Idea 1: Cancer screening is a good idea; releasing confidential records is not

Some health promotion and population health programs are cost efficient and effective (table 1). More than one study has concluded that, for women over 50 years of age, regular mammograms every couple of years helps in the early detection of cancerous lumps, thereby increasing the chances that treatment will be effective. This approach to health care can not only prolong many people's lives, but it can save the health system money. These "savings" then can be spent on other BC health concerns, such as improving ambulance services and access to diagnostic testing. These are reasons why the government's provincial cancer screening program is a good idea.

Cost savings aside though, the main purpose of these programs is to educate people so that they can make wise health care decisions. The premise behind the programs is that if people understood that tobacco contributes to the development of lung cancer, they would choose to not smoke. If people knew that eating junk food is bad for their health, they would choose to eat more nutritious foods. If women knew what their risk of breast cancer was, and what the benefits of early detection were, they would choose to have a mammogram every couple of years once they reached age 50.

The BC Ministry of Health forgot the most crucial point of these programs—to help people make intelligent choices. They decided to release confidential patient records—without patients' knowledge or consent—to the BC Cancer Agency so that the BCCA could direct mail the women between 50 to 74 years of age who are choosing not to have mammograms. Ministry officials no doubt believe that they are acting in the public good, but what's next? Do we really want to give up our freedom to make our own choices, good or bad?

Idea 2: Increasing patient choice is a good idea; creating another legislated monopoly is not

In the nineteenth century, governments gave medical doctors the power to define what constituted medicine and who could practice it. By granting this professional monopoly, the government has contributed to our current reliance on the "medical model," treating illness rather than promoting health.

In recent years though, more Canadians have begun to opt for alternative health care such as chiropractic or acupuncture, and the monopoly power of medical doctors has eroded somewhat. However, as people increasingly have been demanding the services of non-physician practitioners, there have been increasing demands by these providers for "official" recognition by the government (and hence, government funding). They, like the medical doctors before them, use the argument that such regulation is necessary in order to protect the public from unfit providers.

However, while "official" recognition is the preferred policy option for the group demanding it, it is not the best option for patients. It allows members of the "officially sanctioned" group to restrict entry into their occupation and, in effect, it gives each group a monopoly over a defined set of medical services, i.e., they do not have to compete with other groups to provide the designated services. As well, the members within the group no longer have to compete with each other in terms of price or the types of services they offer.

Recently the BC Ministry of Health established a College of Midwives. The newspaper headlines have read "Midwifery Gives Women a Choice" and "Demand for Midwives Rising." <The Vancouver Sun, December 29, 1997, and January 7, 1998, respectively.> However, while increasing patient choice is an excellent idea, creating another government legislated monopoly only prevents such freedom of choice in the end.

For example, before the government agreed to fund BC midwives, they charged between $1,500 and $3,000 for a course of care. By funding midwives' services at a flat rate of $2,250, patients have lost their ability to make quality comparisons between midwives on the basis of price. Obviously, a midwife who was offering a $3,000 course of treatment was offering different services than one charging only $1,500. With the new legislation, a midwife is a midwife—they are all members of the same professional organization, they will be paid a flat rate for a specified course of treatment. Midwives who are particularly good at their jobs will not get paid more. Midwives whose services are in great demand will not be able to offer more than 40 courses of care annually.

Since only people who register with the College of Midwives will be able to offer midwifery services, there is now a restricted supply of these services. This restricted supply will lead to rationing of care, since midwives are publicly funded; patients no longer have to worry about the costs, therefore, they won't. The demand for midwifery services has gone up since the legislation, not so much because they are now "official" members of the health care profession, but because their services are free to patients. It is only a matter of time before wait lists for midwives start forming. Indeed, there already are such lists for midwives in Ontario (the only province other than BC that has "officially" recognized them as a profession).

What should the BC Ministry of Health have done? How could it have truly increased all of the choices available to women, not just the number of government choices? It should have started to dismantle the system of legislated monopolies, replacing it with a system of certification. Certification provides an indication of the "attainment of certain levels of proficiency" rather than specifying certain activities which only the certified group can perform. The market for services is more competitive than that with licensure or registration because health services can be purchased legally by consumers from either a certified or a non-certified provider. Certification allows for some overlap in the services which different providers can legally offer. It increases competition between the institutions certifying providers, and between the providers themselves. And competition is what drives innovation (research and development), creates efficiency, encourages quality of services, and increases the range of consumer choices.

Idea 3: Ensuring access to health care is a good idea; a government health care monopoly is not

Although BC spends more per capita on health care than any other province, there are real concerns about access to its health care system. British Columbia now has the longest waiting times for treatment after having seen a specialist than any other province. <Cynthia Ramsay and Michael Walker, "Hospital Waiting Lists in Canada," 7th edition, Fraser Forum Critical Issues Bulletin, Vancouver, The Fraser Institute, 1997.> Instead of reforming the health care system, the government seems intent on protecting the status quo and on minimizing the importance of waiting lists as a measure of the system's failure to meet the demands on it. There are 2 pieces of evidence to this effect: 1) the way in which the Ministry has chosen to measure wait lists, and 2) the strengthening of the Medicare Protection Act.

"Official" waiting lists

Last Fall, the BC Ministry of Health finally delivered on its promise to provide the public with regular updates on waiting times for surgery, treatment, and diagnostic services provided by BC's health care system. In supposed contrast to anecdotal evidence and to the results of The Fraser Institute's national hospital waiting list survey, which indicated that waiting lists were becoming longer in BC, the Ministry determined that waiting times for elective medical procedures have not changed significantly over the last few years.

However, the Ministry chose to define waiting as "the time the procedure is formally booked until it is actually carried out." <BC Ministry of Health and Ministry Responsible for Seniors, Waiting List Report, Fall 1997, p. 2.> This means, for example, that you are not part of the Ministry's calculation if you have seen your specialist, found out that you need surgery but cannot be booked for surgery until the summer operating room (OR) schedule comes out. Since most hospitals only book OR times a few months out, this method of measuring waiting lists likely misses a large proportion of waiting patients.

In contrast, The Fraser Institute defines waiting as the time you wait after finding out that there is something wrong with your health to the time you actually receive the treatment you need from the specialist. The Fraser Institute measures the entire waiting time: from your referral to a specialist by your general practitioner, to your appointment with a specialist, to the time you receive your treatment from the specialist.

Figure 1 gives a handful of examples, using BC Ministry of Health and Fraser Institute data for 1996, of the differences in waiting time measures, depending on how you define "waiting."

Enforcing the status quo

Using its waiting list numbers, the BC Ministry of Health has determined that the BC health care system is functioning well and thus needs to be protected. Its first news release of 1998 announces the enactment of the Medicare Protection Amendment Act. This Act further entrenches the government's monopoly over health services in the province. It strengthens "the provisions that prohibit extra billing and enhance[s] the [government's] ability to recover premium payments from people who are currently receiving health care benefits and consistently not paying premiums." <BC Ministry of Health and Ministry Responsible for Seniors, "Medicare Protection Amendment Act Enacted," Media Release, January 5, 1998.>

If a British Columbian does not wish to partake in publicly provided health care benefits, he or she must sign a declaration to that effect. This would be a step towards increased patient choice if a person who chooses to opt out could then purchase private insurance. However, it is illegal for the private sector to provide any of the some 3,000 publicly funded services. Therefore, British Columbians who choose to opt out of the public health care system will not be insured. If they get sick, they are on their own—what kind of choice is this?

Conclusion

Having a good idea is not enough—a lot can go wrong from the time someone has the idea to the time that it is implemented. Efficient allocation and use of health care services will never happen if the Ministry continues to usurp the decision-making power of patients and providers. In order to effect health reforms that will truly increase patient choice and improve the overall quality and efficiency of the health care system, the Ministry is going to have to give a little. Until it does, it will be a shame watching all of its good ideas go to waste.