Blurring the line between public and private health care

Canadians are frequently—and rightly—proud of the philosophy that underpins our universal health care system. Speaking at Parkland Institute’s recent conference, journalist and political commentator Linda McQuaig declared that “Medicare enshrines the principle of equality—this is the very opposite of the neoliberal agenda, in which you only get what you can afford.” Unlike other aspects of our market-oriented society, which privilege elites, “When it comes to health care, they can’t buy their way to the front of the line or through the front door. No wonder they’re angry!”

And yet, across Canada, some health care providers have found ways to commercialize medicine while professing to remain within the bounds of the Canada Health Act (CHA). Accessory fees, block fees, private surgical fees, and membership fees are all prevalent attempts to profit from the ill, the injured, and the “worried well.” We often forget that a line exists between free, universally accessible, medically necessary care and complementary, alternative, cosmetic, or preventative care—a line predicated not on the basis of need, but on the ability to pay. Moreover, this line is frequently—and deliberately—blurred by various private, for-profit healthcare services.

Blurred Lines, a new report released by Parkland Institute earlier this week, looks specifically at the phenomenon of private membership clinics in Alberta, which charge annual membership fees for combined physician and complementary practitioner care. Between 2012 and 2014, three such clinics underwent audits by Alberta Health to determine if their billing practices and access policies violated the CHA. Another such audit—of the Copeman Health Clinics in Edmonton and Calgary—is currently underway. Based on documents obtained under freedom of information requests, the report explores the audits process surrounding membership clinics, and asks whether there are sufficient measures in Alberta to ensure that the spirit of the CHA, as much as the letter of the law, is being upheld.

When is a medical clinic not a clinic?

When I walked in and found myself in a spa—complete with gourmet coffee, crystal chandeliers, and soft lighting—I assumed I was at the wrong location. This was certainly not my local walk-in clinic, with its uncomfortable chairs and faint antiseptic smell. Another notable difference: unlike the perpetually packed walk-in clinic, full of people on their only day off waiting hours to see a doctor, this place was virtually empty.

“There’s no waiting here,” my guide chirped. It didn’t take long to understand why.

The concierge clinic I visited in a south Edmonton suburb operates on a membership basis. While some services are offered a la carte—cosmetic procedures and “boutique” diagnostic tests—most of the clinic's approximately 300 patients paid an annual membership fee between $1,900 and $8,500 for the privilege of accessing this “personalized” and “preventative” healthcare. The benefits range from “comprehensive” medical and psychological assessments, to nutritional consultations and body composition analysis, to state-of-the-art genetic screening. After-hours support from the physicians and other health-care providers, “timely” access to prescription refills, and “annual facility access … scheduled for the member’s convenience” convey the impression that this clinic is providing faster and higher-quality care than your average GP.

Yet, the fine print is telling: “Our membership fees are for medical, lifestyle, and other services not covered by your provincial health care plan. Medical services that would ordinarily be covered will be billed to AHCIP [Alberta Health Care Insurance Plan].” In other words, because it remains illegal to pay for medically necessary primary care in Alberta, such clinics insist that you are not paying for medical care but for the extras. I asked my guide (the clinic’s sales director) what they can do for patients (“clients”) who come in seeking help for bronchitis, for example. “Well, certainly our physician here can see you, if you are more comfortable with them than your family doctor, but that’s not really what we do … more often we would suggest for those kinds of things to visit the public clinic”—the walk-in clinic, which is literally across the parking lot, is owned by the same company. They apparently send many of their patients, concerned about cardiac risk factors or a predisposition for certain types of cancer, across to the private clinic for out-of-pocket testing.

I ask what happens when or if any of the “state-of-the-art” diagnostic tests highlight a condition that requires treatment. Can the clinics refer their clients to a specialist? “Of course! Now, we can’t 'jump the queue,' but we have ways around that.” She explains that they operate as an advocate for their clients, placing them on multiple waiting lists, calling several times a day in order to take advantage of cancellations, fostering relationships with the staff at specialists’ offices in order to. as my guide put it, “get you in as quick as possible—much quicker than if you were to do it yourself. Most doctors have you on a list, and leave it at that, regardless of the wait.”

I worry about the costs. “It’s a lot for an average family,” I venture. “Would insurance cover the membership fees?” She replies that many plans do—“We just get creative” with how items are billed, she explains. Employer-provided health spending accounts are frequently used to cover part or all of the fees, while some of the tests can be billed individually in order to satisfy insurers’ requirements. I mention that I work at the university. “Oh, that’s fabulous!” she exclaims. “We have a client who’s a professor. Their plan covers all sorts of our services.”

I suggest that I might not be in need of such extensive testing, being relatively young, active, and with no prior medical history. “But I worry," I say. "My mom had a stroke last year. I wonder if I’m at risk.” Despite having no known risk factors aside from this family connection, she insists that I’ve come to the right place. “Most doctors won’t order the tests without symptoms or lifestyle factors. That’s what we’re here for—to reassure people like you, to give them all the information they need about their health.”

I visited the clinic as a researcher, deliberately skeptical of the sales pitch, and even I can’t help but be concerned as I leave, my complimentary fancy drink undrunk. What if I don’t know all that I don’t know about my own health? What if, for the price of a gourmet coffee a day, I could buy myself some certainty? For those with significant risk factors, or an extensive family history, or a pre-existing condition, the promise of certainty, timeliness, and “extra” care might feel worth the costs.

What is important to remember, however, is that this is a marketing strategy, and it often achieves precisely the intended effect. For anyone who has purchased a new vehicle or a gym membership, this kind of upselling will feel familiar: the mantra that no one ought to be satisfied with the basic package when the platinum version is purportedly more convenient, more efficient, safer, healthier, and less stressful. The private membership model preys not just on the so-called worried well, but on the carefully cultivated perception that the public system is inadequate to provide individualized, timely, or preventive care. That extra health services should be considered an essential luxury belies the fundamental unfairness of a business model based on exclusivity.

Getting beyond the zombie arguments

Right-of-centre commentators are fond of saying that government services ought to be run more like a business. And yet, it is perceived to be a fundamental Canadian value that medical care should not be a commodity to be sold and marketed. The idea that there is a hierarchy of medical care, in which those who can pay have access to greater choice, faster, or higher-quality services, does not sit easily alongside our common understanding of universal health care. Regarding medical care, this approach raises the spectre of American-style health care, in which a lack of private insurance can lead to crippling debt, delayed treatment, sub-par care, or occasionally, even death. In truth, it comes closer to the two-tiered approach adopted by the likes of Australia, which sells its parallel private services on the promise that allowing those who can pay to do so will alleviate pressures on the public system, provide improved access and freedom of choice, reduce wait times, and improve the general quality of care received by patients. 

These myths and misconceptions have been likened to health care zombies: first coined by Barer and Evans in 1998, the term refers to well-worn arguments that, despite their false and misleading nature, return to the debate time and again no matter how thoroughly they are debunked. A particularly persistent myth, frequently deployed by Fraser Institute reports decrying the “crisis” in our health system, both magnifies the scale of long surgical wait times and self-interestedly proposes private-pay options as the solution. However, not only do multiple peer-reviewed studies show that private options do not reduce wait times, in many cases they actually increase the wait times for those in the public system. Naturally, those who can afford to pay can buy themselves a speedy surgery, but those who continue to wait on the public list will see no reduction in wait times. To add insult to injury, new research by Mohammad Hajizadeh finds that patients associated with the lowest socioeconomic status had by far the longest wait times. Those in the upper echelons—those who would be most able to pay for expedited private care—were found to have considerably lower wait times already.

The other great fallacy inherent to the private membership clinic model surrounds “executive” health services, which are marketed as a more thorough, holistic approach, which goes above and beyond the apparently rushed and indifferent annual physicals offered by traditional family practices. These services have been found to be “bad medicine”—useless and unnecessary at best, and at worst a source of potential risks to the patient. A 2016 investigation by CBC reporter Kate MacNamara found that a prominent private clinic in Alberta was pushing an unnecessary suite of diagnostic tests based not on the physician’s assessment of the patient’s chart or declared symptoms, but simply as a matter of policy issued by its remote head office. Such practices place doctors on shaky ethical ground, and contribute to an increased burden on public lab facilities. 

These myths, then, have already been thoroughly disputed. Much like the so-called debate on anthropogenic climate change, there is no real uncertainty, as the majority of evidence supports keeping the profit motive out of health care delivery (much of which has been analyzed in the Alberta context by previous Parkland Institute reports). And yet, these myths are particularly resilient to counterarguments based on facts. Contandriopoulos et al. found that more than half of political statements made about health care privatization “employed little more than a ‘just trust me’ subjective rhetoric." In their analysis, evidence and fact-based arguments were used in only 11 percent of the statements, despite their heavy deployment by academics, think-tanks, and public servants. Those with a pro-privatization stance used evidence-based arguments far less than expected, while those opposed to privatization deployed this strategy the most.

This does not mean that evidence is useless; it means that in order to counter the influence of pro-privatization strategies, those in favour of preserving and improving our public health care system must use that evidence to construct persuasive narratives. As Dr. Danielle Martin, one of the founders of Canadian Doctors for Medicare, suggests, those narratives need to appeal to the aspects of our universal health care that are most valued by Canadians. And, despite that malleability of polls, polling data from the last 15 years consistently points to the importance of universal health care to Canadians.

In an earlier study on the persuasiveness of public opinion polls on public versus private health care policies, Contandriopoulos and Bilodeau found that the success of the argument was linked not to its factual accuracy or to the perceived pros and cons of the proposed policy, but to the pollsters’ ability to shape a compelling narrative—in this case, by playing on public anxieties about “problems” in our health care system.

Blurred Lines attempts to challenge these strategies of manipulation on two levels: first, by calling for accurate data on the prevalence of private clinics in Alberta and their practices; and second, by exposing the political, legislative, and regulatory processes that have enabled these clinics to flourish and promoted the normalization of private, for-profit health care. The report finds that, while all of the clinics under scrutiny were found to be within the law, the audits omitted important avenues of inquiry around access. It also determined that membership clinics are able to closely skirt the boundaries of provincial and federal legislation in order to maximize profits, maintain exclusivity, and promote their business model to Albertans, corporations, and the provincial government. 

It concludes with a series of recommendations crucial to closing off perceived loopholes and clarifying grey areas—and ultimately, ensuring that the blurred line between public and private health care is held up to the light.

Private membership clinics claim they are selling an “innovative approach” to health care, one that goes above and beyond the traditional model of care covered by Alberta’s health care insurance plan. But what they are really selling is exclusivity: privileged access to boutique services on the basis of ability—or willingness—to pay for the VIP treatment.

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