The Canadian Medical Association's General Council passed seemingly contradictory motions during its debate over the funding and delivery of health care, some supporting a public system, others moving to more private aspects.
The motions, approved Aug. 22 and 23, “frankly send a mixed message” about how to solve the wait-time crisis, said outgoing CMA President Dr. Ruth Collins-Nakai at the meeting in Charlottetown, PEI.
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Some of the 19 motions supported access to care based on need, not ability to pay, including a publicly funded recourse mechanism, allowing patients who wait too long to receive care elsewhere. But the 248 delegates, representing nearly 63 000 physicians, also approved motions calling for private alternatives, including a call to “remove existing bans that prevent physicians from practicing in both the private and public sectors.” (In most jurisdictions, physicians who want to bill patients for necessary medical services must opt out of the public system.) Another motion urged government to allow physicians to “opt out” of the public system, provided they don't bail en masse.
The conflicting messages reflect the frustration doctors are feeling as they try to provide timely, quality care to patients, said Collins-Nakai. “This frustration is driving physicians to ask CMA to leave no stone unturned in providing access to better health and better care.” That includes examining “private options as one possible mechanism to reduce wait-times.”
But Collins-Nakai said delegates weren't entirely clear on whether they were talking publicly funded, privately delivered health care or privately funded, privately delivered health care. The CMA Board of Directors “will have to sort this out…. We have to provide some leadership.” But she added, doctors continue to prefer the option of reinvestment in the existing public system.
CMA President Dr. Colin McMillan will proceed “pretty carefully. Some feel funding is the problem, some feel allocation is the problem, and some feel alternatives are needed. We will look at that.”
The delegates defeated 2 motions advanced by Dr. Ben Hoyt, past-president of the 7000-member Canadian Association of Internes and Residents (CAIR), which explicitly opposed parallel private health insurance for medically necessary services.
One stated that such insurance is “inconsistent with the principle that access to medical care must be based on need and not ability to pay,” while the other urged governments to oppose private insurance systems as a solution for improving wait-times.
Dr. Danielle Martin, head of the 1000-member Canadian Doctors for Medicare (CDM) , which was formed in May to stop what it sees as CMA's drift to two-tier medicine, called the defeat of the motions “a real blow to the credibility of the profession,” given they were the most evidence-based of the debate.
A third CAIR motion sought to fix the health care system from within, calling on CMA to acknowledge the strengths of medicare and identify requisite reforms. It was approved by 69% of delegates — the lowest percentage in the entire debate.
“There seem to be blinders in this room that the only solution is private funding,” Hoyt told CMAJ. “There are other solutions. We're not talking the status quo, we're talking improvements.”
Ironically, both Hoyt and Martin argued that the real “mixed message” regards the CMA's commitment to a publicly funded, universally accessible health care.
“The CMA continues to try to sit on the fence and refuses to have clear commitments,” said Hoyt, a 4th year resident in Halifax, NS.
Martin said the motions, combined with the selection of Vancouver private clinic founder Dr. Brian Day as CMA president-elect for 2006/07 (see page 566), are “contradictory in the extreme.”
Martin argued that reforms need to be based on the evidence presented in the CMA's “It's About Access” Wait Time Alliance report (CMAJ 2006;175[1]:18-19), which stated that a parallel private system of insurance would decrease access to health care for most Canadians. “The CMA has now marginalized itself. It has shown it is out of touch with its members and certainly with the majority of Canadians. I hope it will now … figure out what the organized leadership of the profession should be doing for the health of Canadians rather than acting in the best interest of the profession.”
Medical students also expressed concerns about the contradictions. “I hope they will come up with a consistent statement that puts patients first,” said Andre Bernard, president of the Canadian Federation of Medical Students (CFMS), representing 6500 students in the 13 Anglophone schools. “I'm not convinced we're hearing all sides of the argument.”
The Student Medical Reform Group, a grassroots movement, presented CMA with a petition decrying the move to allow more private medicare, signed by 1134 students representing all of Canada's medical schools (CMAJ 2006;175:18). The petition points out that 2-tier health care in other countries promotes queue-jumping and lengthens wait-times in the public system. Many have argued the public–private debate is moot given that there aren't enough physicians in Canada to run parallel systems and that the wait-times issues can't be resolved without redressing the current shortage of physicians, as London, Ont. anesthesiologist Dr. Ron Wexler repeatedly told General Council.
Other approved motions included: a call for more transparent tendering as governments enter more public–private partnerships; development of a code of conduct for physicians who provide health services that are delivered publicly and privately; adoption of the wait-time code recommended by the CMA; and establishment of evidence-based wait-time benchmarks for all major diagnostic, emergency, therapeutic and surgical services by Dec. 31, 2007.
“What we need is the medical equivalent of a building code,” said Comox, BC delegate Dr. Jon Slater. “Other countries have done this; it's time for Canada to get with the program.”