17, 2002 Toronto Star
Beam me up, Tony: Who will cash in on those scans?
Ontario's plan to put MRI and CAT scans out to tender may not cut waiting times as much as some may think
ON JULY 8 Ontario Health Minister Tony Clement announced that his government would be putting out tenders for 20 MRI scanners and 5 CAT scanners. Until now, the government has only funded these high-tech diagnostic instruments in public hospitals but the minister took pride in saying that these contracts could be won by commercial contractors, perhaps from the United States.
It is true that many Ontarians are waiting excessive periods to get such scans, but this new policy direction will not reduce waiting times as much as focusing on the traditional non-profit delivery and is fraught with other problems.
News reports noted that the government claimed that it would be difficult for private clinics to make do by only providing services covered under medicare, so the government plans to permit the clinics to also provide non-medicare scans. These will include those paid for by private insurance (including the Workers' Compensation Board) as well as those paid for by the patients themselves — so-called yuppie scans where perfectly healthy persons have tests looking for hidden cancers and other illnesses.
The public will be underwriting the scanners' purchase by guaranteeing at least 12 or 16 hours a day of use for medicare patients. However, the operators will then get the gravy of another 8 to 12 hours of higher-paying private scans.
This policy results in several perverse consequences. It won't reduce public wait lists as much as they might because 30 per cent-plus of the time they will be used for non-medicare patients. This will inevitably lead to two-tiered access because it will be impossible to police those getting cash scans.
Suppose a patient drops into a private clinic and requests an MRI just because she wants to know what her brain looks like. How will the operator know that the patient might actually have a potential brain tumour for which her neurologist has ordered a scan covered by medicare? And, if, as seems inevitable, the operator gets paid more for non-medicare scans, he will have a strong incentive not to ask.
A direct consequence of this policy will be that operators who choose to run their scanners 24 hours a day to relieve public waiting lists will not be able to generate the cash flow of their competitors who cash in on the private market. As a result, the bids in response to the tenders from public-spirited operators will be higher than the bids from those operators more oriented to profit.
There are also serious medical concerns about whole-body curiosity CAT scans because while they may find some cancers at an early and treatable stage, they inherently expose patients to radiation. They also inevitably find all sorts of other abnormalities, which may or not be serious. The results — costly and potentially dangerous investigations paid for by the public system. The U.S. Food and Drug Administration warns that these scans may cause more harm than good and the American College of Radiology, and other professional and scientific organizations do not recommend such screening.
While in the short-term, it may appear that the government will pay less by issuing their tenders broadly to commercial and foreign vendors, in the long run, the taxpayers will likely pay more. The Ontario government is in love with public-private partnerships where the private sector puts up the capital investment. However, just as a tenant pays his landlord's mortgage, the public sector will still pay the capital costs for the private operators. And, these capital costs will inevitably be higher because no private corporation pays as low interest rates as the Ontario government (or the government of Newfoundland and Labrador for that matter). The U.K. has a longer history of public rents of private capital. After comprehensively reviewing the National Health Service's Private Finance Initiative in 1999, the editor of the British Medical Journal, Dr. Richard Smith, concluded:
"The private finance initiative is presented as using private money to pay for the infrastructure developments needed for public services, but it is still paid for through the public purse — so it is not new money. Unfortunately, the schemes produce more problems than solutions, partly for the simple reason that private capital is always more expensive than public capital."
At the root of this issue is whether the Ontario government regards health care as a right of citizenship or a privilege to be purchased in the marketplace. If it took the former view, it would ensure all new scans were operated on a non-profit basis 24 hours per day. By not taking this position they have made their values clear. Do the rest of us agree?
Dr. Michael Rachlis is an associate professor at the department of health policy, management and evaluation at the University of Toronto.