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The Auditor General found wait times for long-term care that are extraordinary. Crisis clients are waiting more than three months for placement and wait times have tripled.

In Ontario’s privatized clinics (Independent Health Facilities) the Auditor found inadequate monitoring, poor inspections, a lack of financial oversight and inequitable access to care.

A charade is being played out in the courts of British Columbia that should be promptly terminated. The person to blame for failing to do so is Premier Christy Clark. She can easily settle the case. The government, a week before the case was finally going to be heard, "suddenly discovered" that it had about 300,000 documents that were important to its case. They successfully obtained a postponement. The "sudden discovery" may set an all-time record for introducing irrelevancies to a court case in order to obscure the issues and prolong the proceedings. And now the case has taken a bizarre twist. The province has completely undercut its own defence by announcing a $10-million plan to enlist private clinics to deal with the backlog of cases waiting for the kind of urgent treatment that the Cambie Surgery Centre has been providing for years.

This charade can easily be ended in a day. Clark can drop her case against the centre and alter regulations in the Medicare Protection Act to allow for private clinics. Then rationing will end. When Clark was a talk-show host, getting feedback from her listeners, she left the impression of being an enthusiastic advocate of private clinics. Now, after accepting advice from bureaucrats, other ministers and ideologues, she has become a defender of the government monopoly with its infamous queues. There is a further irony to this case. While condemning as queue jumpers those who opted for private clinics to provide urgent treatment for them, the government has all along been choosing its own queue jumpers. These are often workers' compensation cases where the government has found it cheaper to authorize and pay for their private-clinic treatment than to continue paying their layoff benefits. Before Medicare was introduced, there was no such thing as rationing. Cases were never turned away.

When I was an intern in the 1950s, the surgical theatres were run until the last case was finished. Later, as a B.C. MLA, I had long discussions with MPs Tommy Douglas and Lester Pearson about the effects of introducing Medicare as a national program. It could not have been further from their minds that it might lead to rationing. Their idea was to provide a floor so that all Canadians would have access to care. It was 20 years later that the Canada Health Act was introduced, leading to the infamous queues.

The current system of rationing will grow. It cannot be sustained and will eventually be abandoned. In future, judgments will be made in the court of public opinion. After this dark period has ended, historians are bound to judge it harshly - along with all those who promoted its continuing existence. © 2015 Postmedia Network Inc. All rights reserved. Illustration: • Jenelle Schneider, PNG Files / Dr. Brian Day and Cambie Surgery Centre will win a private medical court case with the province, predicts Dr. Patrick McGeer.

In recent years, at least four other companies — Helios Wellness Centres, Inliv, Provital Health and Wellness, and Preventous Collaborative Health — have also opened clinics in Calgary

an inquiry into preferential access to health services heard testimony that Helios clients who paid annual fees of up to $10,000 got screening for colon cancer at a public facility within months, while other routine patients waited up to three years.

At a website where consumers can rate their physicians, anonymous comments indicate some doctors have dumped existing patients in the public system so they can take on paying clients at private clinics.

Dr. Trevor Theman, registrar of the College of Physicians and Surgeons of Alberta, said he’s warned doctors joining these clinics that they risk breaking the disciplinary body’s standards of practice if they terminate their relationship with patients based on their socio-economic status.

he’s ready to investigate.

Health Minister Fred Horne urged patients who may have been dumped by doctors joining private clinics to contact his office.

William Lahey, a law professor at Dalhousie University who prepared a report for the public inquiry, says he’s concerned the private clinics may be violating the spirit if not the letter of federal health legislation.

what’s the impact of moving the routine profitable procedures to clinics and leaving the complex surgeries to under-resourced public hospitals?”

Although clinics will, for now be prohibited from making profits

“There is no doubt doctors stand to benefit from private clinics as the clinics become cash cows.

Surgeries and procedures currently provided in Ontario’s public hospitals are highly regulated under an intense provincial oversight regime. Private, doctor-run clinics are self-regulating. Patient complaints are made to the independent college that polices doctors. 

The penalties are assessed on a dollar-for-dollar basis, meaning they are equal to the amounts patients complained about paying for procedures. B.C. and Newfoundland were the only provinces assessed penalties for the last three years. When the 2013-14 annual report comes out soon, B.C. will once again be penalized, this time $224,000, said provincial Health Ministry spokesman Ryan Jabs.

Since 1994, the federal government has docked B.C. $3.2 million, slightly lower than the record-holder Alberta ($3.6 million). Since 1994, provinces have been assessed nearly $10 million in penalties for extra billing charges. A Health Canada spokesman could not explain why Quebec has never been penalized, even though it reportedly has a thriving private medicine sector. Ontario has also not faced any penalties.

The penalty to B.C. is paltry in relation to the province's $20-billion health budget announced Tuesday. It is also insignificant relative to the federal transfer payments B.C. will collect this year ($4.4 billion) and next ($4.7 billion). In 2006, the then-deputy health minister of B.C., Penny Ballem (now Vancouver city manager) questioned whether B.C. was really the only province where extra billing and private sector queue jumping was taking place. Jabs said Wednesday he can't comment on what happens elsewhere.

In 2005, the B.C. government did not submit a dollar value to the federal government for such extra billing, so Health Canada bureaucrats based the penalty sum on news releases from anti-privatization unions and newspaper clippings about patients who accessed the private system. The Sun learned about that through a Freedom of Information request. The story detailed how discretionary the penalties appear to be and that they are based on "guesstimates" of user fees. Provincial Health Ministry officials often base their reports submitted to the federal government on complaints from patients who go to private clinics for expedited care and then try to collect the fees paid from government. One such patient is Mariel Schoof, who had sinus surgery at a private clinic in 2003. She paid $6,150 for the "facility fee" and then tried to recover the fee from the provincial government or the clinic. She is now one of the interveners in a private versus public medicine trial starting March 2 between Dr. Brian Day and the provincial government. Timeline of Canada Health transfer compliance in B.C.

Early 1990s: As a result of a dispute between the British Columbia Medical Association and the B.C. government over compensation, several doctors opt out of the provincial health insurance plan and began billing their patients directly, some at a rate greater than the amount the patients could recover from the provincial health insurance plan. May 1994: Canada Health deductions began and continue until extra-billing by physicians is banned when changes to B.C.'s Medicare Protection Act come into effect in September 1995. In total, $2,025,000 was deducted from B.C.'s cash contribution for extra billing that occurred in the province between 1992-1993 and 1995-1996. These deductions were non-refundable, as were all subsequent deductions. January 2003: B.C. provides a financial statement in accordance with the Canada Health Act Extra-billing and User Charges Information Regulations, indicating aggregate amounts charged with respect to extra billing and user charges during fiscal 2000-2001 totalling $4,610.

Accordingly, a deduction of $4,610 was made to the March 2003 federal transfer payment. 2004: A $126,775 deduction was taken from B.C.'s March 2004 Canada Health Act payment, based on the amount of extra billing estimated to have been charged during the 2001-2002 fiscal year. Since 2005: $786,940 in cash transfer deductions have been taken from B.C.'s federal health transfer payments on the basis of charges reported by the province to Health Canada. January 2011: Vancouver General Hospital begins charging patients a fee when they elect to have robot-assisted surgery versus the conventional surgical alternative for certain medically necessary procedures. 2013: Deductions in the amount of $280,019 are taken from the March 2013 federal transfer payments of B.C. in respect to extra billing and user charges for insured health services at private clinics. Source: Canada Health Act Annual Report 2012-2013

The branch investigates about 30 cases a year of extra billing, usually related to private surgical facilities or expedited visits to specialists. The government is not sure whether it will be penalized in the future for allowing Vancouver General Hospital to charge patients fees for robotic surgery. VGH spokesman Gavin Wilson says since 2012 patients choosing to have surgeons remove their prostates using the robot have been charged on a partialcost-recovery basis. The B.C. government allows the extra billing because robotic surgery is discretionary, not medically necessary, and there are higher costs associated with it. In 2012, however, Health Canada began examining the Canada Health Act implications of patient charges for robotassisted surgeries. The process convinced the health minister that VGH should stop charging for robot-assisted surgeries as of Jan. 1, 2015. Vancouver Coastal Health collected $345,000 a year for the procedures; most recently, the patient fee was $5,700. Sun health issues reporter pfayerman@vancouversun.com

Across Ontario, 44 clinics have fallen short of basic standards in just three years, according to CPSO inspections. Meanwhile, the number of private clinics has skyrocketed by 31 percent since 2010 under this Liberal government. At least 20 patients in Ontario have contracted serious infections at these private health clinics.

Legal precedent: Whatever way the case is decided at trial, it is likely to be appealed and eventually reviewed by the Supreme Court of Canada. A decision from this level will mean all provincial and territorial governments will have to revisit equivalent laws. The foundational pillars of Canadian medicare - equitable access and preventing twotier care - could well be vanquished in the process. Wait times: Day will likely argue that Canada performs poorly on wait times compared to other countries, and that other countries allow two-tier care; thus, if Canada is allowed two-tier care, our wait times would improve. But this approach is too simplistic. Comparisons to the British health system, fail to recall that, despite having two-tiers, it has in the past suffered horrendously long-wait times. Recent efforts to tackle wait times have come from within the public system, with initiatives like wait time guarantees and tying payment for public officials to wait times targets.

By looking to Britain, we are comparing apples to oranges. British doctors are generally full-time salaried employees while most Canadian physicians bill medicare on a fee-forservice basis. Consequently, the repercussions of permitting extra billing in Canada could eviscerate our publiclyfunded system, whereas this is not the case in Britain. Imagine if most doctors in Canada could bill, as those at the Cambie clinic have done, whatever they want in addition to what they are paid by governments?

Conflict-of-interest incentives: Evidence suggests there is a danger in providing a perverse incentive for physicians who are permitted to work in both public and private health systems at the same time. Wait times may grow for patients left in the public system as specialists drive traffic to their more lucrative private practice. Sound improbable? Academic studies have noted this trend in specific clinics that permit simultaneous private-public practice. And recent U.K. news reports have profiled a case where a surgeon bumped a public patient in need of a transplant for his private-pay patient.

Competition: Proponents of privatized health services often claim it would add a healthy dose of competition, jolting the "monopoly" of public health care from its apathy. But free markets don't work well in health care. Why? Because public providers and private providers won't truly compete if the laws Day challenges are struck down. Instead, those with means and/or private insurance will buy their way to the front of queues. Public coverage for the poor will likely suffer, as is clearly evident in the U.S., with doctors refusing to provide care to low-income patients in preference for those covered by higher-paying private insurance.

Of course, this is all based on an outcome that is not yet known. It may be that the charter challenge in B.C. will be unsuccessful, but clearly the stakes for ordinary Canadians are high. Sadly Dr. Day is not bringing a challenge for all Canadians. Isn't it past time our governments and doctors work to ensure all Canadians - and not just those who can afford to pay - receive timely care? Colleen Flood is Professor and University Research Chair in Health Law Policy at the University of Ottawa. Kathleen O'Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University and Managing Editor of EvidenceNetwork. ca

A notable exception is Toronto’s Kensington Eye Institute, a not-for-profit corporation that performs cataract surgeries.

the McGuinty Liberals have already signalled their intention, if re-elected, to pay doctors and hospitals less for some publicly insured medical services. That raises the possibility that some hospitals could simply stop providing procedures with high overhead costs and low demand, resulting in more of that work being transferred to specialized clinics.

the benefits of specialized clinics are widely accepted

critics say the benefits are not as clear cut when those clinics are profit-driven companies

For example, a 2010 study by researchers at Toronto’s Women’s College Hospital found for-profit clinics that offer colonoscopies tend to ask their patients to return for followup screenings more frequently than is medically recommended.

There is a lot of evidence from the United States, where there are many for-profit providers, that patients are overtreated,” said Dr. Irfan Dhalla

Dhalla said he supports the idea of moving more procedures out of hospitals, but only if they are done in non-profit, publicly funded facilities.

"We will work to identify new tools that can help us continue to protect patient safety no matter where (patients) are receiving treatment. Ontarians have my commitment as minister that we will do whatever is necessary to protect the safety of patients," he said. TPH told the Star 11 patients contracted the liver-damaging virus during three outbreaks over the last three years; three were infected at the Downsview Endoscopy Clinic on Dec. 7, 2011, three at the North Scarborough Endoscopy Clinic on Oct. 17, 2012, and five at the Finch Ave. W. site of the Ontario Endoscopy Clinic on March 15, 2013. Nine of the 11 infected patients have gone on to develop chronic hepatitis C, meaning the virus has remained in their bodies, placing them at risk of serious, long-term problems, including cirrhosis of the liver and liver cancer. None of the clinics offered up anyone to be interviewed, but all three provided written statements. They all expressed concern for the health and recovery of the patients, said they co-operated fully with investigations and emphasized that they are committed to ensuring outbreaks never occur again. The Downsview Endoscopy Clinic also said it no longer uses multi-dose vials.

Wait times Currently, MRI wait time trends are hard to figure out. Because there has been no consistent record-keeping, requests for data are met with several caveats. Looking at raw numbers, waits in 2014 were anywhere from within 24 hours for a Level 1 priority patient, to 287 days for a Level 4 patient. Current wait times also differ markedly between health regions - bad news if you're in Saskatoon, where for the past few years, average waits for all but Level 1 patients have been longer than in Regina. In 2014, for example, patients waited 10 days for a Level 2 scan in the Regina Qu'Appelle Health Region, compared with 19 days in the Saskatoon Health Region. Level 3 waits were 58 days in Regina and 86 in Saskatoon, and Level 4 waits were 96 and 120 days respectively. Duncan admits part of that might come down to overuse of diagnostic imaging - something the Saskatchewan Medical Association and government are working on.

That's backed up by the fact that in the past eight years, the number of publicly funded scans in Saskatchewan has more than doubled and there are more MRI machines, but it hasn't made a dent in wait times. Health policy analyst Steven Lewis can't see the new approach reducing waits, because the only way you do so "is if demand stays constant while you're increasing capacity - and that never happens." Duncan is convinced the new approach "will help toward wait times," but Dr. Ryan Meili, a family physician in Saskatoon and vicechair of Canadian Doctors for Medicare, disagrees. As evidence, Meili points to Alberta. It has private MRIs, he says, yet it "has the longest wait times for MRIs in the country." Erosion of public health?

You would expect Meili to be ideologically opposed to the privatization of MRIs - after all, he ran for NDP leadership and is a vocal opponent of privatizing any aspect of health care - but he also has "evidence-based" objections. "It starts to just further reinforce this idea that we need to privatize care, piece by piece, and it erodes confidence in the system," he says. Duncan argues that paying out of pocket for MRIs already "happens in Saskatchewan today" when people head to Alberta or the U.S. for a scan. The provincial health system doesn't stop them, he says, but "we don't get any benefit from people doing that." Duncan says at least this way, "the public system will get a scan for each one paid for out of pocket."

Because MRIs are generally a diagnostic tool, Lewis says the biggest risk in the change is that people who need a scan and pay out of pocket will end up getting treatment sooner than those who don't pony up the cash. "It's troublesome on so many levels," he says. egraney@leaderpost.com Twitter/LP_EmmaGraney

"The priority of the Medical Services Commission and the Ministry of Health is to uphold the Medicare Protection Act and the benefits it safeguards for patients in this province," B.C. Health Minister Terry Lake said in a statement on Tuesday. "We expect and require these clinics to come into full compliance with the law, and we remain fully committed to seeing out this case to its resolution." The ministry said it could not comment further because the case is before the courts. But the federal government is also watching the proceedings closely and has sought intervenor status in the case. In a statement from Ottawa, Health Canada said many provisions of the B.C. legislation mirror those of the Canada Health Act, "making this case of significant importance not only to British Columbians, but to all Canadians."

Given that Canadians "overwhelmingly" support universally accessible health care, "any challenge to a principle so fundamental to our health-care system is of significant concern to the Government of Canada." During a federal Liberal caucus retreat in Saguenay, Que., last week, Health Minister Jane Philpott said the case and the prospect of health-care privatization are a cause of "concern" for her. "I think I have made it very clear on repeated occasions that our government is committed to firmly upholding the Canada Health Act. The Cambie case deals specifically with that, with the provision of services," she told reporters. "It's fundamentally important to the health-care system in the entire country, not just in British Columbia, that we make sure that medically necessary services are universally insured and there are no barriers to access of those services." Ms. Philpott acknowledged that some health-care services in Canada are delivered privately, citing physiotherapy, which is largely carried out in private clinics because it is not included under the Canada Health Act.

But she said anything similar to a user fee is a barrier to people being able to receive medically necessary care. Ultimately, Dr. Day said, the law, facts and evidence are on the side of his argument that Canadians would best be served by a "hybrid" health-care system. "I kind of hope the judge doesn't hear that, and our lawyers would be nervous to hear that, but that's what I believe," he said. Within that system, public hospitals would offer private services and private hospitals would offer public services. He said he also wants to see competition between and within the systems. "Competition breeds excellence," Dr. Day said. © 2016 The Globe and Mail Inc. All Rights Reserved.

Many within the system believe allowing private, for-profit options is a potential solution. Government has always relied on private facilities such as walk-in clinics, X-ray clinics and laboratories to provide insured services within the public system. Perhaps it’s time to allow Canadians to purchase medical services on the open market.

Although a province may have an oversupply of surgeons, it has a shortage of the other disciplines. The hours nurses and anesthesiologists work in the private system would come at the expense of the hours they can devote to the public system.This is a key caveat on the argument in favour of allowing more private, for-profit health care options: it is difficult to create a private tier that does not ultimately weaken the public tier. In fact, it is tough to find examples where increased private options relieve pressure on the public system and reduce wait times.

There is some evidence of this in Saskatchewan, where the government has been allowing private, for-profit MRIs for about 10 months. To date, Saskatchewan claims it has taken 2,200 patients off public wait lists for MRIs. And yet, its wait times in the public system have not gone down.

In fact, during the first six months Saskatchewan allowed residents to purchase their own MRI tests, the government’s own website shows wait times went up.

Do they? Lysyk looked at 74 public-private projects started since 2005 to answer that question. She found that, in total, they cost $8 billion more than if they had been built and managed by the government alone. In one telling example, she looked at the construction of two near-identical buildings for an unnamed Mississauga college. The first, handled by the public sector, was completed on time and on-budget. Over the objection of the both the college and then mayor Hazel McCallion, the government decreed that the second building be funded and handled by a private project manager. When the figures are adjusted for inflation and other variables, that second building is expected to cost taxpayers 10 per cent more per square foot. The reason is straightforward. Big projects are always built with borrowed money. And governments can borrow far more cheaply than private firms.

Private project managers also tend to charge higher legal and management fees. As well, they must return profits to their owners. Aficionados of public-private partnerships insist that while all of this may be true, privately managed projects are far more likely to come in on time and under budget. That is the argument used by Infrastructure Ontario, the body charged with handling public-private deals. It says that if the 74 projects had been handled by the public sector, delays and overruns would have cost taxpayers - in net terms - about $6 billion more. It also says that publicly managed projects are five times more likely to come in over budget than privately managed ones.

Thomas Walkom's column appears Wednesday, Thursday and Saturday.

He will succeed Dr. Charles Webb, who takes over as president when Dr. Bill Cavers finishes his one-year term next week. Day's lawsuit is expected to last seven months and is tentatively scheduled in the B.C. Supreme Court at the end of the year. So Day could be leading Doctors of B.C. at the same time he's in court against the government.

Health Minister Terry Lake said that could present challenges. "I obviously want to have a positive relationship with the Doctors of B.C. I've obviously had that with the past presidents. It may pose, I guess potentially, some difficulties if we have an active legal case going forward whether I'm able to meet with the president-elect. "I don't know at this moment in time if this will provide any obstacles, but we'll seek advice on that." "But this is a democratic process, it's an organization of membership, of self advocacy, and we have a working relationship with the Doctors of B.C. and we have to obviously abide by their democratic process." Opposition health critic Judy Darcy said she's flabbergasted by the election.

"Brian Day has led the charge to try to bring more private forprofit health care to B.C. I know those are not values shared with the majority of B.C. doctors that I've spoken with, but it is very disturbing at a time when there's an active court case with government about bringing in more private health care in B.C. that this is the person leading the Doctors of B.C." "That's pretty serious if the minister can't meet with him because there's a legal case, but also Doctors of B.C. is involved in many, many joint committees across the province ... so I think it's very worrisome ... and I'm very concerned about what it means for health care in B.C." Darcy said patients end up in the private system out of frustration and she thinks government should do more to improve access to publicly funded care.

But Day said he expects his trial will be over by the time he's president because lawyers for both sides have been trying to scale it back by reducing the number of witnesses testifying. Day's lawsuit contends patients have a constitutional right to pay for private care if their health is suffering by waiting too long for care in the public health system. Under current laws, private clinics are not supposed to collect money from patients if the treatment is an insured service in the public system.

As to Darcy's concerns, Day said: "Everyone like that is against using the private system until you, or a family member or friend, needs it. When it becomes a personal matter, they may want and need to access care in the private sector." Referring to a front-page story in The Vancouver Sun Tuesday about the projected explosion in cancer cases due to population aging and growth, he said: "That's the sort of thing we need to be spending public health dollars on, not skiers at Whistler who harm their limbs and want quick surgical repairs."

Cavers said, in an interview, he couldn't comment on whether Day's simultaneous lawsuit and presidency could present conflicts or potentially awkward interactions between the government and Doctors of B.C. "I can tell you that when you are president, you are representing the interests of all doctors. It's not about your personal agenda. And if anyone has a reason to recuse themselves from board discussions, then they do that. Because sometimes interests do collide."

Cavers, a Victoria family doctor, said the organization is constantly interacting with the Ministry of Health on a multitude of issues involving the health system. But most often, he said, the meetings are between government staff and Doctors of B.C. staff. Cavers recalled having a halfdozen direct encounters with the health minister in the past year. Ruddiman declined to comment.

Dr. Lloyd Oppel, an emergency medicine physician at the University of B.C. Hospital who was third in the balloting, said he has no idea if Day's presidency will "present lots of hiccups," nor if the trial will be a distraction from Doctors of B.C. work. "Brian (Day) appeals to doctors who like his gutsy style, the fact he's not afraid to fight the good fight. They see him as a beacon of hope for change. So I knew when he entered the race that he'd have a big effect," Oppel said. Sun health issues reporter pfayerman@vancouversun.com Follow me on Twitter: @MedicineMatters Read more about Brian Day on my blog: vancouversun.com/medicinematters © 2015 Postmedia Network Inc. All rights reserved. Illustration: • Steve Bosch, PNG Files / Dr. Brian Day will become president of Doctors of B.C. in 2016-17.