Canada's doctors choose a new leader in health care can he bring the system into the 21st century.

For-profit clinic founder is CMA's new president-elect
Laura Eggertson
CMAJ
BC physicians have elected the medical director of a private, for-profit clinic as the president-elect of the CMA.

"[W]e have the potential to design the best health system in the world." Photo by: Cambie Surgery Centre
Pending ratification at the CMA General Council in August, Dr. Brian Day, founder of the Cambie Surgery Centre in Vancouver, will serve as CMA president 2007–2008. The CMA presidency rotates among all the provinces, and members of each provincial medical association vote on the position when their turn arrives.
In 1996, Day, an orthopedic surgeon, founded the Cambie Centre, which treats patients willing to pay out-of-pocket, or those who are covered by third-party insurance or government plans, such as the Workers' Compensation Board or the RCMP. Those organizations pay for the clinic's services to avoid waits in the public system.
Day ran on a platform that included the need for doctors to have a greater say in reforming the health care system, and chastised governments for their "bullying" behaviour.
"We and our patients have suffered at the hand of governments. For 20 years they have tried to fix the system and failed. Now it is our turn," Day states on his Web site (http://www.brianday.ca/). "The exclusion of market forces has allowed increased demands for services to coincide with decreased practice revenue for physicians."
Day has previously stated that private health care should complement, but not replace, the public system. But Day was not a one-issue candidate, he told CMAJ in an interview.
"I think people voted for me because they support change. There's a lot of discontent with the way the government has allowed the massive shortage of family doctors to occur," he said.
The president of the BC Medical Association was one of 6 candidates who ran in the CMA election. Dr. Michael Golbey says he believes the surgeon won the election because "it just reflects the frustration that doctors in BC have in getting care for their patients."
"He comes along with a different way of looking at things and people just latched on to that," says Golbey.
Day is a well-respected figure in the medical profession who has spoken to audiences around the world and has been "extremely persuasive," says Golbey.
Day's position is "different" from what CMA's General Council has said over the years, and the president of the CMA is bound by what's decided at General Council, Golbey pointed out.
"He will absolutely bring a different perspective to the CMA."
However, "Dr. Day's solutions will not provide the relief that the Canadian public seeks," stated Dr. Sacha Bhatia, spokesperson for the New Health Professionals Network (NHPN), which represented 25 000 new health professionals. "On the contrary, they will only serve to make profits for some health care entepreneurs and bring some richer patients to the front of the line while decreasing access to health care for the majority of Canadians."
The fact that Day got only 17% of the total vote in BC "suggests that his ideological message does not have overwhelming resonance," stated the NHPN.
Day says that given Quebec's white paper calling for private health insurance for elective surgeries, Alberta's plan to introduce a "Third Way" and the BC Throne Speech calling for an update to the Canada Health Act, Canada is at a "pivotal moment" with respect to medicare.
"There is no question that reform is coming and we have the potential to design the best health system in the world," he says. "It's not a question of debating the pros and cons. It's more about taking the best from what we can learn about systems that work and also learning from the mistakes that other people have made."
Doctors should not only be at the table for that discussion, "we should be at the head of the table," Day adds. "Governments need more help from doctors than they've asked for or have taken in the past."
In a submission to Senator Michael Kirby's committee on health care in 2001, Day recommended repealing the Canada Health Act. "The Canada Health Act achieves the reverse of what it was set out to do. In fact, the people from lower social economic groups, people who do not have the ability to pick up the telephone and make a phone call, people who do not know how to wheel their way around the system are the ones who suffer in a system like this," he said at the time.
Asked if he still supports that view, Day responded that while there is nothing in the Act that is bad, "it has to be updated."

Switzerland A Health Care System That Works

THE SWISS HEALTH CARE WAY!!

By Melvin J. Howard

Imagine an economist taking the place of a surgeon at an operating table. Such an inhumane experiment would undoubtedly result in a serious bodily harm for the patient. Now let us picture another experiment: a Ministry of Health managed by a physician. What would be the difference? The extent of the death toll. An economist at an operating-table would never be able to cause as many premature deaths as a doctor trying to handle the funding of health care without a basic knowledge of how markets work.

In many countries, common sense is not so common in the health-care finance. We should therefore look at the system used in a country where pragmatism means everything, and ideology means little: Switzerland. No health care system is perfect, but the Swiss one makes very few people complain. It is able to provide services to heads of state as well as the poorest, including immigrants from different countries, who make up about a fifth of the population.

What lesson should we take? Swiss common sense tells us that the market is the best solution for almost all areas of human activity, including the provision of health-care services. Public funding comes only when the private sector fails. What a difference when compared to the static approach prevailing in Scandinavia, United Kingdom, Canada, Czech Republic and many other countries. Also, public does not inevitably mean state. Swiss health care is extremely decentralized. Switzerland does not have any Ministry of Health. Every canton and every self-governing administration unit is in charge of its own regulation, hospital accreditation, and funding. Thus, there are 26 slightly different systems in a country with a population of 7 million. A static bureaucrat will immediately think of the chaos that must reign there. But an economist sees a different phenomenon: competition.

Yes, even though the country lacks a health ministry, it does have the Federal Office of Public Health. Yes, it does regulate health care standards, but financing is mostly left to the market. Yes, health insurance is mandatory in Switzerland, which applies even to foreigners staying longer than three months. However, the system is primarily market-based. There are about 90 competing health-insurance companies. Patients are completely free to choose their insurance company, general practitioner, and specialist. The funding from public resources accounts for some 15 percent of the total cost. About 10 percent is covered from old-age or disability insurance. Health-insurance firms cover almost a half of the expense. About a quarter is financed by the patients in direct payments. The remaining share of the cost is divided between cantons, cities, and the federal government.

There are no officials who would decide how much money should flow into the system. No bureaucrat decides, for instance, that an insurance company pays a hospital about 5 per hour for the use of an operating theatre. Everything is a matter of market relations between the patients, insurance companies, and health-care facilities. The law only lays down that the basic insurance must be provided on a non-profit basis. The insurers make profit on above-standard programs. Its worth noting that even the basic programs would be deemed highly above-standard in most other countries.

In a system based on supply and demand, the patient is not a supplicant left at the mercy of gods in white gowns, but a respected client. Switzerland naturally also remembers its needy citizens. Cantonal hospitals are intended just for them. Switzerland, unlike many other developed countries (the US, France, Germany), has never connected health care to employers, an arrangement that hinders competition in many other countries. In the United States in particular, it is the poor who are most penalized by this system.

Swiss health care is obviously costly. However, any service of good quality, based on top-skilled labor in a developed country will always be expensive. But do we want doctors and other medical staff to take vows of poverty? Should patients be treated by paupers worrying about their basic necessaries of life?

With equal costs, a system based on market prices will always be more efficient than a state-governed one with administrative prices. The money will be used more effectively. Taxpayers will not subsidize poor management of hospitals. A facility or a doctor that provides bad services will go bankrupt. Public subsidies are directed to poor patients, not to poor hospitals, as it routinely happens under the Czech health care system. Even poor patients have lots of power to choose.

It is impossible to set out all the details in a brief article. The Swiss system is not absolutely faultless it lacks proper disclosure of quality of health care facilities, for instance. Also, according to some critics, role of the government has been slowly but surely increasing. Yet we can conclude one important message: health care should be managed not by a physician, nor by an economist, but by the market. And this is why Swiss health care is so good.