Too broad. Open to misinterpretation. Soft on patient responsibility. The recommendations of the Canadian Medical Association’s blue-ribbon advisory panel on health care transformation were met with an array of criticisms a day after being unveiled at the association’s 144th annual general meeting in St. John’s, Newfoundland and Labrador.
Delegates assailed the broad-stroke language of the panel’s report, arguing that its recommendation that the private sector play a bigger role in the provision of publicly funded health services could be interpreted as “opening the floodgates to private, for-profit monetized health care in Canada.”
The six-member panel argued in its report that medicare is nearing the “tipping point” and faces “privatization by default” unless Canada finds “a way to bring together the public and the private, independent providers” (www.cmaj.ca/lookup/doi/10.1503/cmaj.109-3976). They urged the nation’s doctors to “be open to discussing a range of ways of funding services,” including such mechanisms as user fees, franchises and insurance schemes, and to “recognize the value of provider competition in a framework that ensures quality, transparency, accountability and accessibility” (www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Annual_Meeting/2011/presentations/SS1-Advisory-Panel-Dagnone_en.pdf).
If the CMA’s annual gathering approves the panel’s recommendations without articulating the “very fundamental and upfront” condition that private providers be brought under the publicly funded system, then “we really open ourselves up to intense misinterpretation across the country,” argued Ontario delegate Dr. Shafiq Qaadri.
Other delegates expressed concerns that the panel’s recommendations favoured “competition over cooperation,” essentially pitting providers against each other in an already fragmented system.
Advisory panelists, though, countered that cooperation and competition are not necessarily mutually exclusive concepts.
“Every hospital and physician doesn’t have to do the same thing, there can be specialization,” panel member Don Drummond told delegates. “If [private providers] don’t offer services at a lower cost and higher quality then we’ll do it in the public domain.”
Most Canadians don’t care if they receive services from a public or privately-run clinic “as long as they can pull out their provincial [health] card and it’s paid for publicly, and that’s what we’re saying,” he later told reporters. “We are talking about no exchange of dollars between the patient and the provider of care.”
The panel also broached the notion of charging patients nominal user fees for emergency room visits if they could have been treated at a walk-in clinic. CMA President Dr. Jeff Turnbull told reporters it’s not clear whether charging user fees “would fit within the context of equity and social justice.”
“But I think no stone should be unturned,” he added. “I think we should look at everything.”
Delegates also expressed concern that the panel’s recommendations did little to address patient responsibility within the health care system.
“We’re talking about a systemwide improvement process but we’re still focusing on the providers and funding mechanisms for those providers, while my colleagues and I are struggling on a day-to-day basis to meet the sometimes inappropriate demands of the users of the system,” said Dr. Chris O’Brien, president of the Ontario Association of Nuclear Medicine. “How do we educate our 33 million users about the appropriate use of the health care system?”
Both physicians and patients are largely ignorant of the costs of individual services and how they add up, added Alberta delegate Dr. Mike Dufresne. “Conversation about transforming health care needs to get down to the microeconomic level where people can see it’s not just a big buffet table where you can fill up your plate at no cost.”
But panelist Sister Elizabeth Davis said physicians should be careful of blaming patients for misuse of the system. “When physicians say we need to educate patients, they forget that patients learn their inappropriate behaviours from you.”
“Pull us into the conversation so we can act more maturely about our own behaviours and about how we misused the system,” Davis added. “If you think you’re going to educate us, you’re still going to be treating us as children and young adolescents. But we want you to treat us as adults who make mistakes, so help us all together fix the system.”
Delegates will continue to debate the advisory panel’s report in strategic sessions this week.