Private Clinics Discussion

[boodog]

user fees are not that great an idea i don't think. i agree more with a yearly payment ie. $1000/yr to cover visits.

 

see the problem with user fees is that preventative checkups people will not attend to save 5 bucks. also hmmm i've got chest pain, it'll probably go away though, that'll be the typical attitude as soon as its pay per use.

[AdamP]

user fees are not that great an idea i don't think. i agree more with a yearly payment ie. $1000/yr to cover visits.

 

see the problem with user fees is that preventative checkups people will not attend to save 5 bucks. also hmmm i've got chest pain, it'll probably go away though, that'll be the typical attitude as soon as its pay per use.

 

Obviously a reasonable argument, that being said if the fee is low enough it won't be that much of a deterrent. How many people now say, oh I have chest pain, but it's going to be a 15 min drive and a 2 hour wait to see the doc, so i'll just wait for it to go away.

 

To me the 1000 seems steep and also somewhat unfair, at least the yearly fee should be tied to earnings, why should the 6-figure bachelor and the struggling family have to pay the same flat fee, maybe a more progressive fee schedule, which then adds levels of administration, and further begs the question why not just collect the fee through a tax of everyone with a FD?

 

And really didn't we just have this in Ontario anyways, there was that what 1000 fee per family for every single Ontarian to cover health care costs.

 

Small user fees obviously no where near a perfect solution, but at least it's transparent and simple.

[A-Stark]

i disagree, i believe private clinics are actually a great idea. a lot of seniors have pension plans, insurance, etc, etc. these can easily pay $1000-3000/yr. For those that are not as wealthy, many provinces have disability allowances usually paying around 1800/month. These same people on disability usually live in subsidized housing etc, so a big chunk of their benefit is not going to rent. Why not take a little money out of thier allowance ie. $100 per month and put it towards better medical care. I think it is brilliant. Certainly it is one of the more cost-effective solutions to better health care that the government could implement.

 

What? In light of the fact that drug costs (and things like dental and vision) are NOT entirely covered publicly, it is ludicrous to suggest that a substantial number of seniors have an extra few thousand sitting around. For that matter, you suggest that those subsisting on disability assistance and/or those in social housing somehow have an extra $100 per month to spend. This is ridiculously out of touch with reality, not to mention punitive.

 

Anyway, no physician can charge a fee for access - extra-billing is illegal. Such a fee can allow for block payment of uninsured services only.

 

As for user fees and/or co-payments, let us consider their effects. If the fees are too low ($5-10, for example), they will neither have much deterrent nor provide much of a revenue source. Still, there will always be some for whom even this small cost is too high, and this group will grow ever large as the fees increase. Once you require people to make an explicit financial choice about whether to see a physician, there will always be a group who will make the "wrong" decision because they can't afford to.

 

You might respond that such fees could be means-tested, so that the worst off pay lower fees or none at all, but that will require a whole additional layer of bureaucracy that will be serve as a big external cost to the co-payment system, one that could easily make implementing it a net loss.

 

By the way, if we're getting into fees that are tied to earnings, a much better solution would be to do this through the tax system and ensure that billing schedules are improved (but the latter is already happening).

[boodog]

What? In light of the fact that drug costs (and things like dental and vision) are NOT entirely covered publicly, it is ludicrous to suggest that a substantial number of seniors have an extra few thousand sitting around. For that matter, you suggest that those subsisting on disability assistance and/or those in social housing somehow have an extra $100 per month to spend. This is ridiculously out of touch with reality, not to mention punitive.

 

Anyway, no physician can charge a fee for access - extra-billing is illegal. Such a fee can allow for block payment of uninsured services only.

 

As for user fees and/or co-payments, let us consider their effects. If the fees are too low ($5-10, for example), they will neither have much deterrent nor provide much of a revenue source. Still, there will always be some for whom even this small cost is too high, and this group will grow ever large as the fees increase. Once you require people to make an explicit financial choice about whether to see a physician, there will always be a group who will make the "wrong" decision because they can't afford to.

 

You might respond that such fees could be means-tested, so that the worst off pay lower fees or none at all, but that will require a whole additional layer of bureaucracy that will be serve as a big external cost to the co-payment system, one that could easily make implementing it a net loss.

 

By the way, if we're getting into fees that are tied to earnings, a much better solution would be to do this through the tax system and ensure that billing schedules are improved (but the latter is already happening).

 

before you call me out of touch with reality, i'd like to point out that a huge amount of people can easily do without a extra $100 dollars/month on their disability/mental health government assistance. many people on the plan use their money unwisely, ie. buying cigarettes, alcohol, etc.

 

have you ever dealt with people receiving assistance? actually rather than ask, it is obvious that you haven't

[A-Stark]

before you call me out of touch with reality, i'd like to point out that a huge amount of people can easily do without a extra $100 dollars/month on their disability/mental health government assistance. many people on the plan use their money unwisely, ie. buying cigarettes, alcohol, etc.

 

have you ever dealt with people receiving assistance? actually rather than ask, it is obvious that you haven't

 

Oh, I see, those poor addled people on social assistance are simply irresponsible with their money, so obviously they can pay more. The very notion that they'd have vices like most everyone else, or that they'd be particularly prone to be smokers and/or drink more - none of that matters, since this vulnerable population ought to pay more.

[future_doc]

People who receive government assistance need to make responsible choices financially like everybody else, and are capable of doing so.

[A-Stark]

People who receive government assistance need to make responsible choices financially like everybody else, and are capable of doing so.

 

Yes. They also have the right to make irresponsible choices from time to time; the fact that they are receiving social assistance does not change that. That I'm travelling in Euroland at the moment does not mean I become less entitled to student assistance.

[leviathan]

Yes. They also have the right to make irresponsible choices from time to time; the fact that they are receiving social assistance does not change that. That I'm travelling in Euroland at the moment does not mean I become less entitled to student assistance.

 

P101ing while you're in Europe? That is dedication my friend.

[A-Stark]

P101ing while you're in Europe? That is dedication my friend.

 

Or I'm just staying in a sketchy area and didn't want to venture out by myself.

 

(I've also been here five weeks.)

[tooty]

Yes. They also have the right to make irresponsible choices from time to time; the fact that they are receiving social assistance does not change that. That I'm travelling in Euroland at the moment does not mean I become less entitled to student assistance.

 

i completely disagree with this and think it's absolutely absurd. The less capable you are of generating income, the more responsible you should be with the charity money given to you. Social assistance should provide for basic needs for people who cannot otherwise afford them. If these less fortunate put their cigarette addictions ahead of food/shelter/health expenses, then it is their own fault for making these choices, not the public. So, why should we pay for that? Sure, they can cave from time-to-time and spend money on smokes and alcohol, they'll then have less for other things. But to go as far as to dedicate resources to irresponsible choices is bat**** insane.

 

And wow to you claiming that you have the right to get student assistance because you spent all your money on a fun trip to europe. You might as well say we all have the right to get eurotrip assistance. where do I sign up for that program? Hell, I'm gonna put all my money down to buy a used lambo. how about I get a little extra assistance for med school from the government because of it? after all, it's my right, as you say.

 

to tie this back to our focus, i totally think that these people can afford to copay for healthcare if they cutback on their smokes and alcohol. so they're poor and can't afford _everything_ they want. at least we the public is helping them with basic necessities. beyond that (ie smokes/alcs/blow/hos), it's up to them to EARN it like the rest of us.

[A-Stark]

i completely disagree with this and think it's absolutely absurd. The less capable you are of generating income, the more responsible you should be with the charity money given to you. Social assistance should provide for basic needs for people who cannot otherwise afford them. If these less fortunate put their cigarette addictions ahead of food/shelter/health expenses, then it is their own fault for making these choices, not the public. So, why should we pay for that? Sure, they can cave from time-to-time and spend money on smokes and alcohol, they'll then have less for other things. But to go as far as to dedicate resources to irresponsible choices is bat**** insane.

 

Yes, you should be responsible. No, it is not our job to police the activities of individuals receiving social assistance. If someone meets the criteria for receiving such assistance, they are thus entitled to it without a bunch of self-appointed moralistic types attempting to restrict their behaviour. You don't get to dictate individual behaviour because said individual qualifies for assistance. To take another example, if a smoker loses his job and begins to collect EI, no one has any right to tell him to stop smoking or else pay some kind of penalty. That would be the prudent course, certainly, but respect for basic individual autonomy requires that he be allowed to make bad choices that, ultimately, have nothing to do with why he is receiving assistance.

 

And wow to you claiming that you have the right to get student assistance because you spent all your money on a fun trip to europe. You might as well say we all have the right to get eurotrip assistance. where do I sign up for that program? Hell, I'm gonna put all my money down to buy a used lambo. how about I get a little extra assistance for med school from the government because of it? after all, it's my right, as you say.

 

Actually, I have been doing an anesthesia elective and, yes, travelling around a bit. My student loan for the coming year will of course not pay for any of this (that's what the LOC is for), but whether I qualify for it - and the specific amount I qualify for - will not change. The more prudent thing to do would have been to work at home for the summer, doing something researchy. However, it is not for you or anyone else to tell me how to live my life, and you can take your self-righteous judgements elsewhere.

 

to tie this back to our focus, i totally think that these people can afford to copay for healthcare if they cutback on their smokes and alcohol. so they're poor and can't afford _everything_ they want. at least we the public is helping them with basic necessities. beyond that (ie smokes/alcs/blow/hos), it's up to them to EARN it like the rest of us.

 

So who the **** are you talking about now? People on disability assistance, right? They may for a variety of reasons not be able to work. What are they supposed to do? And even aside from that, it's not your role to decide for them whether they have the resources to afford copayments. Sure, many people can, but picking out poor people as being able to pay if only they gave up their immoral and luxurious vices is nothing short of punitive.

[tooty]

To take another example, if a smoker loses his job and begins to collect EI, no one has any right to tell him to stop smoking or else pay some kind of penalty. That would be the prudent course, certainly, but respect for basic individual autonomy requires that he be allowed to make bad choices that, ultimately, have nothing to do with why he is receiving assistance.

 

Sure, whether or not he receives assistance should not depend on his addiction to smoking, but we shouldn't increase the amount of assistance to accommodate for his habits outside of basic necessities.

 

if, based on research, person A needs X amount of money to survive, that X amount of money should not change if person A has M amount of habits. This means that if we can show that they're spending $10 every 2 days on a pack of smokes, they can sure as hell give that up to contribute to an ailing healthcare system.

 

So who the **** are you talking about now? People on disability assistance, right? They may for a variety of reasons not be able to work. What are they supposed to do? And even aside from that, it's not your role to decide for them whether they have the resources to afford copayments. Sure, many people can, but picking out poor people as being able to pay if only they gave up their immoral and luxurious vices is nothing short of punitive.

 

No, it's not my role to tell them what to do. However, if, let's say, a co-payment system would work but we're not implementing it because it will impinge upon the poor's 'right' to buy smokes, I think that's wrong because the public then is forced to adopt an inferior system so that poor people can spend afford to buy unnecessary things.

[medordie]

No, it's not my role to tell them what to do. However, if, let's say, a co-payment system would work but we're not implementing it because it will impinge upon the poor's 'right' to buy smokes, I think that's wrong because the public then is forced to adopt an inferior system so that poor people can spend afford to buy unnecessary things.

 

But how is co-payment going to result in a superior system? I certainly would not be willing to pay my family physician for the current level of care I am receiving, and neither will the majority of Canadians, whether on social assistance or not.

 

The suggestion made in the CMAJ letter posted by Mourning Cloak was that the FP would charge his roster of 2000 patients $250 each and provide them with multidisciplinary care, teaching and health promotion similar to Copeman Clinic, somehow without billing the provincial health system.

 

How would a doc have time for all that with 2000 patients? I can't imagine he would in reality be able to provide more than the status quo 5-10 minutes, 1 or 2 complaint visit. Access to health care will not be improved.

 

And for those talking about $100/month, that is a LOT of money for the majority of people in this country. Even on a resident's salary of around 50k which is above the national average, after taxes, student loans, savings, housing, you yourself would be hard pressed to come up with that.

[tooty]

But how is co-payment going to result in a superior system? I certainly would not be willing to pay my family physician for the current level of care I am receiving, and neither will the majority of Canadians, whether on social assistance or not.

 

whether you're willing to pay is not the question. we do not have enough family doctors. what will attract more family doctors is more money. what i believe is true is this:

 

everyone forced to pay a little --> each family doctor would earn more + lessen burden on government --> attract more family doctors in the future --> improving quality of care

 

and i was speaking about the co-payment system being superior in a hypothetical situation in support of another argument.

 

edit: oh and

 

for you nay-sayers about 2-tier/co-pay/privatization etc, instead of pointing out problems with change (which is easy to do), how about proposing some changes yourself?

[medordie]

I disagree and think that whether or not Canadians are willing to pay is important. What political party would want to put this forward and face a huge backlash, all in order to put more money in doctors pockets? Check out any medical story on the globe or cbc online and see what the public perception is right now of doctors and I think you will see that forcing Canadians to pay more for primary care when ? amount of their tax dollars already goes to health care will not fly.

 

Ontario is already implementing 'Nurse-Practitioner led' clinics and I keep hearing that studies have shown that NPs can do about 90% of what a physician can with shorter training and for less money that a doc would demand for the same thing. Keeping this in mind, I can't see government forcing the public to pay a copayment for the benefit of family physicians, especially when there are now other options available.

[Jochi1543]

What is stopping homeless people in any city from gaining access to medical treatment? There are many docs who target their work specifically for this population. They might have a difficult time finding a family doc, but there is nothing stopping them from walking into a walk-in clinic, urgent care centre or emerg. Is there more that can be done for this population...perhaps. But it is a population that is generally not high-functioning, that don`t always make good choices. These poor choices include finally coming to the ER for treatment, and leaving AMA before tests can be done, or sometimes even after tests have been done but before you even have a chance to look at that CT scan etc. The "system" can`t be blamed for those poor choices.

 

I agree. A while ago I was pulled aside to check on a homeless guy seizing on the sidewalk in DT Calgary (I had my EMS jacket on, and a passerby spotted me). Once he came to, I asked if he's had seizures before, etc. He said yes, several times a day. I asked if he's ever been seen by a Dr or paramedic, he said no. I had already called 911 before that, and an ambulance was already en route, but he vemently refused to wait 5 minutes to go and get his FREE ambulance ride to the hospital where he'd be assessed for FREE, as well (and possibly even admitted for a nice meal, a warm bed, etc).

 

One day he's gonna have a seizure while crossing the street and get run over, I'm sure. You can't MAKE someone take care of themselves, even if every opportunity in the world to do so is handed right to them.

[Jochi1543]

Sorry, mea cupla, I had thought there was a problem of finding physicians in rural commiunities. I don't think you are the representative typical patient in a rural community.

 

 

I work(ed ) in a rural community as well, while living in Calgary, and guess where I couldn't find a doc - I went to 7 clinics in Calgary, all to no avail. In the meantime, our doc at work could always squeeze me in the same day, and it was only a 30-min drive to see another doc (takes you a good 15 minutes to get somewhere in any big city, as well). The rural area here is quite well-covered, albeit every doc I've run into is an IMG.

[Jochi1543]

before you call me out of touch with reality, i'd like to point out that a huge amount of people can easily do without a extra $100 dollars/month on their disability/mental health government assistance. many people on the plan use their money unwisely, ie. buying cigarettes, alcohol, etc.

 

have you ever dealt with people receiving assistance? actually rather than ask, it is obvious that you haven't

 

Well, what the hell do you expect a schizophrenic living in a box to spend his money on, Lil Wayne CDs and double-doubles?

[tooty]

I disagree and think that whether or not Canadians are willing to pay is important. What political party would want to put this forward and face a huge backlash, all in order to put more money in doctors pockets? Check out any medical story on the globe or cbc online and see what the public perception is right now of doctors and I think you will see that forcing Canadians to pay more for primary care when ? amount of their tax dollars already goes to health care will not fly.

 

okay that's valid. i just wasn't focusing on the implementation aspect.

 

Ontario is already implementing 'Nurse-Practitioner led' clinics and I keep hearing that studies have shown that NPs can do about 90% of what a physician can with shorter training and for less money that a doc would demand for the same thing. Keeping this in mind, I can't see government forcing the public to pay a copayment for the benefit of family physicians, especially when there are now other options available.

 

cool. i like.

[fourtytwo]

This whole discussion is kind of absurd in the face of what's going on in the States right now. They tried the capitalist model and it failed. People were unable to pay their medicals bills on their own, and insurance/HMOs were insufficient. It led to fiscal bloat and poorer outcomes. I can't imagine why you would think it would be different here.

 

When you ask someone to balance being a physician and an entrepreneur, they have to choose to put more weight on the entrepreneur side because that's what allows them to be a physician. That is, if they fail as an entrepreneur, they necessarily fail as a physician as well -- even if they are the best clinician in the world. Better to let MDs be MDs.

 

for you nay-sayers about 2-tier/co-pay/privatization etc, instead of pointing out problems with change (which is easy to do), how about proposing some changes yourself?

 

Just because we don't have a better idea, doesn't mean yours isn't terrible. And it certainly doesn't mean yours should be instituted just because its there.

 

But since you asked: open up more medical schools. Even if the ratio of FP : all other MDs stays the same, if we increase the absolute number of MDs, we de facto increase the number of FPs. I don't have any hard numbers, but even if there are only 3 worthy applicants for every spot in Canadian medical school, by allowing all 3 of those applicants admission somewhere, we triple the number of FPs.

 

To deal with residency storages, have rotating international residencies. Students rotate through several international hospitals/placements -- American, Australian, Middle Eastern, whatever -- so that the number of residents in Canada at any given time stays the same or increases slightly, but every medical graduate is receiving training. So, for example, let's say the Mac FP program current accepts 10 students. We increase that number to 30, and at any given time, 10 or 15 of those students are in Canada, and the rest are in a different country. Every student spends the same amount of time in Canada & overseas. Now we have a class of 30 students using the same or slightly more resources in-country as a class of 10 students. Students bring back knowledge and skills from other countries (and bring Canadian knowledge and skills to those countries) and can synthesize that with a standard Canadian curriculum.

 

After residency, these new MDs are free to open practises wherever they want in Canada, and (for FPs) are paid based on the demographics and size of their patient list -- elderly and infants pay more because they're more time-consuming, 5 - 65 pays a moderate rate with a chronic disease management multiplier.

 

Going to a private model is a mistake. It will lead to less access and more emphasis on high-paying procedures as opposed to good evidence-based medicine.

[future_doc]

and (for FPs) are paid based on the demographics and size of their patient list

 

I think this is the situation in the UK, at least regarding the size of the patient list.

[piratefan]

the ambulance is free in alberta? (not so in ontario...)

[tooty]

This whole discussion is kind of absurd in the face of what's going on in the States right now. They tried the capitalist model and it failed. People were unable to pay their medicals bills on their own, and insurance/HMOs were insufficient. It led to fiscal bloat and poorer outcomes. I can't imagine why you would think it would be different here.

 

When you ask someone to balance being a physician and an entrepreneur, they have to choose to put more weight on the entrepreneur side because that's what allows them to be a physician. That is, if they fail as an entrepreneur, they necessarily fail as a physician as well -- even if they are the best clinician in the world. Better to let MDs be MDs.

 

 

 

Just because we don't have a better idea, doesn't mean yours isn't terrible. And it certainly doesn't mean yours should be instituted just because its there.

 

But since you asked: open up more medical schools. Even if the ratio of FP : all other MDs stays the same, if we increase the absolute number of MDs, we de facto increase the number of FPs. I don't have any hard numbers, but even if there are only 3 worthy applicants for every spot in Canadian medical school, by allowing all 3 of those applicants admission somewhere, we triple the number of FPs.

 

To deal with residency storages, have rotating international residencies. Students rotate through several international hospitals/placements -- American, Australian, Middle Eastern, whatever -- so that the number of residents in Canada at any given time stays the same or increases slightly, but every medical graduate is receiving training. So, for example, let's say the Mac FP program current accepts 10 students. We increase that number to 30, and at any given time, 10 or 15 of those students are in Canada, and the rest are in a different country. Every student spends the same amount of time in Canada & overseas. Now we have a class of 30 students using the same or slightly more resources in-country as a class of 10 students. Students bring back knowledge and skills from other countries (and bring Canadian knowledge and skills to those countries) and can synthesize that with a standard Canadian curriculum.

 

After residency, these new MDs are free to open practises wherever they want in Canada, and (for FPs) are paid based on the demographics and size of their patient list -- elderly and infants pay more because they're more time-consuming, 5 - 65 pays a moderate rate with a chronic disease management multiplier.

 

Going to a private model is a mistake. It will lead to less access and more emphasis on high-paying procedures as opposed to good evidence-based medicine.

 

who says we should model after the states?

 

and yes, opening up more medical schools would be awesome. while you're at it, you should grow some $100 bills on trees to pay for those medical schools and the doctors they generate.

 

"Going to a private model is a mistake."

 

^^ put "I think" in front of that and you'd be correct.

[tooty]

On France's System:

 

About seventy five percent of the total health expenditures are covered by the public health insurance system. A part of the balance is paid directly by the patients and the other part by private health insurance companies that are hired individually or in group (assurance complémentaire or mutuelle, complementary insurance or mutual fund).

 

...

 

Hospitals in France

There are two general categories:

 

* The public sector, which accounts for 65% of hospital beds. Public hospitals are responsible for supplying ongoing care, teaching and training.

 

* Private hospitals are profit oriented. They concentrate on surgical procedures and depend on their fee-for-service for funding.

 

There is no significant difference in the quality of care between public and private hospitals.

 

Health professionals and physicians usually work in both public hospitals and private practices. About 36 percent of physicians work in public hospitals or establishments. They are in essence public servants, and the amount they are paid is determined by the government. However, 56 percent of physicians work in private practices because of the difficult working conditions in hospitals.

 

Source

 

This is what I want to see incorporated in Canada. The whole time I was advocating a mix of public and private, not to go to either extremes. Re-read my 2nd post in this thread, fourtytwo.

[future_doc]

A person with addiction to substance x is given y sum of money. They use it to buy substance x. Of course money is not infinite, and it is rationed amongst those in need. Should we not consider that for that individual to spend it on substance x is impinging on another individual's freedom who could have used that y sum of money on something more beneficial to them and society?

 

Well, theoretically although you may have a good point, the problem is in the practical - administratively, it would be impossible to know and impossible to enforce, unless the administration would grow enormously and this growth would be at the expense of those spending properly. In other words, it would cost significantly more than $y to save $y so society would not be further ahead; in fact, if the budget remained the same, the net effect would be to reduce the overall payments to those requiring social assistance.