Health-care policy analysts at home and abroad question whether the Alberta government has done enough to assess whether its plan to allow doctors to offer private services while practising publicly is sound. The province last month announced its plan to let doctors choose to work in the public and private health systems simultaneously. Alberta Premier Danielle Smith said the move is about flexibility for doctors and also about cutting wait times for surgeries in the public health system. Smith says to avoid increased taxes or health-care premiums in Alberta, surgeons will be allowed to offer elective procedures, paid for by patients or their insurance plans, after they commit to a minimum number of publicly funded surgeries per year. But critics, including the Canadian Medical Association, have said the model could lead to Albertans waiting longer to get treatment. The association, which represents physicians across the country, says evidence from around the world shows that where a parallel private health system operates, broader health outcomes and access to care are worse. Australia’s ‘two-speed’ system One country that has a two-tiered system in which the public system is considered slower than the private one is Australia, where former Alberta Health Services (AHS) president and chief operating officer Stephen Duckett now works as an honorary professor in Melbourne. He says the use of the parallel practice streams in his country, which it’s “had forever,” has created a “two-speed system” in which “the vast majority of the population who don’t have private insurance have slower treatment.” “Rather than everybody being in the same boat, some people are in an ocean liner and some people are in a rowboat that is leaking, so it de-emphasizes looking after the public hospital system,” Duckett, who headed up AHS from 2009-10, told CTV News Edmonton in late November. “There’s no evidence in the statistical analysis I’ve done that if you have more private work, it actually reduces the public hospital waiting costs.” In Australia, Medicare covers essential healthcare for all citizens and permanent residents. There is also a significant private sector. According to the Australian government, more than half of the country’s residents access private doctors and hospitals, mainly paid for by private insurance. Smith, in a social media video, named Australia as one of the countries where a hybrid model works. Duckett says what the premier describes isn’t what happens. “The evidence from Australia is that if you start to introduce private care, you end up with longer waiting lists in the public sector and so on,” he said. Fears of reduced public priority And a health policy analyst in the province says the risk “of all of this” is if practising privately proves to be more lucrative to doctors or means private patients have less complex medical needs and are easier to treat, that would mean those patients would get priority over those using the public system. “There is this link between wealth and health, on average, those who have the most complex medical needs, who need treatment most acutely, are very often going to be those who just aren’t in a position to pay to expedite their care,” Lorian Hardcastle, an associate professor in the University of Calgary’s Faculty of Law and Cummings School of Medicine, told CTV News Edmonton. Matt Jones, the province’s surgical services minister, said last week – on the day the bill opening the door for surgeons to offer their services privately was tabled – that it is about offering flexibility to doctors, reducing wait times and giving Albertans the option to pay for procedures without having to travel out of province. He told media that the legislation would also help recruit and retain health workers in Alberta, countering criticism it will siphon them from the public system. “I think this is a tool that will help us retain physicians and other health professionals that are frankly going to other jurisdictions, and it will retain that activity in the Alberta economy,” he said. The bill doesn’t cap private surgical costs for procedures like hip, knee or cataract surgeries, but the government promises to lay down guardrails to protect public health care. That may include requiring doctors to perform a minimum amount of practice in the public system before expanding to offer private surgeries or restricting some specialties to public practice if shortages emerge. Legislators say they’re not putting those specifics in legislation so they can change things quickly if issues arise. Duckett says having two different systems also increases admin costs. He credits other parts of the Australian system for shorter wait times and lower healthcare costs. “We’re very, very strong and able to implement research findings into the system ... relatively quickly,” he said, but that “there are multiple differences between the two countries.” Staffing shortages a major hurdle One of those differences is the number of doctors. Data from the info hub Organization for Economic Co-operation and Development shows that in 2023, Canada had 2.72 practicing physicians per 1,000 people. Australia had 4.2 per 1,000. European countries led the pack, with Austria taking top spot at 5.51 doctors per 1,000 people. “If some are treating private patients, there’s not as much opportunity for the public system to suffer as perhaps there is here, where we’re stretched more thin in terms of human resources,” Hardcastle said. And Canada has “a plethora of issues” when it comes to recruiting health professionals, she said, including geography. “We are a very spread-out country,” Hardcastle said. “There are very rural areas. It’s hard to recruit physicians to those areas, whereas when we look at some of the European systems that people like to compare us to, they just don’t have those issues. The countries are very small. Much of the country is either urban or suburban or close to urban areas, and so you don’t have these rural areas where it’s extremely difficult to staff and to deliver care.” Emergency physician Paul Parks, who works in Medicine Hat, says a shortage of certain types of healthcare workers is already limiting important surgeries. “We have empty operating rooms because we do not have enough anesthesiologists and nurses already to staff those,” Parks, a former president of the doctors’ advocate Alberta Medical Association, told CTV News Edmonton. “I’m not talking empty at nighttime, I’m talking always empty.” Hardcastle said if the Alberta government “is determined to forge ahead with this,” it should take its time to implement any changes to best protect the public system and figure out what restrictions it should put in place. “Is it volume? Is it kinds of procedures? Is it medical specialties?” she said. “Look at the evidence and look at what other places are doing to try to protect that access in the public system, and to not move ahead with this until those protections are in place.” With files from The Canadian Press
