Thursday, February 11, 2010

CLUB MEDICAL Need a doctor? Here's how to move to the front of the line

Reprinted from ELLE Canada
March 2010

By Amber Nasrulla

Andrea Seet’s back ached. The doctor at a Vancouver walk-in clinic said it was spasms and sent her home. That was Christmas, 2005. The 24-year-old couldn’t find a family doctor so, for the next three years, with her pain worsening, she visited several walk-in clinics. In the fall of 2008, her legs became stiff and it became hard to walk and sit. That December Seet finally found a GP, who took an X-ray and found nothing. “He said, ‘You’re young and healthy. It’s all in your head’,” she recalls. “I was scared – I knew something was wrong.”

Last March, a desperate Seet paid the $3900 annual membership fee (plus one-time $1000 initiation charge) to join Copeman Healthcare Centre, a private clinic that specializes in preventive health care. Over the next two months her medical team (a GP, physiotherapist, and sports-medicine specialist) treated her and conducted bone and CT scans. The diagnosis? A three-cm schwannoma (tumour) was choking a nerve root several vertebrae above her coccyx.

“The schwannoma filled her entire spinal canal and was protruding,” says Dr. Broughton, Seet’s new GP, a clinical assistant professor in the department of family and community Medicine at the University of British Columbia in Vancouver, who acts as the in-house physiotherapist and sport-medicine specialist for the Copeman Healthcare Centre. “It had flattened her spinal cord against the bone.”

Last July, a surgeon took four hours to remove the dumbbell-shaped tumour. If it hadn’t been excised, the growth – though not cancerous – could have destroyed bone, damaged her muscles, and worst of all, robbed her of the ability to walk.

Seet’s case is extreme but it vividly demonstrates how our health system is in tumult. Dismayed by GPs who spend barely seven minutes with them and excruciatingly long wait times for specialist appointments, Canadians are turning to independent, for-profit clinics. Some, like Seet, are in crisis when they turn to preventive healthcare facilities. Others want a family physician to work with them on a long-term wellness plan, which the public system can’t always provide.

Zoltan Nagy, president of the Canadian Independent Medical Clinics Association (CIMCA) says it’s not only wealthy seniors who are populating the clinics’ elegantly decorated lobbies – younger Canadians, like nutritionist Kristen Schiener, are coming in too. The active 34-year-old was feeling sluggish and went to Toronto’s Medcan Clinic for a medical assessment. She became a convert after doctors there diagnosed hypothyroidism, which her GP had overlooked. She still sees her GP for minor ailments but relies on Medcan for detailed investigations.

CIMCA estimates Canada has between 200 and 300 private clinics, including numerous surgical centres and imaging facilities, and 30 to 50 executive or preventive health-care clinics. (It doesn’t keep statistics on patients.) These boutique clinics roll out the red carpet for wealthy athletes, actors, executives, and increasingly, the middle-class. They boast state-of-the-art-technology, spa-like layouts (no decades-old issues of Reader’s Digest and torn fabric chairs here), specialists of many stripes, electronic medical records, and short wait lists.

Yes, two-tier medicine is blossoming.

The majority of for-profit clinics aren’t in the business of urgent or emergency care; they sell prevention. “Many of us have financial advisors [and] fitness trainers but there aren’t enough health care professionals helping people stay on track,” says Dr. Elaine Chin, founder of the Scienta Health Group in Toronto. The proactive health-and-wellness model includes physicians, naturopathic doctors, and fitness trainers who identify a client’s risk factors and design a health action plan.

Even the Canadian Medical Association (CMA) supports private sector involvement although it’s drumming for public funding so patients won’t be left with the tab. Its two past presidents – Dr. Richard Ouellette and Dr. Brian Day – operate for-profit clinics. This August, the CMA introduced Toward a Blueprint for Health Care Transformation: A Framework for Action. Behind that clunky title are resolutions to accelerate use of electronic medical records, improve access to doctors, and study the role of private resources in a public system. In 2005, concerned about long wait lists, the CMA recommended the creation of a “public safety valve”, through which governments reimburse patients for treatment, travel, and other costs if they go to private clinics at home or abroad. All Canadian provinces and territories have adopted the measure, though reimbursement varies. With pre-approval from each province and territory’s ministry of health, treatment, not travel, is covered. (Medical middlemen, like the Star Hospitals organization in India, oversee international care. These brokers arrange travel, secure hotel packages, and treatment at hospitals around the world.)

Canadians are famously proud of universal healthcare, so it’s surprising that other prominent medical organizations aren’t clamouring for a ban; in fact, they’re oddly silent. The Royal College of Physicians & Surgeons of Canada (RCPSC), the Ontario Medical Association, and the College of Physicians & Surgeons of Ontario declined to comment for this story, saying they don’t have a policy on the issue. (The RCPSC does have a position paper suggesting private clinics be studied.)

But public health-care advocates aren’t skeptical, calling it “chequebook medicine.” The Calgary-based group Friends of Medicare (FOM) believes that private clinics violate the Canada Health Act by charging for services. Clinic owners explain they charge for services that governments don’t pay for, like nutritionists, kinesiologists, and personal trainers. FOM also fears that private clinics siphon doctors from the public system.

Dr. Michael Rachlis, a Toronto-based physician and health-policy analyst, maintains that private clinics actually make things worse. “Private insurance costs more than public coverage and it's less equitable,” he wrote in an op-ed article in the Toronto Star last April.

Dr. Brian Day, a Vancouver orthopedic surgeon who opened the Cambie Surgery Centre in 1996, says the rise of private clinics has less to do with capitalism, and more to do with reducing admissions to medical schools in the 1980s; deeming procedures like knee replacement elective; and cutting OR times. The public system is a relic, he says. Over the past 30 years, advancing technology has made treatment more expensive. “Government found it couldn’t afford to deliver on those promises [of universal coverage] so they started rationing health care.”

But for-profit clinics don’t always deliver. On January 11, 2008, Jean-Jacques Sauvageau died in the waiting room of Clinique Médicale Viau, a private, urgent-care-clinic in Montreal. No-one tried to resuscitate him. An autopsy showed Sauvageau died of massive pulmonary embolisms and resuscitation wouldn’t have helped. But staff couldn’t know that and should have tried, reported the coroner. The clinic also lacked a proper triage process, and an on-site defibrillator, and its upfront staff didn’t know CPR.

The Sauvageau case is a reminder that every medical boutique operates independently. Regulation varies from province to province and there’s no registration per se except doctors must be licensed to practice medicine. Membership fees vary and run into the thousands and tests often cost extra.

Some centres are hybrids, with medical staff working part-time in the public system. One expensive import is the Cleveland Clinic. Its Canadian staff bills the Ontario government for medically necessary services but patients pay for elective procedures and the clinic sends patients to Ohio treatment when wait lists are long.
Broughton explains that his patients at the Copeman Healthcare Centre often secure appointments with specialists sooner because of thorough work-ups. He refers patients to both private specialists and those who work in the public system.

For 14 years, Lynn Spence’s family doctor in Vancouver rarely ordered tests. “My GP never checked my cholesterol,” she says. (In British Columbia an annual physical fee isn’t covered.) In 2006, Spence had a silent heart attack. Astounded by her physician’s oversight, she joined a private clinic. “I didn’t care that they offered me a latte,” says Spence. “I knew that if I didn’t get that comprehensive care and make the necessary lifestyle changes I could die.” The 63-year-old doesn’t pause for a nanosecond when asked how she’s changed since joining the Copeman Healthcare Centre. “I smoked for 35 years. I never ran a day in my life,” she says. “Now I’m training for the Boston Marathon and my cholesterol is perfect.”

Meanwhile, Seet is recovering and on an indefinite leave from her accounting job. Her faith in the system has withered. “None of the doctors at walk-in clinics spent more than five minutes with me,” she says. “They were oblivious.”

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