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.

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