Skip to main content

What if you were handed a bill when you visited the hospital?

Stretchers are seen in the reflection of in an emergency room. Winnipeg’s health authority is investigating after two patients were sent home in taxis and died on their doorsteps in the dead of winter shortly after being discharged from hospital.

Kevin Van Paassen/The Globe and Mail

Earlier this week, David Musyj, the chief executive officer of the Windsor Regional Hospital, proposed that all patients be provided with an annual summary of the costs they have incurred in the public health system.

The idea has been around as long as medicare itself. Before that, people had real bills they had to pay, not pretend ones to ponder.

In fact, the very reason medicare was created was because so many people could not pay their bills or afford premiums for private insurance.

Story continues below advertisement

A public insurance plan – what we call medicare – spreads the risk across the entire population.

We know the cost of that: $148-billion in 2013, or $4,192 per person in public funds. (We spend another $63-billion, or $1,796 per capita, privately.)

Of course, those are averages. Not everyone's care costs the same and not everyone pays the same amount of taxes. In any given year, most people need minimal medical care but, over a lifetime, the average Canadian uses about $220,000 in publicly-funded health services.

Again, there is a wide variation: Most people don't get really sick (read: expensive) until the end-of-life. Some have a dizzying array of health challenges. In fact, a tiny percentage of the population – 5 per cent – accounts for half of all health spending.

We tend to get self-righteous about the so-called million-dollar patients, but anyone could potentially be struck by a catastrophic illness that propels them into that high-cost group. Again, this is why we have insurance, to spread risk, the share the financial pain.

But do we need to know how many or how little any given individual costs the system?

The idea is an attractive one, at least superficially.

Story continues below advertisement

Mr. Musyi argues that transparency is a good thing. True, it's a lovely principle.

But where we really need transparency is about the value of care we provide. Is the distribution of our health spending – a lot on hospitals and physicians, very little on prevention and rehabilitation – hitting the right balance? Are the procedures we do, the drugs we prescribe, and so on, effective and cost-efficient?

That's the data could really benefit from having and pondering: It could help improve the quality of care and help ensure we get more bang for the buck.

Paying for what works: There's a principle that hospital CEOs and other health care leaders should be advocating.

But mathematical calculations of the cost of individual patient care? That sort of transparency is useful in a competitive marketplace, where there are wide price variations, like the U.S.

In a monopsony, however, there is essentially no competition and therefore little price variation.

Story continues below advertisement

Beyond the curiosity factor, beyond the voyeurism, what purpose would it serve to tell people the cost of care on an individual level?

Will providing itemized bills make the health system any more efficient or cost-effective? Or will it simply add an unneeded level of bureaucracy, tinged with self-righteousness?

The idea of shadow bills, or whatever you want to call them, floats up to the surface with predictable regularity, just before provincial elections, then it tends to fade away again.

It's even been tried in a couple of different ways. Alberta conducted a pilot project in the early 1980s where patients were asked to sign off on mock bills when they went to the doctor or the hospital, to give them a sense of the cost of their care.

Later, in the late 1980s, when Alberta introduced health premiums, the province sent annual statements to show each citizen the cost of health services that were billed under their provincial health insurance number.

In both instances, the experiment was short-lived. Why? It was a huge administrative headache with no financial or political payoff. If anything, underscoring the cost of individuals' care irritated them.

Story continues below advertisement

The public is insightful enough to recognize that if you are sending them a bill or statement, the intention is ultimately to change their behavior (read: save money).

There is no evidence to support this contention that knowledge of health costs affects demand for services. In reality, consumers have little choice around the types and intensity of services they receive and no choice of lower- (or higher-) priced alternatives.

Patients may feel guilty (for no good reason) upon receiving a mock bill but they cannot be "scared straight."

If your granny slips on an icy sidewalk, falls and breaks her hip, then spends the next 21 days in the hospital, does she need an itemized bill telling her that the care she received cost $30,000?

No. She needs salt on the walk, not salt in her wounds.

The notion that there is widespread abuse and overuse because our health care is "free" is a canard. One would be hard-pressed to identify anyone who goes to the hospital for fun. It's pretty condescending to suggest so.

Story continues below advertisement

The other principal argument that Mr. Musyj made was that the technology exists to provide the information so we might as well do it.

While it's true that we have computer software that can spew out dizzying reams of data, why would we single out health costs as something that needs to be shared?

If we truly want to improve care and reduce costs we should use health technology to do things that are proven to help improve the efficiency of care and save money.

Use those fancy computers to send people reminders of their appointments; provide them with educational material on the proper use of medications; do follow-up calls after hospital discharge to see if patients are suffering side effects as a way of minimizing costly hospital re-admissions.

If you want healthier, more responsible patients, you need to educate and empower them.

You don't do that with useless financial information, you do it with useful medical information.

Story continues below advertisement

André Picard is The Globe's health columnist.

Report an error Editorial code of conduct
Due to technical reasons, we have temporarily removed commenting from our articles. We hope to have this fixed soon. Thank you for your patience. If you are looking to give feedback on our new site, please send it along to feedback@globeandmail.com. If you want to write a letter to the editor, please forward to letters@globeandmail.com.

Welcome to The Globe and Mail’s comment community. This is a space where subscribers can engage with each other and Globe staff. Non-subscribers can read and sort comments but will not be able to engage with them in any way. Click here to subscribe.

If you would like to write a letter to the editor, please forward it to letters@globeandmail.com. Readers can also interact with The Globe on Facebook and Twitter .

Welcome to The Globe and Mail’s comment community. This is a space where subscribers can engage with each other and Globe staff. Non-subscribers can read and sort comments but will not be able to engage with them in any way. Click here to subscribe.

If you would like to write a letter to the editor, please forward it to letters@globeandmail.com. Readers can also interact with The Globe on Facebook and Twitter .

Welcome to The Globe and Mail’s comment community. This is a space where subscribers can engage with each other and Globe staff.

We aim to create a safe and valuable space for discussion and debate. That means:

  • Treat others as you wish to be treated
  • Criticize ideas, not people
  • Stay on topic
  • Avoid the use of toxic and offensive language
  • Flag bad behaviour

Comments that violate our community guidelines will be removed.

Read our community guidelines here

Discussion loading ...

Cannabis pro newsletter