Care at for-profit hospitals

William Nuttley raises the issue of competing interests for our article on costs of care in for-profit hospitals,1 with reference to coauthor Gordon Guyatt's candidacy for the New Democratic Party in the 2004 federal election. The choice of our research question was undoubtedly one of people's interests and values, but that is true of all investigators and all projects.2 Our work was conducted before Guyatt was nominated as a political candidate. The researchers on our study team hold widely varying political views, but they shared a common conviction that it was crucial to answer the study question (regardless of the results), given the active debate about the future of Canadian health care. Knowing a priori that some people would not like whatever our systematic review would uncover, we used several measures to minimize any possible bias. For example, we established explicit eligibility criteria and blacked out all study results before determining study eligibility, so that we were unable to select or reject an article on the basis of the study results. Therefore, we did not, and indeed could not, select studies to reach a preconceived conclusion.

Using our estimate of the additional costs of care in for-profit institutions and a corporate tax rate of 38.1%, Vincent Richman estimates that for-profit hospitals would have to pay $1.37 billion in corporate income taxes. Even if corporations were to actually pay all of this income tax and the money was reinvested into health care, Canadians would still be paying an extra $2.2 billion annually for health care.

Richman also states that we ignored the effect of competition in moderating prices. The 3 studies in our meta-analysis that controlled for market competition all demonstrated significantly higher payments for care at private for-profit hospitals.3^,4^,5 Furthermore, a health care system can have competition without private for-profit hospitals, as is the case in many cities with several private not-for-profit hospitals.

Finally, Richman claims that we ignore case mix because we extrapolated our pooled estimate of a mix of hospital payment ratios to the entire Canadian hospital system. We acknowledge that our $3.6 billion annual excess expenditure is an estimate that assumes a relatively similar case mix to US hospitals. Even if we assume a lower-acuity case mix among Canadian patients, any realistic assumption would result in the Canadian public having to pay billions of dollars in excess expenditures if we introduce private for-profit hospitals.

Considering this reality and given our previous finding of higher death rates in private for-profit hospitals,6 our policy recommendation remains robust (i.e., the evidence strongly supports a policy of not-for-profit health care delivery at the hospital level).

P.J. Devereaux Department of Medicine Greg Stoddart Department of Clinical Epidemiology and Biostatistics Deborah J. Cook Department of Medicine McMaster University Hamilton, Ont.