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Should doctors be able to do private work on the side?

Ottawa overstepped its bounds when it clawed back health-care coverage for refugee claimants without consulting the provinces and other stakeholders, doctors and lawyers charged Tuesday.

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Earlier this week, the Calgary Herald published a fascinating story about a retired nurse who travelled to the Turks and Caicos to get a knee replacement.

By doing so, she waited two weeks for surgery instead of lingering on a wait list, in pain, for seven months back home. She also spent an eye-popping $40,000.

The twist on this medical tourism story is that her Calgary orthopedic surgeon actually did the operation on the tropical island, ensuring that her care was as good as back home, if not better.

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Dr. Jim MacKenzie moonlights at the private hospital in the Turks and Caicos because, he said, there is too little operating time in Canada's publicly-funded system and he can provide relief to some of his patients. (The deep-pocketed ones presumably.)

This is the kind of story that sets the hearts of Canadian policy wonks aflutter.

Imagine someone actually jumping the queue, and with a doctor's help, no less. Shock, horror.

Needless to say, this was cited as definitive proof that the medicare system is on the verge of collapse and the only solution is a) a massive influx of money for more doctors/surgeries/beds/etc. or b) throwing the doors wide open to private medicine or c) we have to outlaw this kind of thing.

In Canada, we tend to get a bit too worked up about the outlier stories, of which this is a classic example.

A doctor and patient from Calgary both travel to the Turks and Caicos at great expense so a routine knee surgery can take place; money is exchanged abroad because it is illegal to do so domestically. The absurdity of the situation is palpable and the notion that it will become commonplace is laughable.

Still, there are some lessons to be taken.

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The case underscores two eternal challenges: 1) wait times remain the Achilles heel of Canadian health care and; 2) we have yet to figure out the place of private health care.

Waits are largely an engineering problem, an organizational challenge. We have to stop repeating the tiresome mantra that we just need to do more more more of what we're doing now.

The classic quote of Henry Ford springs to mind: "If I had asked people what they wanted, they would have said faster horses."

To reduce wait times, we need to actually do things differently. That was demonstrated eloquently by the Alberta Hip and Knee Replacement Project, a pilot project that dramatically reduced wait times but has never been fully scaled up.

That would be a more productive discussion than whether Canadian doctors and patients should be able to do business – outside our borders or otherwise.

We have a mix of private and publicly funded medical care in Canada, but we haven't got the mix quite right. Under medicare, 100 per cent of physician and hospital services are publicly funded.

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There are a series of regulatory barriers that essentially make it impossible for a private market to develop: It is illegal to purchase private insurance to cover "medically necessary" in most provinces and physicians cannot practise simultaneously in the private and public system, they have to opt out of medicare entirely (though some provinces don't even allow that option).

These measures are justifiable but they are also debatable.

After all, private payment is not only legal, it is the norm in other parts of the health system. There is almost no publicly funded dental care in Canada, and the majority of home care, nursing home care and drugs are paid for privately.

Is all hospital and physician care medically necessary? Are prescription drugs and home care not just as essential? Why can dentists or radiologists sell their services to the public but orthopedic surgeons or oncologists can't? Why can nursing homes charge for care but hospitals can't?

Ensuring universal access to medically necessary care should be the goal, especially since we're not doing a very good job of meeting those standards now.

We have to rethink the arbitrariness of our public-private mix. We need to discuss and debate what public health insurance covers and what it doesn't cover, and why.

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Ideally, we should move toward a European model, where a broad range of health services are funded through public insurance, but all health services are also supplemented with private insurance.

In Canada, some medicare purists consider this to be heresy, that it will lead to a "two-tiered" system, where the wealthy can buy quicker and better care.

But the reality is that situation already exists.

People are free to go elsewhere for care, and some do. The Fraser Institute estimates that 41,938 Canadians sought medical care outside the country in 2013, or about 1 per cent of patients. While the methodology of that calculation (a poll of specialists) is dubious, the number (whatever it is) is not insignificant.

There is also a growing inter-provincial market. A fair number of patients travel to private clinics in B.C. and Quebec and pay for care they could get "free" in their home provinces.

That doesn't necessarily mean patients are 'fleeing socialist medicine,' as some contend. There are a host of reasons to become a medical tourist: convenience, speed, secrecy, more options, quality, language, being close to family, and so on.

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Not many people are going to fork over $40,000 to speed up their access to care, nor should they have to.

But the growing mobility of patients and their willingness to spend for choice and convenience should serve as a message to policy-makers that we're ready to have this discussion. There are also cases before the courts that will accelerate the debate, but policy-makers should be proactive, not sit back and wait for legal rulings.

It's not about abandoning medicare, or our values. It's about adapting to the needs/demands of Canadians by bringing our system more into line with what exists elsewhere in the world, and acknowledging the reality of a more global health market.

After all, no health system is an island.

André Picard is The Globe's health columnist.

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