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“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.

Why then are doctors and OHPs getting flack?

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. 

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3 comments

  1. Rick Janson

    Funny how a post primarily on remittance for colonoscopies concludes with a rant about the perceptions of private health care. There are many types of private health care, including non-profits (like the Kensington Screening Clinic), for-profits (like the majority of Ontario long-term care homes and home care agencies) and even hospitals are technically private not-for-profit corporations. You would have to work hard to find any health service that is truly “public” in this context. However, there is a vast difference between how all of them interact both within and outside of the public health system and their level of accountability to the public when it comes to paying the bills. It is also incredibly misleading to lump them all together. You cannot deny “private” is also often linked to a lack of transparency when profit enters the picture. Without transparency, how can we ever measure the efficacy of these parts of the system, especially at a time of intense budget restraint? Executives of private for-profits operating in the public health system do not have to post their salaries on the Sunshine list, for example. The Toronto Star recently raised concerns about the fact that the CPSO has not made public the list of failed private clinics it inspected — some not-for-profit, most for-profit. Without the Star’s coverage, I’m wondering if we ever would have ever found out? Detailed performance data? In most situations, forget about it when it comes to private operators. Will the list of clinics with conditional passes from the CPSO be also made public, for example? The failures of private for-profit health care in a public context has been well documented, from the financial ruin of health trusts in the UK by misguided public-private partnership hospital projects to the lower levels of staffing in for-profit nursing homes right here in Ontario. Ontarians are very unhappy about the status quo when it comes to the health system, so its not about fear of change. We are all waiting for it. But what is that status quo? Increasingly its been a more fragmented system, a more privately-run system, and a more costly system. It is a system that runs significant and unnecessary costs from unneeded diagnostic referrals, some of it constituting self referrals from docs who have a share in the company. Ontario also leads Canada in the percentage of health care that is totally outside the public sphere (about a third). Stand alone clinics that perform a single function are always going to appear more efficient given they cream skim profitable services away from entities such as public hospitals. They also frequently mean patients have to travel further to access these services (while claiming to be patient-centered). But when hospitals do adopt these processes – such as the Bowmanville cataract clinic at the local site of Lakeridge Hospital — they can be just as efficient and the public revenues can support other more complex activities in the rest of the hospital.

  2. R. Cunningham

    The faster physicians are in command of patient care, the better it will be.

    Kudos to Ian Bookman for running an efficient clinic that sees patients in a timely manner.

    However, I fail to see how opening your own office yet still billing the public system constitutes a private clinic. True private clinics would bill outside the public system.

    When hospitals take control of physician practice, gross inefficiency is invariably the result. The focus becomes less about delivering optimal patient care and more about rationing, and hospital CEOs are more concerned about bottom-lines than patients.

    Physicians should instead be able to freely run clinics and diagnostic services outside of the influence of hospitals. Such services would still bill the public system and thus be tied to the public interest, but be run by physicians and not by hospital administrators. Simple as that.

    If costs in the public system are mounting uncontrollably, then fee schedule reviews should be a regular occurrence so that overvalued procedures are brought down, and vice versa. Value in this case should be calculated by the costs brought upon the health care system as a direct result of someone NOT providing the service. The difference would be the value.

  3. Martin van der Vyver

    There are many variants of ‘private clinics’ with different business models. The Kensington Cancer Screening Clinic provides timely access for patients in a environment that is efficient and provide high quality care for a procedure that is well established to prevent deaths.

    Originating from South Africa where private healthcare is one of the reasons why public health care is in ruins – I still believe that private per se is not the devil – the devil is in the details.

    I suggest rather than making it public vs. private debate – we move on towards studying the criteria where private does provide a transparent, safe, cost-efficient alternative to public health care that is often very inefficient.

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