Lots of Surgeons, Not Enough Money

“It’s fundamentally important to the health-care system […] that medically necessary services are universally insured and there are no barriers to access to those services.”

Thus spoke federal Health Minister Jane Philpott to explain why her department is supporting the government of British Columbia in its litigation with Vancouver’s Cambie Surgery Centre.

The CSC advertises that it has cared for patients from around the world, including many famous celebrities and athletes. They are contesting regulations in BC that prevent them from doing the same for Canadian patients willing to pay their own way.

The governments are choosing to ignore the real barrier to access in the public system, which is not the existence of private sector alternatives, but rather the limits governments put on funding for publicly provided care.

Taxpayers fund 100% of the cost of publicly insured care. The patients pay nothing, and have no incentive to limit usage, so there is no limit on demand. The only way governments can manage cost is by limiting supply.

This is achieved by giving hospitals fixed budgets, which mean that the number of physicians and other health care workers is limited to what those budgets will provide. Operating room (OR) time is a prime driver of cost so it is carefully rationed.

Not surprisingly this has an impact on wait times. At the QE2 hospital half of the patients needing hip surgery have to wait more than five months. Ten percent have to wait more than 22 months.

This is not because of a shortage of orthopedic surgeons. Plenty of them in Canada are unemployed and underemployed. The ones who are employed get less OR time than they would like.

The same is true for many other specialists. A 2013 report from the Royal College of Physicians and Surgeons of Canada tells us that 16% (208) of new specialist and sub-specialist physicians said that they could not find work and a further 31% (414) are doing more studies in an effort to become more employable.

Some of these highly trained practitioners leave the country; others stay but are underemployed because they develop practices without full access to the necessary resources such as OR time.

Nova Scotia’s Department of Health produces a ten year forecast of recruiting requirements for each area of specialty, taking into account migrations, retirements, and changes in mode of practice. By far the largest cohort is family physicians, for which we will need an additional 46 per year for the next decade.

In contrast most areas of surgery, including cardiac, plastic, thoracic, and vascular will require fewer than one new surgeon per year. All areas of surgery combined will need only about 15 new specialists per year.

That low demand puts downward pressure on how many residents can be trained. Some specialties can only admit one new student per year which makes it difficult to maintain a viable program. The story is similar across Canada.

It is in this context that we can consider a report commissioned by the federal government, in support of its position, which claims that public resources, including highly trained nurses and doctors, would be siphoned off by a private system.

That is entirely at odds with current realities. We have a surplus of surgeons.

In Nova Scotia we have private suppliers in areas like diagnostic imaging and physiotherapy, yet the public system maintains it staffing levels. Scotia Surgery employs nurses and doctors for non-insured plastic surgery, but there is no shortage of plastic surgeons for work in the public system.

It is legal for the Cambie Surgery Center and others like it to employ health care professionals to treat Americans for what ails them, and yet the public system does not lack for surgical resources. It is legal for a Canadian to go south of the border to get treatment at her or his own expense, thereby reducing the waiting time for others.

It is ironic that governments invest so much energy trying to prevent Canadians from paying for surgical services in Canada, a right that we extend to citizens of any other country. This is bad policy born of an enduring myth about our public health care system.

Unlike what Minister Philpott would have us believe, taxpayers cannot afford to pay for every insured service that Canadians might want. Cost is managed by restricting supply.

Acknowledging that would open the door to initiatives that would reduce pressure on the public system, provide better opportunities to train surgical residents, and create high paying work here that might otherwise go south, taking the surgeons we paid to train with it.

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