Allowing people to self-refer may allow them to get tests faster, but it doesn’t magically create more health professionals to deal with the results.Chris Young/The Canadian Press
Albertans can now get some diagnostic tests – MRIs, CT scans, ultrasound, X-rays – without a referral from a physician.
They will also have the pleasure of paying for these services out-of-pocket, and they will be eligible for reimbursement only if the tests detect a new cancer.
Talk about a lose-lose.
In announcing the Patient Choice and Self-Referral for Preventative Health Testing initiative, Premier Danielle Smith called it “peace of mind” testing. She also said the change would result in earlier detection of cancer, improve health outcomes and ease pressure on the public system.
But these claims are dubious.
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Physicians have an important role as gatekeepers, to ensure that tests, from blood tests through to diagnostic imaging and genetic testing, are done purposefully.
Still, it’s not very difficult to get a referral for a diagnostic imaging test if there is even a mild suggestion it may be useful.
Alberta alone does more than seven million of these tests annually. Research suggests about one in five of the procedures are unnecessary.
According to “Waiting Your Turn,” a report from the Fraser Institute, the average wait time across Canada is 8.8 weeks for CT scans, 18.1 weeks for MRI scans, and 5.4 weeks for ultrasound.
Waits are long and problematic, but unregulated self-referral will create more problems than it solves.
More than 30 years ago, Alberta allowed patients to purchase diagnostic imaging tests privately, with a referral. (Most other provinces have since followed suit.) That was supposed to ease wait times, but they’ve only grown worse.
Allowing people to self-refer may allow them to get tests faster, or “jump the queue,” to use Canadian health care parlance. But allowing more testing doesn’t magically create more health professionals to deal with the results.
The most likely result of self-referral will be more “incidentalomas” – incidental findings that ultimately mean nothing but trigger a cascade of further tests.
The Alberta Medical Association says private-pay outsourcing will not meaningfully reduce wait times or public system burdens.
“On the contrary, the evidence shows it may introduce new risks, including overuse, incidental findings, downstream publicly insured costs, erosion of the public system, widening equity gaps and further destabilization of the workforce,” it concludes in a recent report.
So why does the Alberta government want to urge more testing?
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Certainly, there is an element of ideology at play. Among the United Conservative Party’s base, there is a lot of distrust of health professionals and a lot of rhetoric about medical freedom. They don’t want some smarty-pants doctor toiling in a socialist system preventing them from getting whatever test they want.
There is also a stubborn clinging to the “steam valve” argument: The notion that allowing people to pay privately for services will ease waits and access problems in the public system.
That was the principal selling point for a related change, announced late last year, allowing some physicians to work simultaneously in the private and public systems, providing elective procedures like cataracts and hip and knee replacements, in an approach known as dual practice.
Neither of these changes will make an appreciable difference to access or waits. Nor is there any promise to regulate thoughtfully or measure if the changes are actually effective.
So we need to ask: What’s the end game?
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In the case of dual practice, Ms. Smith has been careful to say it’s for elective procedures. With self-referral, the government is emphasizing that it is for “preventative” diagnostic testing.
In other words, Alberta is allowing more private payment and private delivery for services that are not “medically necessary.” And, under the terms of the Canada Health Act, only “medically necessary” care must be publicly funded.
With its action, the province is gnawing away at the edges of legislation that has very vague wording, and, in doing so, gradually opening a door for parallel public and private systems of care.
The way to counter this approach is not to get overly worked up about the changes, which, in isolation, are not that important.
Rather, Canadians who care about the robustness of the publicly funded health insurance system should be taking the bull by the horns and asking: What are the limits of medicare?
Because, ultimately, that’s the gauntlet being thrown down by Ms. Smith.
Clearly, a publicly funded health care system cannot provide all things to all people all the time.
But drawing the lines between public and private provision and payment care should be done deliberately, not stealthily.