Rosalie Wyonch is a senior policy analyst at the C.D. Howe Institute.
The recent controversy sparked by Ontario’s announcement that it will expand the use of private surgery and diagnostic-imaging clinics has missed the point. Health care in Ontario is already much more “private” than most people know, and the province has never had a universal system that is publicly funded and publicly delivered in a truly comprehensive manner. Myths about how our health care system does (or does not) work are unhelpful when attempting to address the very real challenges that result in long delays for surgeries and doctor’s appointments.
A major point of contention is the spending of public money on procedures completed at “for-profit” clinics, which is usually a criticism levied at the province for moving certain surgeries, such as cataract removal, to private operators. But the irony is that every single independent family physician practice, for example, could be labelled a “for-profit” health clinic.
Yes, your family physician actually operates a private, for-profit business. The profits come from the fees your doctor bills to the province for delivering your primary-care needs, which in turn fund the salaries of the physician and their support staff, as well as equipment and office expenses. Without private profits, family doctors wouldn’t have incomes. Specialists performing operations in hospitals are also for-profit, private business operators – they generally aren’t employees of the hospital and get paid based on the number of procedures and treatments they provide.
Hospital capacity and wait times to access specialists were challenges before the COVID-19 pandemic, but it also exacerbated the situation. Hospitals had to redirect their limited capacities to treating COVID patients, and, as a result, many surgeries, diagnostics and routine health checks were disrupted, delayed or cancelled. Redirecting surgeries away from hospitals to private clinics reduces the demand for hospital services, and can free up resources that can be redirected to more complex cases or other procedures. In response to the Ford government’s expanded use of private surgery providers, the Ontario Hospital Association said it “welcomes the opportunity to work together with government and system partners to integrate Community Surgical Centres into Ontario’s health care system.”
Independent surgery clinics are not a new idea and are already a well-established part of our publicly funded, privately delivered health care system in Canada. Ontario plans to direct additional funds to certain private providers it already has existing relationships with for MRI and CT scans, eye surgeries and certain gynecological and plastic surgeries. Saskatchewan also has well-established non-hospital treatment facilities, with plans to expand its orthopedic surgery options in this manner as well. In British Columbia, public contracts for diagnostic imaging and surgeries across 39 private clinics have amounted to about $75-million in annual spending since 2018.
Private, for-profit surgery is also a common feature of other universal health care systems. For example, in Australia, specialists commonly split their time between private and public practices, charge patients co-payments, and can set fees higher than what the public system will reimburse. It also has private hospitals that are majority-funded by the private sector. In Denmark, specialists are either employed by public hospitals or are self-employed and work in privately owned facilities. Self-employed specialists are paid on a fee-for-service basis for public patients (similar to Canada). Likewise, in France, about 36 per cent of specialists are exclusively self-employed in offices or private clinics and paid on a fee-for-service basis.
Opponents of privately delivered surgery might argue that it takes resources away from the public system. But privately delivered surgery is already widely used in Canada, which shows that it hasn’t been the death knell of the public system. Despite constant increases in public spending on hospitals since the mid-1990s, the private sector consistently accounts for 14 per cent of hospital spending and about 30 per cent of spending at other health institutions. Shifting surgeries to private clinics is not a result of cutbacks to public health care spending or delivery, but is instead due to the inability of the public system to meet the needs of the population and its increasingly complex health care requirements.
In the midst of arguing about who pays for what and where care should be delivered, there are thousands of Ontarians waiting for surgery. At the same time, there is a continuing need to ensure adequate hospital capacity so that these facilities can manage emergencies and other types of care while having enough resources left over to handle surges of infectious disease (such as COVID-19, seasonal influenza and the recent surge of RSV).
Increasing surgical capacity without putting additional pressure on hospitals is something to be celebrated – at least if you put the needs of patients ahead of fears about a “private, for-profit” health system that is, arguably, already largely private and for-profit.