In a surprising move, the College of Physicians and Surgeons of Alberta has challenged financial barriers to medical imaging.
While some believe that regulatory colleges should limit themselves to individual physician discipline, the Canadian public should support the growing willingness of Colleges to move beyond disciplinary issues to act as a voice for the public interest in the many conversations that shape our health care system.
We must be clear about what the College is and is not proposing. They are not proposing to shutter existing clinics. They are taking a stand that aligns physician ethics—the imperative to provide care to those who need it and not preferentially to those who can pay—with the public’s interest in an efficient and equitable system. In effect, they are proposing a new kind of partnership between the profession and government to improve care for patients.
The idea that professions should serve the public interest through self-regulation is not new. However, physician associations in Canada have long maintained an ambiguous relationship with Medicare, testing the boundaries of public toleration for private-pay solutions.
It may be surprising that leadership in a new direction is coming from Alberta, the province that gave birth to private-pay imaging 20 years ago. Private-pay imaging clinics have since opened in BC, Quebec, and, to a lesser extent, Ontario and Nova Scotia. Most of their business comes from third-party payers (motor vehicle insurance, workers compensation, and others). Some have claimed that a second tier of private pay imaging would “relieve pressure” on the public system. A rigorous analysis has not been performed, but CIHI data on wait times in the public system suggest that this benefit has not been seen. Indeed, twenty years into the experiment with a public-private mix of payers in medical imaging, the lack of data and accountability raise questions about the idea that private imaging was ever meant to improve the public system. Some predicted this failure from the beginning.
It is perhaps more surprising that the College decided to address private-pay imaging while it was formulating policy for an entirely different practice area: concierge medicine. In concierge practice, patients pay a membership fee covering non-insured services from physicians and from other health professionals—and, many argue, securing access to insured services. In January, the Alberta Health Services Preferential Access Inquiry uncovered concerns that patients at Helios clinic, a clinic with $10,000/year membership fees and ties to the University of Calgary medical school, were receiving screening colonoscopies within days of referral, rather than months or years—the normal wait times for average risk men in their 50s. The AlbertaCollege considered a proposal to bring standards for concierge medicine in line with those of other Colleges. The question arose: if private-pay MRIs and CT scans are acceptable, why not private-pay primary care?
Private-pay imaging is an anomaly in Canada: unlike other physicians, radiologists may bill the government for a service in one setting, and bill patients directly, setting their own fee, for the same service in another. The acceptability of this practice in Alberta turns on the distinction that Medicare covers imaging in hospitals, not in the community. The same service is insured in the hospital, but uninsured in the community—much like prescription drugs. But unlike prescription drugs, with imaging physicians can work both sides of the system. Romanow recommended a decade ago that this loophole be closed, to no effect.
Although the College’s proposal can be seen as fallout from the Preferential Access Inquiry, Commissioner Vertes declined in his report to make recommendations pertaining to private imaging and concierge medicine. He nonetheless commented that they are ethically troubling. If his side-comments have this much effect, we should take note of his twelve official recommendations on access, referral practices, wait list management, and the proper exercise of the discretion physicians have as gatekeepers to the system.
The College’s proposal is important for physicians, health care policy makers, and citizens across the country. A two-month consultation period starts Sept 15. It could fail under pressure from the segment of the public that is used to paying for expedited access. It could, despite its intentions, return patients to a public system that has the worst wait times for public MRIs among provinces reporting this data to CIHI, without fundamental transformation of referral practices and wait list management. It could simply loosen the public purse strings for medically inappropriate imaging and boost the profits of private facilities’ owners. All of these questions must be addressed in the coming months.
Those who care about equity, the future of Medicare, and good medical practice should be watching closely and contributing their views and their expertise, whether as consumers, providers, or researchers. We now have decades of international learning on improving wait times and wait list management; the movement for appropriate testing is gaining force. These are powerful allies in the work to secure the future of Medicare.