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Dr. Isabelle Leblanc, president of the pro-medicare group Médecins québécois pour le régime public, said the survey results show that radiologists in Quebec are increasingly choosing to work in the private sector to the detriment of the public system. "For us, this is the best example of how mixing the public and private systems can lead to decreased accessibility for most patients and increased accessibility for those who have the money to pay," Leblanc said. "Radiologists have no incentive to increase access in the public system, and in fact, they're draining resources from the public system." Leblanc explained that radiologists can earn more money charging patients for scans in private clinics than they would if they worked exclusively in hospital and billed the Régie de l'assurance maladie du Québec. Leblanc's group warned in a report three years ago that wait times for MRIs in hospital would increase.

"We're the province that has the highest number of MRI and CT scan machines per capita in the country - with a third of the machines in the private sector - and yet our public wait times are going up," Leblanc added. Health Minister Gaétan Barrette, a radiologist by profession who had worked in a private clinic before entering politics, was unavailable for comment. Officials with the Association des radiologistes du Québec could not be reached for comment, either. The Fraser Institute report observed little progress in cutting wait times for medically necessary surgery or treatments. The median wait time in Canada for treatment inched up to 18.3 weeks from 18.2 weeks last year. In Quebec, the median wait time for treatment by a specialist rose to 16.4 weeks from 7.3 weeks in 1993, when the Fraser Institute first started compiling such data. The median wait time denotes the midpoint for those waiting, as opposed to an average. In Quebec, the median wait time to see a medical specialist following referral from a general practitioner rose to 7.3 weeks from 7.1 weeks last year. The survey found that the longest median waits in Canada were for orthopedic surgery at 35.7 weeks, or almost nine months.

"These protracted wait times are not the result of insufficient spending but because of poor policy," Bacchus Barua, the author of the Fraser survey, said in a statement. "In fact, it's possible to reduce wait times without higher spending or abandoning universality. The key is to better understand the health policy experiences of other more successful universal healthcare systems around the developed world." aderfel@montrealgazette.com Twitter.com/Aaron_Derfel

The median wait time in hospital for a magnetic resonance imaging (MRI) scan in Quebec jumped to 12 weeks this year from eight in 2014, a survey has revealed. Wait times also increased slightly for other medical imaging. ALLEN McINNIS-MONTREAL GAZETTE FILES • MONTREAL GAZETTE / Source: Fraser Institute

CATHERINE CULLEN (REPORTER): The Cambie Surgery Centre is taking on the province of British Columbia in court next week, trying to overturn two provincial regulations. One bans private health insurance from medically-necessary surgeries. Advocates of private healthcare says it's too expensive for most people if there's no insurance. The other regulation forces doctors to choose between working in the public or private system rather than letting them to split their schedule. And now Justin Trudeau's government has been accepted as an intervener in the case. CBC News has obtained the expert report federal lawyers will use. It cites numerous studies to paint a bleak picture of a Canada with more private health care, arguing "society as a whole would be worse off." Resources like highly- skilled doctors would be siphoned from the public system. Even bankruptcies if people buy health insurance they can't afford as sometimes happens in the United States. Day says that he wants to see a European-style system with a public/private mix. DR. BRIAN DAY (CAMBIE SURGERY CENTRE):

To me it's a very simple question and that is: if the government promises health care, fails to deliver it, do they have the right under the constitution to stop you or your loved ones from extricating yourself from the pain and suffering that then ensues? CATHERINE CULLEN (REPORTER): The federal government says it's concerned about anything that would create a barrier to quality healthcare. JANE PHILPOTT (MINISTER OF HEALTH): It goes completely against the principles of the Canada Health Act which include accessibility and universality and we're committed to upholding those. CATHERINE CULLEN (REPORTER):

Now, the Supreme Court has already ruled on a similar case about private insurance, specifically in Québec, and in that case private healthcare won. People on both sides of the debate say that this new case could have some very important consequences for the whole country and that it could also wind up in front of the Supreme Court. Catherine Cullen, CBC News, Ottawa. © 2016 CBC. All Rights Reserved.

Online balloting has opened and will continue until May 15. While Day and Larsen Soles are both repeat contenders, they are distinctly different candidates who will appeal to different segments of the association's 12,000 members.

As an orthopedic surgeon, Day should draw more votes from specialists who have long felt the organization is too loaded with primary care doctors. Indeed, the current board of five doesn't include a single specialist and such doctors have long felt that has disadvantaged them when it comes to negotiations over fees with government. Family doctors have made impressive gains in the past two contracts while specialists, such as fee-for-service anesthesiologists, have complained bitterly about their fees and work terms. If Larsen Soles wins, she would become the fourth consecutive family doctor to be president and the second consecutive rural doctor; Ruddiman, the presidentelect, is from Oliver. She said in an interview she expects doctors will naturally want to mull those questions over.

"The thing is, people who choose rural medicine are those who are attracted to challenges and change and that's who doctors would be getting if they elect me. "Day, a private medicine pioneer, is hardly a stranger to challenge and change himself. Evidence of that is his seven-year-old lawsuit against the provincial government over whether private surgery clinics can bill patients for publicly insured services normally done in hospitals, usually after waiting long periods. Day said the litigation should not be a factor in the campaign, as it was last year. The oft-deferred sixmonth trial was supposed to begin in June but it has now been delayed to the fall. Day said provincial government lawyers recently asked for another deferral because they need yet more time to prepare. Providing the trial does start in September and lasts six months, as expected, if Day won the presidency, he'd be assuming the helm about four months after the trial ends. But regardless of which side in the trial wins, appeals all the way to the Supreme Court of Canada are expected in the landmark case that could reshape the health care system.

Day said only about 60,000 B.C. residents pay out of their own pockets to use 60 or so private surgery clinics. "I'm not saying we should privatize the health care system," he said, but he believes in a hybrid system in which private centres are used far more, as Saskatchewan is doing with its large scale contracting out of cases in which patients are waiting too long for care in hospitals. "Saskatchewan, the birthplace of socialized medicine, has taken a more pragmatic, less ideological approach, and it seems to be working. They are empowering patients to get their treatment in other places (like private surgery and radiology centres)." Larsen Soles said she's interested in the innovations in Saskatchewan but worries that a burgeoning private sector will draw health professionals away from the public sector. Sun health issues reporter pfayerman@postmedia.com twitter: @MedicineMatters

Underlying both reforms is a quiet resignation to the idea that two-tiered health care is inevitable. This sense of resignation is understandable, coming as it does on the heels of a decade-long void in federal leadership on health care. Throughout the Harper government's time in office, the Canada Health Act went substantially unenforced as private clinics popped up across the country. Even in its reduced role as a cheque-writer, the federal government took steps that undermined national unity on health care, switching the Canada Health Transfer to a strict per capita formula, which takes no account of a province's income level or health-care needs. If Canadians hope to reverse this trend, we cannot simply wage a rearguard battle for the enforcement of the Canada Health Act as it was enacted in 1984. Even if properly enforced, the act protects universal access only for medically necessary hospital and physician services. This is not the blueprint of a 21st-century public health-care system.

We desperately need universal coverage for a full array of health-care goods and services -- pharmaceuticals, mental-health services, home care and out-of-hospital diagnostics. Canada is unique among Organization for Economic Co-operation and Development countries in the paucity of what it covers on a universal basis despite falling in the top quartile of countries in levels of per capita health spending. Far from being our saviour, the Canada Health Act in its current incarnation is partly to blame -- not because of its restrictions on queue-jumping and private payment, but because it doesn't protect important modern needs, such as access to prescription drugs.

There are limits on what a public health system can provide, of course -- particularly as many provinces now spend nearly half of their budgets on health care. But fairness requires these limits be drawn on a reasoned basis, targeting public coverage at the most effective treatments. Under the current system, surgical removal of a bunion falls under universal coverage, while self-administered but life-saving insulin shots for diabetics do not. A modernized Canada Health Act would hold the provinces accountable for reasonable rationing decisions across the full spectrum of medically necessary care.

Instead of modernizing medicare, Saskatchewan and Quebec are looking to further privatize it. Experience to date suggests allowing two-tiered care will not alleviate wait times in the public system. Alberta has reversed course on its experiment with private-pay MRIs after the province's wait times surged to some of the longest in the country.

The current wisdom is long wait times are better addressed by reducing unnecessary tests. A 2013 study of two hospitals (one in Alberta, one in Ontario) found more than half of lower-back MRIs ordered were unnecessary. Skirmishes over privatization have to be fought, but they should not distract us from the bigger challenge of creating a modern and publicly accountable health system -- one that provides people the care they need, while avoiding unnecessary care.

Achieving that will make National Medicare Week a true cause for celebration. Bryan Thomas is a research associate and Colleen M. Flood is a professor at the University of Ottawa's Centre for Health Law, Policy and Ethics. Flood is also an adviser with EvidenceNetwork.ca.

he main difference is that although these countries have universally accessible health-care systems, they also allow people to receive private medical services by paying outof-pocket or purchasing insurance. Their systems result in better overall care, for two main reasons. First, competition from private hospitals and medical practices provides an incentive for the public system to improve. As the C.D. Howe Institute's Åke Blomqvist and Colin Busby argue in a policy paper released last month, in Canada, "lack of competition between provincial health insurance plans and privately financed medicine has lessened the pressure on publicsector managers and politicians to improve an inadequately performing system."

Having a parallel private alternative also helps reduce wait times in the public system. Last year, Canadians waited an average of 9.8 weeks to receive medically necessary treatments after seeing a specialist - three weeks longer than what most doctors consider to be "reasonable." In the Commonwealth Fund study, Canada ranked dead last in terms of "timeliness of care," while the U.K. came in third and Australia sixth. (The U.K. and Australia also ranked first and second respectively in terms of quality of care.) Fears of a mass migration of doctors into the private system are easily answered. In the U.K., doctors trained in public universities are required to work in the National Health Service (the public system) for at least two years before they can move into the private system. Doctors who receive NHS funding are also allowed to set up parallel private practices, but must work 40 hours a week for the NHS.

Fortunately, Canadian provinces have quite a bit of leeway to experiment with allowing more privately delivered medical services. As Mssrs. Blomqvist and Busby argue, "Although this is not widely understood, the [Canada Health Act] does not rule out transactions in which providers are paid privately for their services. There is also no prohibition on private insurance that covers the same services as those under the public plans, provided these services are supplied entirely independent of publicly funded services." Indeed, all that is needed is for provincial governments to take the initiative and remove some of their restrictions on private health services.

The health-care debate in this country has traditionally focused on comparing our system with that of the United States. Yet the truth is that we have much more in common with European and other industrialized countries. As many of these countries have shown us, it is possible to provide world-class health care that is accessible to all people, while allowing those who choose to pay for private services to do so here at home, rather than travelling overseas.

Opposition Liberal health critic Bill Fraser said there are many questions about the private clinic, including what kind of oversight and safety practices the province will be enforcing.

"This is a major piece of equipment, and it is not without health concerns both in sighting, installation and use of the magnet," said Whelan, chief of diagnostic imaging at the Saint John Regional Hospital.

Knight said he's not sure there is much need in New Brunswick for the private service. The New Brunswick government has recently invested in the purchase of five smaller 1.5 MRI machines for hospitals across the province. As well, it is looking at buying 3T MRIs for the Saint John Regional and the Moncton Hospital.

Who OK'd the use of this in the province? Did the private operators have to jump through the same kind of hoops we have to go through in the hospital?"

"We have 70 per cent of patients who can get diagnostic imaging access within one month, according to data from the New Brunswick Health Council. We also know that patients who are the sickest get care immediately, including MRI scans. So it's the less urgent cases who will be pursuing this private service."

The clinic's clients must have a referral for a scan from a doctor.

will employ four full-time technicians and one nurse

It is a client's doctor who makes the final diagnosis and determines with the patient where to go from there.

A private MRI clinic has been operating in Nova Scotia for almost 10 years. Across Canada, there are at least 40 for-profit magnetic resonance imaging (MRI) and computed tomography (CT) clinics.

This clearly puts the doctors involved in a conflict of interest. In a health system experiencing a significant shortage of practitioners, medical resources are drained from public hospital-based "free" care and into private purses. It also ties health care quality and accessibility to a patient's wealth - precisely what the Canada Health Act tries to prevent. For example, Montreal Children's Hospital - one of Montreal's two pediatric university hospitals - has decided to stop offering many medically necessary services. Instead, it will direct some patients to a new outpatient clinic. There, parents may be billed for such services as dermatology, endocrinology, general pediatrics and other important specialized care.

This steady disintegration of the principles of health care could soon be irreversible. Premier Philippe Couillard's new Bill 20 will legalize direct patient billing for medically necessary services provided outside of hospitals. The provincial government is confident that Ottawa won't intervene to enforce the Canada Health Act in Quebec (the federal government hasn't intervened in the past decade). Bill 20 makes legal practices that were grey-zone breaches in the universal public health system. This is creates a parallel, legal private health-care system subsidized by public health insurance. This could be the final blow to health care in Quebec. An unhealthy coalition - the Couillard government, private clinic owners, medical federations, private insurers and even some hospital administrators - is irresistibly pushing to decrease the care offered in public institutions and to increase the market share of direct payment and privately insured services. The only chance to save health care in Quebec is direct intervention by the federal government. Prime Minister Justin Trudeau and federal Health Minister Jane Philpott must enforce the Canadian Health Act in Quebec, even cutting federal health transfers until the province conforms.

Doing anything less will mean access to care according to a Quebec patient's wealth, rather than their needs. Astrid Brousselle is a professor in the Community Health Department, and researcher at the Centre de recherche de l'Hopital Charles-LeMoyne, Universite de Sherbrooke and Canada Research Chair in Evaluation and Health System Improvement. Damien Contandriopoulos is a professor in Nursing and a researcher at the Public Health Research Institute at University of Montreal (IRSPUM). CIHR Research Chair in Applied Public Health.

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 of the Doctors of B.C. I'll have to obviously seek [legal] opinion about that." Darcy questioned why the province's doctors would choose a champion of private medicine to represent their concerns to government. "Brian Day has led the charge to try and bring more private, for-profit health care to British Columbia," she said. "I know those are not values shared with the majority of B.C. doctors that I've spoken with."

Darcy said many doctors end up referring people to the private system, not because they believe in it but out of frustration. "We need to hear those voices loud and clear saying we need to be investing in innovation and improving wait lists in the public system. And that's the answer rather than moving to a private system." The current president, Victoria family physician Dr. Bill Cavers, will step down on June 6, to be replaced by Dr. Charles Webb until Day begins his term.

Cavers said the president's job is to represent 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."

While the association does not support two-tier health care, Carvers said there is room for private care clinics to help relieve pressure on the public system, by providing elective day procedures, for example. "We believe the patient should get timely access to care and if they can't, then the government and/or health authority should provide some public funds so they can get access to care as a backstop, as a safety valve," Cavers said.

A total of 2,176 votes were cast Tuesday. Day was elected with 946 votes, while Dr. Alan Ruddiman received 945 votes. Dr. Lloyd Oppel was a third with 285 votes. ceharnett@timescolonist.com

Dr. Brian Day is the 2015-16 president- elect of Doctors of B.C. He will assume the position in June 2016.

MacKinnon also challenged two frequent criticisms of private clinics: that they’d cream off the easiest surgeries and steal the best staff. Instead, she says surgeries were assigned by health regions and clinics hired retired nurses and nurse practitioners who liked the better hours and low-hassle atmosphere. She noted that surgeries — which covered only an array of specialties, not a complete list of surgeries — came in 26 per cent cheaper than in hospitals. “I think it was extremely well done.” Only in Canada, she said, would there be any fuss over who owns the clinics providing service in a single-payer system, MacKinnon said.

To put all of that in place requires that one looks at this as a system issue."

"If you're a doctor who is about to strike out on your own and open a new clinic, while you're busy picking out your office furniture, remember there's a huge chunk of [opening a clinic] — and that is equipment reprocessing … and that is the piece that can slip through the cracks," says Gardam.

Such high-profile failures to meet proper patient-care standards can undermine public confidence in the health-care system, notes Hugh MacLeod, CEO of the Canadian Patient Safety Institute.

not every province oversees private clinics

Pamela Fralick, president and CEO of the Canadian Healthcare Association

Fralick, who is part of a multi-stakeholder group discussing issues of mutual concern in the health-care system, says "there's a lack of integration in this country. When you have so many stakeholders and official bodies involved

"As we increasingly farm out various procedures to private-sector organizations, we have to look at if they are under the same standards," she says.

"I would say things have gotten better and out of crisis comes opportunity," Fralick adds.

July 8 the Ontario Health Coalition brought more than 80,000 signed cards to the Ontario legislature opposing the transfer of clinical services from hospitals to private clinics. (Photo courtesy the Ontario Health Coalition)

They may have learned from the Ottawa Hospital’s ill-timed decision early in 2013 to divest 5,000 endoscopies to the private sector at the same time the TCPSO was making public the list of clinics that failed inspection public – including one Ottawa endoscopy clinic that may have exposed patients to HIV, hepatitis B and hepatitis C from equipment that may not have been properly sterilized.

Health Canada’s annual reports show that Quebec has sometimes complied with its concerns. But in its 2003-2004 report, the agency observed that the Quebec government was “not at liberty to reveal the status of the province’s investigation” into user charges imposed by a private surgical clinic. A year earlier, Health Canada expressed concern “about private surgical clinics that allow individuals to privately pay for medically insured services and thus jump the queue. … Health Canada asked Quebec to confirm that the matter had been resolved.” A long-standing complaint of Quebec by Health Canada is that it allows patients to be charged for MRIs and CT scans if they are done in private clinics. In its 2004-2005 report, Health Canada held discussions with British Columbia, Alberta and Nova Scotia about charging for medical imaging in private clinics, but Quebec refused to participate. 

Health Canada officials did not respond to requests for an interview since last Thursday. Reacting to the Quebec lawsuit last week, federal Health Minister Jane Philpott said she’s a strong supporter of the CHA, and did not rule out reducing transfer payments to provinces that flout the law.

The procedures are publicly funded and patients come from Island Health's standard wait lists. The B.C. NDP said Island Health's call for contracts entrenches stop-gap measures in which the use of private clinics to reduce wait times drains funding, doctors and nurses from the public to the private system. On Vancouver Island, there are 1,265 people waiting (for an average of 39 weeks) for all types of colonoscopies, including screening colonoscopies, at Victoria General and Royal Jubilee hospitals. There are 352 people facing an average wait time of 26 weeks for hip replacements, and 566 people facing an average wait time of 28.7 weeks for knee replacements.

There are 404 people waiting for a hernia repair (an average wait time of 22.4 weeks) and 445 people waiting for varicose veins to be treated (an average wait time of 99.2 weeks). Canadian Institute for Health Information executive Kathleen Morris said working through a list of people who had waited longer than the recommended limit might have temporarily made wait times look worse than they typically are. "The question, I guess, is if the strategy is successful and it's a one-time strategy, you'll have one year with funny results and then things will kind of - hopefully - go back to a better spot," said Morris, the institute's director of health-system analysis and emerging issues. Meanwhile on the East Coast, Nova Scotia posted the worst numbers for joint replacement surgeries. The province has high obesity rates and an older population, which increase demand for these procedures.

But so do several other provinces that performed better. "Nova Scotia, particularly on joint replacements, has historically had a difficult time getting all of the patients done within a timely fashion," Morris said. The battle to improve wait times for key surgeries began in 2004, with provinces setting targets for hip and knee replacements, hip-fracture repairs, cataract surgeries and radiation therapy. The goal is to ensure that 90 per cent of patients wait no longer than 48 hours for a hipfracture repair, 182 days for joint-replacement procedures, 112 days for cataract surgery and 28 days for radiation.

"It has been so undertreated (in the public system) that there's no way you can bring it into the 21st century without some expenditure," Dooner says. He suggests de-insuring older treatments such as sclerotherapy - the injection of saline fluid into veins to make them shrivel away - and putting that money into surgery.

At the root of the issue is the idea that varicose veins are a strictly cosmetic problem, says Dr. David Liu, an interventional radiologist at Vancouver General Hospital who also works in a private clinic with vascular surgeon Dr. Joel Gagnon. "Venous disease is really a redheaded stepchild of diseases because we're only starting to understand it now ... and the funding structures are based on antiquated concepts," Liu says.

Varicose veins can result in more serious leg damage if left untreated. The range of options and their prices can make it overwhelming for patients to choose, Liu says. Even worse are so-called vein clinics that aren't overseen by doctors using ultrasound imaging, where patients get superficial laser treatments, missing the underlying problem. Susanne Ziltener of Vancouver has experienced both traditional vein-stripping surgery and one of the new treatments, a medical glue approved last year for use in Canada. Liu and Gagnon were the first to use it in Western Canada. The 66-year-old waited about three years for the publicly-funded surgery and then paid $4,000 to have the other leg treated privately.

Ziltener says neither was particularly painful although she was dreading the surgery, based on the experience of her mother who had the same operation. The biggest difference in her experience was having to wear a compression bandage 24 hours a day for about a week following surgery, something not required after the less-invasive treatment. The choices are vast enough that B.C.'s Ministry of Health has created an online guide to walk people through their choices. In an emailed statement, ministry of health's Laura Heinze said officials reviewed alternatives to surgery this year and decided not to fund them because they are more expensive than surgery and results are similar.

Regarding waiting lists, the government added $10 million to the health system in June to reduce the number of people waiting more than 40 weeks for surgery, including surgery on varicose veins, she said. eellis@vancouversun.com Varicose veins The common condition is viewed as a cosmetic nuisance by most, but can lead to painful leg ulcers if severe cases are left untreated. What are varicose veins?

Bulging, painful veins typically in the lower leg, occur when valves inside them stop working properly and are no longer able to push blood upward to the heart. This causes it to flow backward and pool in the veins, pushing them into tortured shapes. The extra blood also makes legs feel heavy. What causes varicose veins? Family History Aging Pregnancy Being over weight Standing or sitting too long

Who gets them? At least 15 percent of Canadian adult have varicose vein although some estimates are much higher. What are the treatments? In all cases, the aim of treatment is to remove or disable damaged veins so healthier ones will take over the task of pushing blood upward. Surgery usually called vein stripping, entails making cuts in the skin above, below and in the middle of the vein to be removed, which is then pulled out. It is done under a general or spinal anesthetic.

Sclerotherapy is the injection of a saline solution directly into the vein where it irritates the lining of the blood vessel and causes its walls to stick together. It needs no anesthetic. Minimally Invasive technique are grouped under the heading of endogenous ablation, which is the destruction of veins from the inside using a tiny probe inserted through a cut in the skin which is then guided by ultrasound imaging. It can employ laser or radio frequency to heat and essentially cauterize the vein; a fluid or foam that causes the vein to collapse; or medical glue which sticks the walls of the vein together. It may require local anesthetic around the incision.