André Picard
In recent days, two high-profile groups have stepped up to demand the Ontario government ban "medical tourism" – the practice by some hospitals of offering health care services (mostly surgery) to non-Canadians as a way of generating revenue.
The Canadian Health Coalition statement began like this: "One of the greatest Canadian values is that everyone receives health care based on their need and not their ability to pay. Why then are several Toronto-area hospitals actively seeking and treating international patients on a pay-for-treatment basis?"
The Registered Nurses Association of Ontario said this: "Our system is under attack as experiments with medical tourism continue in some hospitals in Toronto. These experiments are eroding the quality and accessibility of health services for all Ontarians. For a fee, usually paid up front, international patients are treated by hospitals as a means to generate revenue."
There are some sweeping assumptions here, but let's start with the raw data.
What we know is that Sunnybrook Hospital has treated eight foreign patients for payment, netting a whopping $16,000 in profit. The University Health Network, a collection of hospitals in downtown Toronto, has treated 381 patients since 2011; last year it had net revenues of $7-million.
The Hospital for Sick Children treats around 200 children from around the world each year, mostly for conditions that cannot be treated in their home countries. Mount Sinai Hospital, for its part, treats about 10 women a year from poor Caribbean countries who have high-risk pregnancies. This care is provided on a compassionate basis, with insurers, public or private, paying on a cost-recovery basis; Sick Kids also has the Herbie Fund, a charitable initiative that pays for the care of about 25 kids a year, most of them from developing countries and suffering from disfiguring or life-threatening conditions.
The key argument by those who oppose these initiatives – and the profit-generating ones in particular – is that they undermine access to health care by Canadians. There is an assumption that people coming from other countries will "jump the queue" for surgery. The classic "slippery slope" argument is also invoked: If we allow foreigners to pay for care then Canadians will soon be demanding to do so as well. (We'll save that discussion for another day.)
While there are fears, there is no actual evidence that care for Canadians is being denied or delayed because of the influx (read: trickle) of medical tourists.
In a publicly-funded system like Ontario, elective surgical procedures are not offered in an open-ended manner; they are rationed. Practically, that means that surgical suites sometimes sit idle, as do surgeons.
One can argue that, given our surgical wait lists, governments should fund more surgeries, but that's a different issue.
What institutions like the UHN and Sunnybrook are doing, given the current allocation of resources, is making rational use of their facilities and workers to generate much-needed revenue and improve care.
Surgeons get better and safer by doing more surgery – regardless of the nationality of the person on the table, and cost-efficiency comes from volume. Having idle facilities and personnel benefits no one.
We also cannot allow ourselves to view this issue in isolation.
Our not-for-profit hospitals engage in all manner of revenue-generating activities, from charging exorbitant parking fees (an issue that rankles patients and family members like few others) to doing consulting work in other countries (UHN has done $30-million in consulting in Kuwait alone), to renting commercial space to retailers like Tim Horton's and Shoppers Drug Mart, without mentioning their ubiquitous fundraising campaigns.
We have to be careful too about getting on our high horses about the idea that wealthy foreigners might come to Canada to purchase health care. It is estimated that close to 50,000 Canadians travel abroad each year – to India, to Costa Rica, to the U.S. and so on – to purchase health-care services privately.
If we're going to ban patients from coming here as medical tourists, why don't we also ban Canadians from being medical tourists?
And if we're going to vilify those who would come here from places like Saudi Arabia and India and Hong Kong to take advantage of our excellent health care, maybe we should pause to reflect about our well-ingrained practices of wooing health-care workers away from poorer countries like the Philippines, South Africa and Egypt? Is it ethical for wealthy Canada to pilfer health workers from countries where health services are inadequate?
Universality – the notion that all Canadians should get access to medically necessary care regardless of their ability to pay – is an important principle.
But insularity, this notion that health services are ours and ours alone, is short-sighted and counterproductive. And the constant refrain, that the way we do things in Canadian health care should never change, is tiresome.
A couple of Toronto hospitals went out on a limb, and – gasp! – showed a glimmer of entrepreneurship, a characteristic sorely lacking in our health system.
We should be encouraging innovation, not quashing it.
Medical tourism is not a cash cow, nor is it a panacea for our health-care funding challenges. It's at best marginal – so far, it's generated $7-million in revenue in a province where there is $80-billion in health spending annually.
We should not throw our hospital doors wide-open to medical tourists, but we should experiment and learn.
We need to regulate the practice, ensure there are ballasts so profit-making does not take precedence over providing care to all.
What we don't need is "the sky is falling" rhetoric and a ban medical tourism.
André Picard is The Globe's public health columnist.
André Picard