As you may know, the pleadings are finished in the major court case in British Columbia challenging the universality of Canada’s Medicare plan. The case has been brought by an orthopedic surgeon, Dr. Day, on behalf of the Cambie Surgical Clinic in Vancouver. The case is now in the hands of the judge. Apparently we can expect careful reflection before receiving his judgment in several weeks time. Since it is highly likely that the decision will be appealed I thought it would be timely and helpful to share some reflections about a subject which, to the best of my knowledge, was never raised in the trial.
Public/Private Healthcare: Who Pays for Patient Harm?
A report commissioned by the Canadian Patient Safety Institute in 2017 (The Case for Investing in Patient Safety in Canada – produced by Data Analytics) presents a cogent business case to support increased funding and resources in the healthcare system to address patient harm. The business case? Reducing the incidence of a variety of harm events will generate impressive savings – according to the projections in the report the cost of patient safety incidents amount to almost 3 billion dollars. The report did not differentiate between costs arising in the public and private sectors of the healthcare system.
This brings us to the one subject which never seems to be discussed when talking about the advantages or disadvantages of healthcare services being provided by the “private sector”. What happens when there is significant harm to the patient that arises from the treatment they receive? And who pays for it? The answer is simple – the publicly funded system provides the necessary care and rehabilitation to all Canadians regardless of what kind of facility had provided the initial service. Is this fair or equitable?
Of course, implicit in the concept of a universal system is that all Canadians should have access to necessary services and there is no doubt that treatment following unintentional harm is definitely necessary. The issue of fairness arises when we wonder if the cost of treating patients that are harmed during care in the private sector should be assumed by the public sector. Somehow there seems to be an imbalance in this equation.
Implicit in this scenario is the assumption that unintentional patient harm following treatment exists in both the public and private sectors. While this question has not been studied specifically in Canada there is no reason to think that the existence or extent of patient harm will vary according to the location of the services provided. After all, the same highly trained and motivated staff are providing the services. The equipment used is similar, based on what is accepted as the standard of practice in a given case. And the processes and procedures of treatment will also be determined by accepted guidelines and standards. There is some evidence from the USA that the incidence of patient safety events may even be higher in the private sector. Why would we be different in that regard in Canada?
There is also no reason to distinguish between harm that follows treatment or procedures that are no longer funded by provincial health insurance plans (for instance cosmetic surgery) compared to harm following treatment in the private sector for various conditions that are still funded by the provincial plans (for instance various orthopaedic surgeries).
The answer seems quite straightforward. The cost of providing the necessary treatment for patients who have experienced harm following treatment in the private sector should be borne by the private sector. That only seems fair.
Is there a solution? It will be important to begin to study the extent of harm arising from care in the private sector and to calculate the costs that are associated with the treatment of patients who have been harmed. While those studies are undertaken, it is not hard to imagine ways in which cases can be identified – at the present time provincial health insurance plans routinely identify cases involving litigation so that procedures can be initiated to recover the cost of treatment when there has been a finding of negligence by the courts. Those cases are rare – why would provincial health insurance plans not track the costs associated with treating patients who have experienced harm from a patient safety event?
This will clearly require some legislative framework and perhaps more importantly it will require governmental courage. Beginning the open discussion of this issue is the first step to making progress.