanics and the cars to go into that garage. The mechanic goes out and builds his own garage. That is essentially what we did.

Canada is the only OECD country in the world that does not allow private delivery of surgical services and hospital services as an alternative. We are the only system in the world that believes in a government monopoly.

I would like to ask each of you this question because no one has ever answered it to my satisfaction: If it is okay to spend money on alcohol, on gambling, on tobacco, what is wrong with Canadian citizens being allowed to spend their own after-tax dollars on their own health care? Does anyone have a moral problem with that? If they do, I would like to hear the explanation for that, because I have never heard it.

Whenever I have asked that of a politician, whenever I have asked that in a debate with a Dave Barrett or with somebody else, they have generally said, "Well, that is a good question," and then they have gone on and answered another question I did not ask them. That has been the strategy. There is nothing immoral about spending money on your own health. We do it all the time. It is just that we have kind of selected arbitrarily what is medically necessary and what is not medically necessary.

We have the ludicrous situation, for example, where a lens that is slightly crooked is considered refraction and it is not covered by medicare. You have to buy your own glasses. If it is slightly opaque, that is medically necessary to alleviate the problem. "Medically necessary," a phrase in the Canada Health Act, has never been defined. It certainly has not been defined by any doctor. Each provincial government can interpret it as it likes.

There is no question that we have reached the level where people want everything in unlimited amounts for free; that the system has run out of money: and that we have to start making choices.

In Alberta, in 1999, they tried to have a citizens' forum, a summit on defining core services and what was medically necessary so that the government could consider pouring the assets of health care into the most medically important areas. At the conclusion of the summit, the delegates who represented both public and private and health care, were unanimous in saying that everything was equally important and that they did not want to cut anything out of the health care system. This is something that has to be imposed by government because people will not voluntarily give up something.

In the press yesterday, Colin Hanson announced that routine eye examinations were not going to be covered. There was an uproar on the TV. People were complaining. Essentially what he was saying is that we are going to stop paying for new sets of glasses so that we can pay for your cancer treatment. Somehow that message has to be gotten across, and it has not been gotten across.

Senator St. Germain: It seems that every government tries to out-socialize the next. They look at this as the sacred cow that cannot be touched but now the cow is really in trouble and is at risk of dying.

I have one quick question on user fees. We currently pay user fees for chiropractors and physiotherapists. I believe, in British Columbia, the cost is $20 for each visit. Do you see anything wrong with that, sir?

Dr. Day: No, I think we must have user fees. You can exempt people on lower incomes. No country in the world - and I have worked in Switzerland, Britain, the United States and Canada, and I have studied this now for 12 or 13 years - does not have user fees. Not one. Of course, there is the possible exemption of Afghanistan or somewhere like that but, of the civilized countries, none is exempt from user fees.

It is like the deductible on your car. If everyone had comprehensive car coverage, every time you scratched your bumper you would take it into the dealer and get a respray and a polish because it would be covered completely. It is human nature that we will take everything for free, if it is offered, in unlimited amounts.

You will be faced with lots of quotations from studies. I used to be editor of a medical journal and one of the jobs of a medical editor, as opposed to an editor of a newspaper or a magazine, is that you have to check every reference that is given to you when someone submits an article to publish. Once you publish in a peer review journal, some people interpret it as fact. You will find quotes from "studies" done in Alberta on cataracts, "studies" published in the New England Journal of Medicine, and "studies" published by eminent Harvard professors. I have looked at all of these

"studies." I have gone back to the original source and not one have I found where the reference that is now entrenched in the literature is supported. I have heard Allan Rock quote these studies. They are entrenched in the literature because they have been printed in so many newspaper articles, but if you go back to the original quote, look up the reference, in fact they say nothing of the kind. I will just give you one example.

The Canadian Health Coalition, for instance, will quote you the study on cataracts that was done in Alberta when Calgary contracted out cataracts to the private clinics. Lo and behold, the waiting lists are now longer in the private clinics than they were in the public system. However, you must qualify that information. Wendy Armstrong who is head of the Consumers Association of Alberta and, by the way, is a paid consultant for CUPE, did an audit on private clinics a day or two after the region handed all the cataracts to the private clinics, that is, before they had had a chance to treat any patients. The government has also issued quotas. They tell the private clinic that they will pay for five a week. Clearly it is not the private clinic's fault that there are waiting lists, it is because the government is not allowing patients to pay. They are saying we are going to pay for you, but we are only going to pay for five a week, so the waiting list is longer.

Those kinds of editorialized factoids will be given to you, and have been given to you. They are printed and on Web sites, and there are many of them. The same applies to the New England Journal of Medicine article that is quoted all the time that talks about studies which indicate that private hospitals in the States cost more than public hospitals. In that study, what they did, effectively, was compare the cost of a hernia repair at the L.A. County Hospital to the same operation done at a Beverly Hills private clinic where patients were provided with limousine service, caviar and wine. You will find a lot of that.

There is one quote in here from the Canadian Health Coalition that I hope you will read with magnifying glasses. They boast about how they bombarded the National Forum on Health Care. It is on the first page of the handout I gave you. They state that they were successful in the National Forum on Health Care in removing any talk of privatization off the table and that they are going to try to do the same with the Romanow commission and with the Senate committee.

Senator St. Germain: My doctor happens to be South African as is every doctor I seem to see. Do you have a view of the morality aspect of siphoning off doctors from countries such as South Africa?

Dr. Day: No, because I was born in Liverpool and I came here from Britain in the early 1970s. I think you cannot limit the free movement of doctors any more than you can journalists or any other group. We must make the system attractive enough that doctors will stay here and stay in the workforce. I listened to the dean talking about increasing the size of the medical school.If 25 to 30 per cent of the doctors graduating from medical school or, in the case of our specialists, if 11 out of 16 leave the country, it is not a solution to train 32 so that we will be left with 10. We have to "fix" why they are leaving. They are leaving because we are not offering them access to patient care. We are not offering them access to what is needed for them to perform their profession at the highest levels.

One of the big problems with the public system, as compared to a private facility, is that a patient in the public system, under the funding system in Canada now, uses up the resources of the hospital. Say the Vancouver Hospital is given $600 million a year. If you go there as a patient or a doctor brings a patient to that hospital, that patient is consuming that hospital's money.

Although a hospital vice-president or president will not admit this, that is not how it used to be. It used to be that a hospital was funded partly based on its performance. There is no reward for productivity in the way we fund our public hospitals. If they are in a crunch for money, they close down. We have a thing in British Columbia called "reduced activity days" when, even though we have one-year or two-year wait lists for surgery, 12 times a year we close the hospitals for what we call "rad" days.

Senator Morin: Your reputation as an orthopaedic surgeon is well known. In fact, Senator Carney just whispered to me that you are one of the leading orthopaedic surgeons in the province.

Senator Carney: Which means in Canada.

Senator Morin: In Canada, of course. I know you are very busy and we certainly appreciate the time you are taking to come here to discuss these aspects of health care.

I would like to talk to you first of all about your clinic. If I understand, you practice both in hospital and in your clinic; am I right?

Dr. Day: That is right, yes.

Senator Morin: We are trying to get a feel of what a private clinic is. It is, in fact, a private hospital, and there are not many in the country. Is there a difference in your practice between the hospital and the clinic? Do you treat the same types of patients?

Dr. Day: Yes. Actually, I am often asked why our facility is not targeted by the unions. Let me say right off that I am not an anti-union. I was brought up in a labour party family in Liverpool, a working-class family in Liverpool. My father's best friend was Bessie Braddick who was the MP that Winston Churchill did the "I am drunk but you are ugly" joke about." At least 60 per cent of the patients in our facility are working-class patients.

Senator Morin: What is the situation with respect to your hospital patients?

Dr. Day: They are a cross-section of the population. In our private facility our biggest client is the Workers Compensation Board and we deal with those patients who are injured at work.

Senator Morin: For those who are not part of that group, are your more difficult cases, your sicker patients?

Dr. Day: I see what you mean. No, no. That is another thing that is bandied around: that we skim off the easy stuff.

Senator Morin: So you have the same clinical mix.

Dr. Day: A couple of weeks ago I was asked by a reporter, "Where are you?" I said that I was at UBC doing surgery. He then asked me, "How many operations are being done there today?" There were five operating rooms, with an average of seven in each, so that 35 operations were being gone at UBC. All but one of them we could have done at our facility.

Senator Morin: So it is the same clinical mix.

Dr. Day: Yes.

Senator Morin: What is the quality control in your private hospital?

Dr. Day: There are several levels of quality control. One is the physical plant, which is under the City of Vancouver. The second is the College of Physicians and Surgeons of British Columbia. They do an extremely detailed audit of everything that goes on in our facility. They do the random taking out of patient files, they do audits of any patient that has any complication. That has to be reported to the college. If any patient has to be admitted to hospital subsequently, that has to be reported to the college with the file and an explanation, and the records have to be audited by the college. The audit mechanism for patients treated in our facility is far more rigorous than at UBC Hospital; far more.

Senator Morin: You are saying that the quality control is more in-depth than it is in the hospital.

Dr. Day: Yes. Every patient treated at our facility is sent a stamped, addressed envelope with a lottery ticket to win tickets to a hockey game and they are asked to fill in a patient-satisfaction or dissatisfaction questionnaire. We collect those and audit them.

Senator Morin: You say your hospital is more efficient than the publicly owned hospital. Can you give me some more details on that?

Dr. Day: When I came to the Vancouver Hospital in 1973, the hospital was run by one medical director, Dr. Lawrence Renton. Back then, the Vancouver Hospital had children's and obstetrics as well. It was the biggest hospital in the British Commonwealth. He was in charge of the laundry, the ICU and so on. By 1996 we had a president of Vancouver General Hospital, and we had seven vice-presidents, and each one had associates and so on under them. In 2001 we now have a CEO, two presidents,11 vice-presidents, an endless number of associate vice-presi dents and so on and so on.

The problem is decision making. Decision making is not happening in the hospital structure as it is now. It is a bureaucratic nightmare. Everyone is afraid to make a decision because everyone is under the political gun. It is unbelievably inefficient. I think it is the one area where we and the public sector unions would agree: It is very inefficient.

Senator Morin: Putting aside for the moment your patients from the Workmen's Compensation Board, are all your current patients, with the exception of tourists and so forth, medicare patients?

Dr. Day: No. We have patients whose treatment is paid for by insurance companies. I will give give you a statistic on the private facilities in B.C. Last year, in wage loss benefits, we saved the Workers Compensation Board $95 million. The disabilityinsurance companies are in a similar position, and they will pay for workers who were not injured on the job.

Senator Morin: I am trying to deal with the group of patients who are covered by medicare.

Dr. Day: Medicare does not pay for patients in our facility.

Senator Morin: You have no medicare patients at your facility?

Dr. Day: That is correct.

Senator Morin: Is it 100 per cent private, either insurance or WCB?

Dr. Day: Insurance companies such as Canada Life insure you in case you become disabled, and they will pay for you to go to a private facility.

Senator Morin: If you were in Alberta, under Bill 11 - and I understand you have objections to it - you would treat medicare patients.

Dr. Day: Only if the government contracted to send them.

Senator Morin: I realize that.

Dr. Day: There is nothing to stop the government from contracting with private facilities, and they have indicated their intention to do so.

Senator Morin: Would you think that is the way to go, to have patients with medicare that could go to your clinic.

Dr. Day: I do not think our clinic can solve the problems of this system. I feel sorry for anyone who is in administrative health right now because I think I know a lot about this subject and I don't think I could solve it. It has been battered so badly. I think that we can help. We can show the way to better administration. We do not have 11 vice-presidents. Perhaps I do not understand

Senator Morin: My question is, what would prevent you from receiving patients that are from medicare?

Dr. Day: Nothing, except we would have to charge the patients a facility fee.

Senator Morin: Why?

Dr. Day: Our operating rooms and our nurses are paid for by the corporation, the private corporation.

Senator Morin: Let us say you had a contract with the government. Would you have any objection to that?

Dr. Day: No, we would like that.

Senator Morin: You have nothing against the government being the payer?

Dr. Day: No.

Senator Morin: It is the provider part of it that you are interested in.

Dr. Day: That is right. We made an offer to the last government in British Columbia to take patients, for example, for cataract operations. Let us assume that Vancouver Hospital does 1,000 cataract operation a year at a cost of $1,000 each. That is $1 million. I am just making up these figures.

Senator Morin: Certainly.

Dr. Day: We offered to do them for, say, $600,000. We told them to figure out their costs and we said that we would do it for 60 per cent of the cost. I know we can do it for 60 per cent of the cost using the same doctors. We just were contacted by a hospital here this week to consider contracting our services. They ask us how much it is going to cost. I tell them that we will do it for 60 per cent of what it costs them. We do not know what it will cost us. However, that is the problem with the public system.

Senator Morin: Thank you very much.

Senator St. Germain: I have a short supplementary question. Is the government now sending people to private clinics in the States and not sending them to you?

Dr. Day: About four years ago, there was a patient who needed to have a hip arthroscopy. It is an unusual operation. I believe I am the only person in Canada who does that operation. There are five centres in the states. We did not have the equipment at the UBC Hospital. Our private facility said that we would treat this patient for Can. $3,500. The provincial government sent that patient, who happened to be the next door neighbour of one of the MLAs, to San Francisco to have the operation done at a cost of U.S. $14,500.

Senator Keon: Dr. Day, your infrastructure staff, are they unionized or non-unionized?

Dr. Day: Many of our nurses also work at hospitals. They may be mothers with young children, two or three-year-old kids, and they do not want to work nights. They find that they cannot work nights and weekends at the hospital. They elect to work at our place, and they do some shifts at the hospital. They have to belong to the union.

We are not a unionized facility because if we were, we would have the same trouble getting nurses as the hospitals have. We pay our nurses 15 per cent higher than the highest level they can achieve after 12 years in the public system, because we need these nurses. In many cases, we are taking nurses who are otherwise out of the workforce.

Senator Keon: What about your technical and support personnel; secretaries?

Dr. Day: Secretaries are not unionized. Similarly, the technical group would, in the hospitals, belong to the hospital employees union. The central sterile technicians who sterilize all the equipment, clean the equipment, are not unionized. Again, to attract those people, we have to pay higher than union wages. If we were unionised, the workers would have to take a cut in pay. We will never be unionized until public sector catches up with our wages.

Senator Keon: That is an interesting paradox, because the argument for contracting out services from the institutions, from the hospitals, whether they be financials services, cleaning services, food services or whatever, is that you can contract them out cheaper because you do not have to deal with CUPE; and the private sector can hire people cheaper than the hospital sector. Paradoxically, you are paying your people more than unionized people.

Dr. Day: Yes, we are. However, if we need to have the grass cut or tulips planted, we do not pay a gardener at health worker rates. That is one of the problems with the public system. If you plant rhododendrons at UBC Hospital, you get paid $10 an hour more than the same unionized job in the private sector union because you are a health care worker. We do save money there. We are not big enough to have a full-time gardener, but hospital employees, union workers at the hospital, if they are not in the technical area, then they still get paid higher wages than they would in the private sector.

The Chairman: Surely the real reason you are able to do it and I am referring to chapter 5 of our report - has to do with the fact that you are operating a very specialized clinic. This is not a criticism. It is always true that, if you have a very specialized facility, focused on a limited number of things, you ought to be able to operate more efficiently. One of the points we made in the report is that the move toward specialized facilities clearly has economies of scale, in terms of specialization and focus.

Dr. Day: You are correct. That is a Harvard Business School philosophy.

The Chairman: Right. I am not disagreeing with you, by the way, that you do it cheaper than the public sector. All I am saying is that, in a sense, when we look at the cost data we are comparing apples and oranges because we are comparing the cost data of a large general hospital with that of a specialized facility. One would have to compare a public specialized facility, which does not exist in the public sector, with a private facility in order to truly know the costs. Any specialized facility, regardless of who owns it, if it is as focused as your organization is, ought to be able to operate at a cheaper price and more efficiently.

Dr. Day: We have a situation here where we have limited nurses, doctors and facilities in the public system. People are waiting nine months for heart surgery and cancer surgery while, this week at UBC, in the hospital operating rooms dermabrasions are going on, face lifts are going on, cosmetic surgery and dental surgery is being done. These are the same nurses, and the same operating rooms.

The Chairman: People are paying for that.

Dr. Day: No. They are paying the surgeon; they are paying the anaesthesiologist; and the patient is paying the hospital. For a 10-hour operation the patient will pay the hospital, if they are a B.C. resident, $290. In other words, the taxpayer is subsidizing to the tune of $10,000.

The Chairman: Even for non-medicare expenses?

Dr. Day: Yes. It is even worse than that. If an American comes to UBC Hospital, and he has $10 million worth of Blue Cross insurance from the States, and I have to operate on him, I might do an operation on him that costs $6,000. I know these costs because of working in the private system. The hospital will bill that patient $560 Canadian. I phoned the director of finance and told him that that was crazy. The answer I got was, "We do not have the policies in place for that kind of auditing." It all comes back to the same thing: What is lacking in the public system is accountability. If you eliminated the global system of funding a hospital and made a hospital get its revenue based onperformance, you would make a major change.

The Chairman: That is essentially separating the payer and the provider.

Dr. Day: Yes.

Senator Carney: I should explain for the record, as Dr. Morin has pointed out, that Dr. Day has been my orthopaedic surgeon.

The Chairman: Dr. Day, you are here because Senator Carney recommended that you come.

Senator Carney: He asked for this opportunity. I want to make it clear that I was on his waiting list for eight months.

Dr. Day: She refused to make the phone call.

Senator Carney: In view of his comments about people phoning their neighbours and politicians pushing the system around, I wanted to make it clear that I was very pure in this matter.

Senator Morin: Was that a three-year waiting list and you waited eight months?

Senator Carney: No, it was one year - until an older lady fell and broke her hip, making a $3,000 surgery a $25,000 surgery. She was on the waiting list and I took her place.

I have one point on the structure. I am surprised that Senator Morin did not raise this. It says here that you are the first private company to develop the first private health care facility of its type in Canada.

Dr. Day: Of its type, yes. There are other private facilities, but nothing that is licensed by a city as a hospital that has five inpatient beds and has unlimited access and unlimited capability to keep patients overnight.

Senator Carney: You talked about the fact that you pay above scale and your expenditures are below norm. Are your fee structures the same as in the public system?

Dr. Day: That is the problem. The public system cannot tell us what their costs are. All I know is that I am confident enough to tell the vice-presidents of the hospitals that, if they figure out their costs, we will underprice it by 40 per cent and treat public patients.

Senator Carney: If I have a procedure done in the Cambie clinic, obviously I will pay more than the Government is going to pay you to do it if you did it in a public facility.

Dr. Day: It comes out of a different fund. That comes from more or less general revenue.

Senator Carney: You are not getting $500, or whatever.

Senator Morin: What you are referring to is operating room fee.

Dr. Day: Surgeon fees and anaesthetist fees are the same, whether it is in the public hospital or private hospital.

Senator Carney: I did not know that. Is your clinic the optimum model for you? Why have they not shut you down? Why has Victoria not come out and said, "You are running a private facility. We will shut you down"?

Dr. Day: We made sure they would not do that before we built it.

Senator Carney: Is this because of this specialized service?

Dr. Day: We talked to them. The fact is that the most common single patient group using our facility is an HEU worker, Hospital Employees' Union worker.

Senator Carney: Is that through the Workmens Compensation Board?

Dr. Day: Yes. We are treating public sector workers, union members, at our facility.

The Chairman: That is amazing.

Senator Carney: I am trying to establish whether senators can go to this facility.

Dr. Day: You might be able to. I can tell you that bureaucrats - and one of my friends is an orthopaedic surgeon in Ottawa - and civil servants in Ottawa go to Buffalo for their MRIs, and that is a public expense.

The Chairman: We can go across the river to Hull also.

Dr. Day: That has changed then.

Senator Carney: There is something I would like your views on too. You have included in your brief the "Hypocritical Oath for Ministers of Health."

Dr. Day: That was actually published in the Vancouver Sun about two years ago.

Senator Carney: Mr. Chair, this "hypocritical oath" is a play on the Hippocratic oath. I will read it. We are talking sardonically here. It states:

No private health care will be allowed in Canada, except for private, extended "two-tier" insurance such as we, the privileged, enjoy courtesy of the taxpayer.

That does include senators.

The 30% or more of Canadians that do not have such benefits will pay for treatment of their abscessed teeth, artificial limbs, arthritic braces, private rooms and nurses in public hospitals, and expensive, safer drugs. Queue jumping will depend on who you are or who you know. This works well for us.
We have had discussions about this, and I think you have suggested to me that one of the reasons for the inertia in changing this system is that those of us who are at the decision-making levels already have a two-tier system. All public service employees, all MPs and all senators have the government plan which pays for all sorts of services that my twin brother, who is not a member of any of these groups, has to pay for himself. You say that this is a very large group in Canada.

Dr. Day: Seventy per cent of the population has what I call

"two-tier" insurance.

Senator Carney: Could you address this issue? Is one of the reasons for the inertia in changing it that all of us benefit from a two-tier system, even glasses?

The Chairman: Can I just, for the record, just make sure our definitions are consistent? We have used the term, "two-tier" in the general way it is used, which is to mean a parallel hospital system. Senator Carney is using two-tier as meaning that we have insurance that covers not just hospitals and doctors but all of the other ancillary services such as physiotherapy, drugs, home care and so on. I am clarifying that for the purposes of our record. Senator Carney is raising an issue that bothers us, that is, the huge gap in the safety net for people who do not have "two-tier" insurance.

Dr. Day: That is right. The 30 per cent who do not have it are often the working poor. If you are really poor you have it. Everything is paid for you. If you are a unionized worker you have it, and if you are a non-unionized worker working for a big corporation, you have it. It is the small, lower middle-income group that does not.

The Chairman: In some provinces it applies to seniors, although not in British Columbia.

Dr. Day: I think it is important to point out that in this secondary insurance it is a completely grey area as to what is considered medically necessary. For example, a child might have a hindquarter amputation as a result of cancer. The artificial limb in British Columbia is not covered. It is not considered medically necessary to have an artificial limb. A patient brought me a letter, which I have on file, from the Ministry of Health in British Columbia from an assistant deputy minister saying, "Dear Mr... we have reviewed your file and have determined that a voice is not medically necessary." This patient had his larynx removed as a result of cancer. These would be covered if you have extended health insurance. We are not talking about a plastic cast for cosmetic purpose, these are important items.

Senator Carney: You have created your clinic to meet a need that is allowed under legislation. Is your clinic the optimum model for you? Piggybacking on that is the issue of how many orthopaedic surgeons do we have in Canada and how many do we need?

Dr. Day: We need a great deal more. There is an extreme shortage of orthopaedic surgeons. The new generation of orthopaedic surgeons is not like ours. New graduates do not want to work 80 or 90 hours a week. They will take call for no pay. Part of it is economic. This whole thing is about economics now. Part of it is remuneration. I will just give you an example in my own specialty.

Fifteen years ago we were the third-highest paid group of specialists in British Columbia. Orthopaedic surgeons of British Columbia are now seventeenth out of eighteen in annual income. Much of that is as a result of orthopaedic surgeons being cut off from access to hospitals to treat their patients. However, they are also diverting themselves away from clinical work. We are now in a situation, and this is an accurate statement, where orthopaedic surgeons are giving up clinical practice, and often at the peak of their skill level in their early 50s, to go into consulting, to do evaluations for insurance companies, and so on. An orthopaedic surgeon gets paid four or five times the hourly rate for describing an operation to a lawyer or an insurance company than he gets paid for doing the operation. That is an economic reality.

Senator Carney: I just want to establish on the record an analogy that you have made with me and that is that a hockey player who was given only five hours a week of access to ice time would lose his professional NHL skills, but this society deems that an orthopaedic surgeon is only allowed five hours a week to practice his skills.

Dr. Day: The Canadian Orthopaedic Association recommended a minimum number of hours a week for operating to maintain skill level, as pilots do in planes, and that was 15 hours. At St. Paul's Hospital the surgeons are given about four and a half or five hours. At UBC it is five and a half to six hours. That is why they need a facility like ours, and that is why 40 per cent of them would not be here if it were not for that.

Senator Roche: Doctor, I think you said earlier in your presentation that a significant percentage of patients who come to you are working-class people. In such cases do you deem it necessary that they be treated but they have not got the money to pay you? Does that occur?

Dr. Day: Yes, it does. They are not allowed under the Canada Health Act to pay for the service. When I said the working class, those patients are usually Workers Compensation Board patients who are going to our private facility and their fee is being picked up.

Senator Roche: Are these only Workers Compensation cases?

Dr. Day: Yes.

The Chairman: When the Canada Health Act was passed it explicitly excluded Workers Compensation Board patients. From the get go in 1984, Workers Compensation Boards were allowed to work in a two-tiered system in the sense that they could hire and pay their own doctors, and they would pay the hospital a fee and so on. As Dr. Day pointed out, certain other groups, were also entitled to this. However, by far the biggest group - and that is why we mentioned it in the last report - who clearly operated a two-tiered system was Workers Compensation Boards. If you are going to get injured, please get injured on the job because then you will automatically go to the top of the waiting list to be taken care of.

Dr. Day: It should also be pointed out that in our facility last year we treated 3,000 patients. If we did not exist, those 3,000 patients would be on some waiting list somewhere. They are extra to what would have been done. That is just one facility. They would have been on the public wait list. In British Columbia right now we probably have 100,000 people on surgical wait lists. We probably treated 15,000 we treated in private facilities last year. The waiting lists would be 115,000, if it were not for the private facilities.

Senator Roche: Mr. Chairman, I do not quite understand the differentiation between patients who come to your clinic who come via the route of the Workmens Compensation Board and other patients who come from other routes.

Dr. Day: Supposing a carpenter is on disability insurance because he was injured playing hockey. However, he is a carpenter who is unable to work. A disability insurance company, like London Life or Great West Life, would pay that person's wages while he waits a year or two to be admitted to a hospital for treatment. He was not injured on the job. The insurance company is in the same position as the Workers Compensation Board. It is paying out, say, $5,000 a month while the carpenter is waiting a year for an operation that could be done for $1,000. The insurer would pay the $1,000 and save $55,000 in wage-loss benefits.

Senator Roche: Are billing the Workers' Compensation Board for the WCB cases?

Dr. Day: I was talking about disability insurance. Suppose you have two carpenters, one is a homeowner and the other, he is hired to do a job, and they both fall off the deck and they both incur the same injury. One will be covered by Workers Compensation because he is an employee. The homeowner, who is also a carpenter, has to take time off work, but his only way to get into our facility under the Canada Health Act is - and even this is a grey area and could be challenged - if his insurance company will pay for his facility fee the way the Workers Compensation does.

Senator Roche: It is the insurance company that you bill in that case.

Dr. Day: Yes, in that case an insurance company will be billed. I would absolutely support that man's right to spend his own money on his own health care if he so wished. We did not elect our government to dictate to us that we cannot spend money on our own health care, and that is the practical effect of the Canada Health Act.

The Chairman: Dr. Day, thank you for coming.

Senator Carney: I just want to say that it will take me six months to see him, after waiting four months for my rheumato logist so I am walking him out to the hall for a consultation.

The Chairman: I must say, we got to see you a lot faster than Senator Carney did. We only contacted you about a month ago. Thanks for coming.