本文发表在 rolia.net 枫下论坛The hidden costs of private clinics
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Mar 30, 2007 04:30 AM
Danielle Martin
At face value, the private for-profit Don Mills surgical centre seems like a great way to offer needed surgery to Ontarians at low cost to the public purse, doing 1,500 more knee replacements while saving the taxpayer $1.6 million.
With long wait times for orthopedic surgery in Ontario and a commitment that patients would not have to pay out of pocket, who could find fault with that?
Of course, nothing is ever as simple as it seems – especially when it comes to Canadian health care.
The Don Mills centre proposed to do knee replacements entirely funded by the public system 15 per cent cheaper than what hospitals are paid to do the same procedure.
This approach looks good, in part because it does not violate the most basic principle of medicare, which is that patients should not pay out of pocket for medically necessary services.
No private, for-profit corporation would ever come up with a business model that loses money for its shareholders.
So when evaluating proposals, we need to look to be sure there isn't a catch.
The catch is this: The average patient at Don Mills is 30 per cent less complex to treat than the average hospital patient.
This means our most vulnerable patients waiting for hip and knee replacements, including the frail elderly, would likely not make the cut.
This is just one of the ways for-profit corporations can ensure a higher profit margin.
As health economist Raisa Deber said in her Romanow discussion paper on private, for-profit delivery, in some cases better management or high volumes can bring the cost of care provision down without sacrificing quality of care.
However, she noted that savings often result from the sacrifice of some intangible measures of quality, and, perhaps most important, risk selection, or "cream skimming," of patients.
Cream-skimming is the means by which many private clinics and hospitals protect their profit margins.
By selecting only healthy patients with few or no other medical problems, they can ensure that the level of care needed by these patients is less than the average –and therefore provide the service at a lower cost.
The savings can indeed allow a surgical centre to charge the public system less for a procedure. But that's not the only place where the savings go. The rest go to shareholder profit, rather than back into the health-care system as they do in a hospital setting.
It's the overall mix of more, and less complex, patients that allows most institutions to provide care at a particular average cost per case.
If we allow private, for-profit centres to siphon off the less expensive cases, inevitably the average acuity of the cases in our hospitals increases. Is this really a good idea?
How will hospitals be able to balance out the cost of those more complex cases if clinics like Don Mills are caring for all the "less expensive" patients?
As for medical research and education of health-care workers – integral parts of our health-care system that tend to cost money – private, for-profit centres are much less likely to engage in it.
Within the publicly funded model, there is and has always been a major role for some forms of private delivery, in particular, private physician offices, group practices, private, not-for-profit hospitals, and other common models of care.
However, there is little Canadian experience on the issue of private, for-profit (corporate) delivery, particularly with respect to investor-owned, shareholder-driven models.
Evidence from other countries points to concerns about equity, cost, quality, transparency and accountability in shifting to for-profit, investor-owned delivery.
There is a common misconception that competition and investor-owned private delivery will necessarily lead to higher quality and lower prices.
However, health care is not widget-making, and the issues that drive quality and profit in the world of health care are not as simple as we might wish.
Nobody wants to see Ontarians suffering on wait lists, but we need to be careful about how we address the issues.
It may be that in some areas of medicare for-profit delivery providers can innovate to bring costs down while maintaining quality.
But if the ripple effect on the hospital system results in a more costly caseload for everybody else, our government is right to approach with caution.
The most promising ongoing projects to reduce wait times seem to be the ones that take into account the whole continuum of patient care, from initial referral to the orthopedist/specialist to post-operative rehabilitation.
The public system is already gaining efficiency by treating low-risk patients in new public day-surgery centres that will not bleed money into the private sector.
At the end of the day, the patient, not the political ideology, is what should drive health-care reform.
We need to be sure that in our haste to reduce wait times for some patients we don't get tricked into simple equations that fail to see the ripple effect on the rest of medicare.
--------------------------------------------------------------------------------更多精彩文章及讨论，请光临枫下论坛 rolia.net
Email story
Choose text size
Report typo or correction Tag and save
Mar 30, 2007 04:30 AM
Danielle Martin
At face value, the private for-profit Don Mills surgical centre seems like a great way to offer needed surgery to Ontarians at low cost to the public purse, doing 1,500 more knee replacements while saving the taxpayer $1.6 million.
With long wait times for orthopedic surgery in Ontario and a commitment that patients would not have to pay out of pocket, who could find fault with that?
Of course, nothing is ever as simple as it seems – especially when it comes to Canadian health care.
The Don Mills centre proposed to do knee replacements entirely funded by the public system 15 per cent cheaper than what hospitals are paid to do the same procedure.
This approach looks good, in part because it does not violate the most basic principle of medicare, which is that patients should not pay out of pocket for medically necessary services.
No private, for-profit corporation would ever come up with a business model that loses money for its shareholders.
So when evaluating proposals, we need to look to be sure there isn't a catch.
The catch is this: The average patient at Don Mills is 30 per cent less complex to treat than the average hospital patient.
This means our most vulnerable patients waiting for hip and knee replacements, including the frail elderly, would likely not make the cut.
This is just one of the ways for-profit corporations can ensure a higher profit margin.
As health economist Raisa Deber said in her Romanow discussion paper on private, for-profit delivery, in some cases better management or high volumes can bring the cost of care provision down without sacrificing quality of care.
However, she noted that savings often result from the sacrifice of some intangible measures of quality, and, perhaps most important, risk selection, or "cream skimming," of patients.
Cream-skimming is the means by which many private clinics and hospitals protect their profit margins.
By selecting only healthy patients with few or no other medical problems, they can ensure that the level of care needed by these patients is less than the average –and therefore provide the service at a lower cost.
The savings can indeed allow a surgical centre to charge the public system less for a procedure. But that's not the only place where the savings go. The rest go to shareholder profit, rather than back into the health-care system as they do in a hospital setting.
It's the overall mix of more, and less complex, patients that allows most institutions to provide care at a particular average cost per case.
If we allow private, for-profit centres to siphon off the less expensive cases, inevitably the average acuity of the cases in our hospitals increases. Is this really a good idea?
How will hospitals be able to balance out the cost of those more complex cases if clinics like Don Mills are caring for all the "less expensive" patients?
As for medical research and education of health-care workers – integral parts of our health-care system that tend to cost money – private, for-profit centres are much less likely to engage in it.
Within the publicly funded model, there is and has always been a major role for some forms of private delivery, in particular, private physician offices, group practices, private, not-for-profit hospitals, and other common models of care.
However, there is little Canadian experience on the issue of private, for-profit (corporate) delivery, particularly with respect to investor-owned, shareholder-driven models.
Evidence from other countries points to concerns about equity, cost, quality, transparency and accountability in shifting to for-profit, investor-owned delivery.
There is a common misconception that competition and investor-owned private delivery will necessarily lead to higher quality and lower prices.
However, health care is not widget-making, and the issues that drive quality and profit in the world of health care are not as simple as we might wish.
Nobody wants to see Ontarians suffering on wait lists, but we need to be careful about how we address the issues.
It may be that in some areas of medicare for-profit delivery providers can innovate to bring costs down while maintaining quality.
But if the ripple effect on the hospital system results in a more costly caseload for everybody else, our government is right to approach with caution.
The most promising ongoing projects to reduce wait times seem to be the ones that take into account the whole continuum of patient care, from initial referral to the orthopedist/specialist to post-operative rehabilitation.
The public system is already gaining efficiency by treating low-risk patients in new public day-surgery centres that will not bleed money into the private sector.
At the end of the day, the patient, not the political ideology, is what should drive health-care reform.
We need to be sure that in our haste to reduce wait times for some patients we don't get tricked into simple equations that fail to see the ripple effect on the rest of medicare.
--------------------------------------------------------------------------------更多精彩文章及讨论，请光临枫下论坛 rolia.net