Quebec backs off health user fees, but the cost challenge remains - Macleans.ca
 

Quebec backs off health user fees, but the cost challenge remains


 

News that Quebec has retreated from its daring proposal to impose a user fee for visits to the doctor is bound to be greeted by advocates of market-oriented health reforms as a dispiriting setback, and as a victory by defenders of universal insurance that doesn’t impose direct costs on patients.

The proposal last spring in Quebec Finance Minister Raymond Bachand  budget struck us here at Maclean’s as big enough news that we used it as an entry point for a wider look at how mounting health costs, driven largely by an aging population, must inevitably force provincial governments to seek solutions.

But it was far from clear that user fees were the best option. Anne Doig, the Saskatoon family physician who was then president of the Canadian Medical Association, warned that fees would discourage visits to doctors—ultimately leading to higher costs for delayed treatment.

There’s considerable research to back up that position. A key study published in the American Economic Review in 1987 found, not surprisingly, that user fees prompted patients on low incomes cut their use of medical services the most. So proponents of the fees have to ask themselves: Are the poor really more prone to making wasteful, unnecessary visits to doctors than the well-off?

In fact, it’s not so easy for anyone to clog up the system unnecessarily, a point made by the Canadian Health Services Research Foundation here. Beyond that initial visit to a family doctor, clinic or ER, a Canadian patient needs a doctor’s approval for specialist visits, prescription drugs and devices—and those are without question the real drivers of rising health costs.

As well, the very real cost of discouraging proper care by imposing a financial penalty for seeking follow-up treatment has emerged as a major concern in the United States. As the New York Times has reported: “Avoidable readmissions are the costliest mistakes for the government and the taxpayer, and readmissions within thirty days of discharge now occur for one in five patients, gobbling $17.4 billion of Medicare’s current $102.6 billion budget.”

One obvious reason U.S. patients might not get proper follow-up care soon after, say, a heart attack is that they’re worried about having to pay at least part of the cost. The Times story talks of progressive hospitals having to arrange emergency insurance for patients before they can safely be allowed to go home.  The U.S. government’s Agency for Healthcare Research and Quality recently reported that American patients who have private insurance were the least likely to require multiple hospital readmissions or make multiple visits to the emergency department.

Of course, in Canada what sort of insurance one has isn’t a factor. Dr. Jack Tu, senior scientist at Toronto’s Institute for Clinical Evaluative Sciences, says there’s surprisingly little difference in outcomes for heart patients between Canada and the U.S., but Canada does somewhat better when it comes to patients having to be readmitted to hospital after being discharged following treatment for heart failure.

In the U.S., about a quarter end up back in hospital within a month; in Canada, it’s about one-fifth. Tu suspects pressure to keep hospital bills down means U.S. patients are more likely to be discharged a bit too soon. “In Canada, hospitals are on a global budget,” he observed. “We don’t have insurance companies bugging doctors to send people home quickly.”

So making cost a pressing factor for both patients and hospitals seems to lead to perverse, expensive results. Does all this mean that Canada’s universal health-care purists are entirely right and market-oriented reformers are completely wrong? I don’t think so. It just means reforms should aim to inject a market-like, competitive sensibility into the system in other ways—imposing a crude out-of-pocket cost just doesn’t seem to be the right strategy.

A more promising approach might be to maintain true universal insurance, without co-payments, but still require hospitals and clinics to compete for patients.

Wendy Thomson, director of the School of Social Work at McGill University in Montreal, who was chief adviser on public service reform to former British prime minister Tony Blair when he was driving health reform, suggests that Canadian health ministries look at how British patients have been given the ability to shop around for care on websites that rate hospitals and clinics.

The idea is to use the Internet to tell patients what they need to know to find the fastest, best solutions available for their health problems. Many provinces have already, in their drives to reduce wait times, put at least some facts and figures of this sort on-line over the past few years. Expand and improve those sources of information, do everything possible to encourage patients to actively choose where they go for their care, and make sure the insurance money follows the patient—that formula has got to be at least part of the solution.

Quebec’s retreat from user fees is probably a wise move, not just because it was unpopular, but also because it probably wouldn’t have worked out the way Bachand hoped. But the instinct behind his gamble—the urgent sense that reforms must happen—has got to be right. The trick now is to seek more sophisticated ways to accomplish the same goal.


 

Quebec backs off health user fees, but the cost challenge remains

  1. It'd probably be a good thing to impose a fee, considering that a lot of visits are just from people that have a cold or some other placebo-fixable problem.

    • This is my initial thought too. Interesting the article says there is evidence that low-income people will avoid going if user fees are in place. Therefore, two proposed solutions: 1) lower the user fee for everyone. 2) Refund or waive the fee for low-income earners.

      The second option is really no different than what we do with G/HST rebates.

      • Wow, someone thinking almost the exact same thing as me.

        I'd like to tweak your proposal slightly, in that fees would be refunded if the need for the visit/access to the service was necessary. Gets rid of people calling an ambulance instead of a taxi when they have a headcold, or those with nothing to do and nowhere to go making weekly doctor appointments. Well, unless they are rich enough that they don't mind paying the small user fee that is. I guess the rich could still waste resources.

        • I like this idea. The only problem is that I can see the refunds being abused. There will be immense pressure on the doctors to issue refunds.

          There will be cases where the patient is indeed sick, but the doctor cannot determine the cause and declares it a cold, and doesn't issue a refund, and the patient is readmitted later when it turns out it's a serious issue.

          In some cases doctors will issue refunds for the flimsiest of reasons (patient came in with flu-like symptoms, but while he was there I took a look at his ingrown toe-nail).

          There will be cases where it will be difficult to categorize whether something was an emergency or not (patient thought heart attack warning symptoms, was really heartburn, but refund issued because the difference difficult to tell).

          It will really be too complicated, and I expect in the end almost everyone will get refunds.

          So I don't think it can work.

          • Heh, I was halfway through your comment when I started thinking "Stop! Stop! This won't be cheaper–it'll cost a fortune in paperwork!"

            I agree. Nevermind.

        • People aren't necessarily the best judge of the treatment they will need and shouldn't be penalized for not having medical expertise.

          And of course, it helps detect dangerous conditions earlier, hopefully reducing costs in real sense and helping people longer (of course, delaying identifying a serious illness raises costs of treatment up till a certain point, at which point it becomes too late and it actually reduces them).

  2. So you have to build up, on public money, so much medical infrastructure so that people aren't just going to go to the closest decent treatment but will have to "shop around" about a specialized service they have no professional-level way to evaluate?

    Usually when people talk about competition it's about who will charge the government less for providing care to patients. And the single biggest factor isn't who provides the most innovative care, it's who uses non-union staff.

  3. Quebec is sleeping its the bed it made of Massive Stalinist Bureaucracies and Marketing Boards, out of control Unions and out right stupidity. I left 30 years ago, and after a visit there in August can categorically state that I would submit to that level of government again… Time Quebec was treated like another Canadian Province not a spoiled child…

  4. Quebec is sleeping its the bed it made of Massive Stalinist Bureaucracies and Marketing Boards, out of control Unions and out right stupidity. I left 30 years ago, and after a visit there in August can categorically state that I would NEVER submit to that level of government again… Time Quebec was treated like another Canadian Province not a spoiled child… Sorry fixed a typo!

  5. Well I see the nutcases are off and running already.

    Expand and improve those sources of information, do everything possible to encourage patients to actively choose where they go for their care,

    I don't follow how this will reduce cost. To me it seems like it will increase cost and delays as everyone flocks to wherever the best rated treatment is available.

    • And just after they got done saying how the most expensive part of the system is specialized care, which is done from referrals, not web-based research.

      • So it's;

        selection via research
        ?????
        reduced costs

        How are costs reduced if I make the selection rather than my doctor making it for me?

  6. Why don't they simply charge a 5$/visit. Then people will think twice before going to the ER after stubbing their toes, have a cold, etc etc.

    I`ve seen people on Welfare call an ambulance to avoid paying for a cab. They dont pay for it? really?

  7. Perhaps instead of saying that it is the patient who is the problem why not look at the healthcare system itself. Do we need 13 provincial health ministries and their bureaucracies? Do we need a federal health minister and its bureaucracies? Do we need hopsitals in major locations providing all the same services?
    There are changes that could be made but it is not in the interest of those running the various provincial and federal bureaucracies to make those changes. However, someone is going to have to eventually make those changes and stop the politiking on this important issue.

    • Do you think Quebec would accept the centralization of health ministries?

      Your other ideas, however, seem reasonable.

      • Ron…..I agree. Bad me. I forgot Quebec was still a province in Canada and wants what's best for the country.

  8. A few years ago The Economist reported 80 per cent of health care spending is in the last six month of life. If this is the case then the way to reduce health care costs is quite clear but death and dying being a highly emotional issue it will bed very difficult to do. (The writer of this comment has a weblog – Economics … and other things – at http://stickychief.wordpress.com/)

  9. A couple people are saying people call ambulances instead of paying for a cab because it's free.
    Are ambulances free in Ontario?

    5 years ago I blacked out at a restaurant. The employees called me an ambulance (I was unconscious the entire time) and I woke up in the hospital. Doctor couldn't give me an answer why I blacked out. A week later I received a 45$ ambulance bill.
    A cab would cost significantly less than an ambulance for most people. They must end up being billed later without realising they will be when they call? Unless it's changed since my last use of an ambulance and it's now free.

    • I don't think they're free in Ontario, but they are very low cost, and in most cases cheaper than a cab ride, just like your example. The situation today is the same.

    • Actually, there is this one woman in the Shawinigan area who often calls the ambulance for a ride to the hospital to visit her husband. She is on welfare and thus the costs are absorbed and paid by ME and other taxpayers. She once got into the ambulance with balloons for her husband. She never even hurt, but the ambulance has to respond even though they know her and that it's not for real…they just can't take that chance.

      And so she has a taxi with sirens on.

  10. Anne Doig, the Saskatoon family physician who was then president of the Canadian Medical Association, warned that fees would discourage visits to doctors—ultimately leading to higher costs for delayed treatment.

    There's considerable research to back up that position. A key study published in the American Economic Review in 1987 found, not surprisingly, that user fees prompted patients on low incomes cut their use of medical services the most.

    That's a non-sequitur. The study you showed indicates that people with low incomes will see the doctor less, which intuitively would mean lower costs, not higher.

    Frankly, the research shows that Doig's opinion is a fallacy. It has not been shown that fewer visits lead to more costs later on. In fact, the opposite has been shown in some studies.

    Studies have shown that reducing preventative trips to the doctor does not increase costs later on, and the reason is because of the large number of false alarms, and the large amount of testing that produces negative results. Most of the time people go to the doctor, they turn out to be fine, or the testing done by the doctor fails to isolate a cause of illness. Since this accounts for the vast majority of cases, the savings produced by reducing such wasteful visits far exceeds the amount saved on the few people who detect illnesses earlier.

  11. In the U.S., about a quarter end up back in hospital within a month; in Canada, it's about one-fifth. Tu suspects pressure to keep hospital bills down means U.S. patients are more likely to be discharged a bit too soon. “In Canada, hospitals are on a global budget,” he observed. “We don't have insurance companies bugging doctors to send people home quickly.”

    So making cost a pressing factor for both patients and hospitals seems to lead to perverse, expensive results.

    Once again, another non-sequitur.

    You fail to show that the amount saved by discharging patients sooner is exceeded by the costs of additional re-admissions.

    The majority of cases in which patients are discharged do not lead to re-admissions. These savings from the majority of visits exceed the costs imposed by the few cases where people are readmitted.

  12. Everyone has missed the obvious problem here. It's not the patient who is driving up costs. It is the doctor submitting his or her bill for services rendered. So, OBVIOUSLY, the best place to scoop up twenty-five bucks per visit is by witholding a "service charge" from the payment to the physician. And presto! We now have a well-funded universal health care system.

    (Note to provincial health ministry bureaucrats whose lightbulbs suddenly started beaming above their heads: No, this is not your Eureka moment. I was mocking you.)

  13. Why is it Conservatives always blame the poor. It is true that there are some who abuse the system but most do not have the time or desire to spend all day in an emergency room. Someone sees something once or hears about a story from someone & all of a sudden it is happening all the time. The reason our health system is strained is really really simple. Our population is older & there are fewer people paying taxes to cover the cost. So leqave the poor alone & deal with the issues that are a problem. Hey s c f. You are of dubious intellegence. Our health rates are better than those in the US because we can get to see a doctor & not go broke. If we reduce that ability it will result in problems down the line. It is far cheaper to see a doctor then treat cancer at a later date. BTW, I am from a medical family so I get my info from medical data bases. Not FOX News & Sarah Palins FB page