“Private” is not a curse word in medicine
As physicians, we hope to not only improve quality of life for our patients, but also help them live longer. Colorectal cancer deaths are widely agreed to be up to 90% preventable by regular screening with colonoscopy. A major barrier is getting people to participate in screening programs. Now that awareness is increasing, another limiting factor is availability of endoscopy time. Hospitals are not able to open more endoscopy rooms because this eats into their global budget. This budget must cover all hospital costs. More endoscopy expenses means less money available for other hospital services.
Doctors who perform colonoscopies are under immense pressure to see patients in a timely fashion. The pressure comes from patients, referring physicians, and published guidelines. To address these needs, many doctors now work in privately owned screening clinics. The doctors get paid by OHIP, the same way they do in hospitals; however, since the clinics are not provided with government funds, they charge doctors a user fee to cover the overhead costs. Up to this point, the clinic fees have amounted to approximately 35% of the physician’s OHIP income. In a hospital, overhead costs are covered through a global budget and also through additional government money provided for each colonoscopy. Doctors are not charged a user fee in the hospital.
More recently, the new doctors’ agreement with the Ministry of Health changes this cost. OHIP fees from these procedures have been cut by 10%. That means that doctors now contribute closer to 40% of their OHIP income to pay for clinic overhead costs. However, because of these clinics, doctors are under less pressure from patients, the hospital system resources are freed up a bit, and patients are screened in a more timely fashion.
The College of Physician and Surgeons of Ontario (CPSO) has appropriately stepped up and developed rigorous standards for these Out of Hospital Premises (OHP). To cover the cost of this new inspection system, each doctor that practices at an OHP is charged an additional $825 per year, on top of the regular College dues.
Governments and hospitals recognize that these OHPs are potential centres of excellence that can offer the same or better standard of care for services at a lower cost than hospitals.
Some convulse at the word “private”, as in “private clinic”. This conjures up images of doctors or CEO’s making millions of dollars off of the public purse. The logic does not add up. Doctors that perform colonoscopies are paid the same for the procedure, whether at a privately owned for-profit clinic, not-for-profit clinic or at a hospital. Illegal user fees are just that, illegal, and can be reported by anyone to the College. Accordingly, concerns about inappropriate repeat procedures or self-referrals can apply equally in both settings. Yes, monitoring is needed, but the issues of concern have nothing to do with hospitals versus OHPs. Similarly, concerns about quality are often misplaced. Let’s put the widely referenced articles about office-based endoscopy into perspective: (1) The data is 10 to 15 years old, from 1997 to 2003; (2) The authors could not distinguish between reasons for the colonoscopy, for example, banding of hemorrhoids versus colon cancer screening; (3) The authors could not identify the intention of the endoscopists. In other words, many office-based endoscopic procedures could have been intentional sigmoidoscopies for assessment of hemorrhoids, but the study methodology would have classified these as incomplete colonoscopies. This is because the analysis was dependent on which billing code the endoscopist used: Flexible sigmoidoscopy, billing code Z580, and colonoscopy to the descending colon, Z555, both pay the same fee, and are often used interchangeably in practice.
Today, clinics undergo quality inspections by the CPSO which has the ability to impose penalties and revoke licenses. CPSO is in the process of making these results available to the public. In other words, these clinics are becoming increasingly transparent and accountable. Consequently, quality standards today are just as good if not better at OHPs than in hospitals. Indeed, many physicians that I know who work at OHPs choose to have their colonoscopy in a private clinic.
In my opinion, there are two reasons why people are against private clinics, and both have to do with fear: (1) fear of change of the status quo; and (2) fear of the word “private”. Subscribers to these misperceptions offer fear-mongering stories, conjuring images of substandard private clinics with illegal practices that abuse the healthcare system, stealing public money in the name of greed. These perceptions are inaccurate and misleading. Here are two truths that should replace these misperceptions: (1) the status quo needs to change; and (2) “private” is not a curse word in medicine.
Ian Bookman is the Medical Director of Kensington Screening Clinic (a not-for-profit OHP), a staff gastroenterologist at St. Joseph’s Health Centre, and Adjunct Assistant Professor of Medicine at the University of Toronto. The views expressed in this article are solely that of Ian Bookman and do not necessarily reflect the views of the institutions with which he is affiliated.