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Thursday, 20 September 2012

Canada Health Act and the Shouldice Clinic - an Opportunity to focus on the real issues?

Ontarians have been blessed and cursed by the Shouldice Clinic for decades.  Established in the 1940’s, it is a family owned independent facility that balances its books by billing the provincial health system (OHIP). Its speciality and expertise is in fixing hernias, and outcomes are exceptionally good.   Seems the owners are interested in selling to another private interest, a company traded on the TSE stock exchange. 

So a debate rages over the appropriateness of the sale to a company that specializes in running health care facilities and already owns facilities in Ontario. 

The Canada Health Act is clear on the need for “public administration” of health services.  Such discourse has fueled many a debate and sparked labour outcries relative to contracting of services as “privatization”.  The principle is a clear one, the government holds and dispenses the funds that pay for the coveted Canadian health system (or in reality some 14 distinct systems between the provinces, territories and federal services such as First Nations)

The Canada Health Act (Section 9 Canada Health Act )  however only covers “comprehensiveness” as it relates to physician, dentists and hospital services. (and only those services deemed as non-“elective”).  Sure there has been lots of debate about expanding the definition to include residential care, home care and pharmacare.  However it has not happened. 

We widely engage in different styles of ownership of other health services for things like long term care and home care.  We have tended to covet in the public realm services for the public good or marginalized populations like public health and mental health.  

In reality, most physicians and dentists are private businesses already.  The provincial payment plan provides for the public administration and distribution of public funds to these private businesses. 

Long term care and home care are a mish-mash of public own, non-profit, for profit publically traded companies and privately owned.  There are even some of these facilities and services that are privately owned and exclusively private pay outside of the health system.  Despite the non-inclusion in the Canada Health Act, the majority have fallen to not only publically funded, but also in many cases publically administered.  Most provinces retain some regulatory oversight to ensure that even for private pay settings, vulnerable people in long term care settings are not abused.  When abuse occurs, irrespective of the involvement of the public administration, it is unacceptable to us as Canadians that such persons were not protected, so the demand for public administration is high. 

Hmmmm, even if we look to public health and mental health, there are innumerable contracts in place for provision of various services ranging from clinical activities, education, harm reduction, program coordination.  Such contracts may be rendered to non-profits, private individuals or even businesses.  Perhaps more disconcerting is that there is less public oversight of private pay activities in these fields.

Of course, there are all the other health services that are neither covered by the Canada Health Act, provincial insurance programs, and sometimes not even self-regulated.  Most such services are limited to private pay – some depending on Worker’s Compensation or employee insurance programs.  Speech therapy, some physiotherapy, chiropractic, naturopathic, herbalist, massage, hypnotists – the list and types of “professionals” deserves its own posting.

Then there is the whole mix up about pharmaceutical programs which are a bizarre mixture of public coverage, welfare, employment insurance, and private pay.  Not surprising that the inability to afford drugs leads to complications that require other insured health services. 

And, can someone please explain why dental services are explicit in the Canada Health Act but since most dental services are excluded from provincial insurance plans (a requirement for inclusion in the provision of the Canada Health Act for overbilling penalties), that Canadians are driven into private pay or employment benefit approaches to payment?  It is a highly inefficient use of funds though no doubt highly lucrative arrangement for practitioners.

Discouraging in all this debate is the lack of quality evidence to inform good decision making on how service governance impacts the outcomes we are trying to achieve.  One can clearly look to comparisons between countries to show where Canadian publically administered services rank well on population outcomes and limit the development of inequities, but perhaps dampen innovation and experimentation.
The main point, is that under public health administration we already permit a wide variety of public, private and other structures to oversee the provision of health services.  That public administration can range from legislative oversight, disbursements of public funds, regulatory investigation structures, contracting between agencies through to the direct provision of service. 

So the debate over the Shouldice Clinic is merely a minor variation on an existing theme. A few experts  have contributed their thoughts if you want to dig into the detail Picard on Shouldice  Healthy Debate on Shouldice

But rather than fight over the Shouldice Clinic, can we be brave enough to open the discussion on what we as Canadians want as the outcomes of our health system and use that to define what belongs in the Canada Health Act?  He grand matron of the Act Monique B├ęgin (Minister of Health in 1984) has repeatedly stated it was designed as the first step.  Can we get a pan-Canadian government accord brave enough to take the second step?  

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