Alberta regulatory body makes important

move to address private MRIs

In a surprising move, the College of Physicians and Surgeons of Alberta has challenged financial
barriers to medical imaging.

While some believe that regulatory colleges should limit themselves

to individual physician discipline, the Canadian public should
support the growing willingness of Colleges to move beyond
disciplinary issues to act as a voice for the public interest in the
many conversations that shape our health care system.
We must be clear about what the College is and is not proposing.
They are not proposing to shutter existing clinics. They are taking a
stand that aligns physician ethicsthe imperative to provide care to
those who need it and not preferentially to those who can paywith
the publics interest in an efficient and equitable system. In effect,
they are proposing a new kind of partnership between the
profession and government to improve care for patients.
The idea that professions should serve the public interest through
self-regulation is not new. However, physician associations in
Canada have long maintained an ambiguous relationship with
Medicare, testing the boundaries of public toleration for private-pay
solutions.
It may be surprising that leadership in a new direction is coming
from Alberta, the province that gave birth to private-pay imaging 20
years ago. Private-pay imaging clinics have since opened in BC,
Quebec, and, to a lesser extent, Ontario and Nova Scotia. Most of
their business comes from third-party payers (motor vehicle

insurance, workers compensation, and others). Some have claimed

that a second tier of private pay imaging would relieve pressure on
the public system. A rigorous analysis has not been performed, but
CIHI data on wait times in the public system suggest that this
benefit has not been seen. Indeed, twenty years into the experiment
with a public-private mix of payers in medical imaging, the lack of
data and accountability raise questions about the idea that private
imaging was ever meant to improve the public system. Some
predicted this failure from the beginning.
It is perhaps more surprising that the College decided to address
private-pay imaging while it was formulating policy for an entirely
different practice area: concierge medicine. In concierge practice,
patients pay a membership fee covering non-insured services from
physicians and from other health professionalsand, many argue,
securing access to insured services. In January, the Alberta Health
Services Preferential Access Inquiry uncovered concerns that
patients at Helios clinic, a clinic with $10,000/year membership fees
andties to the University of Calgary medical school, were receiving
screening colonoscopies within days of referral, rather than months
or yearsthe normal wait times for average risk men in their 50s.
The AlbertaCollege considered a proposal to bring standards for
concierge medicine in line with those of other Colleges. The
question arose: if private-pay MRIs and CT scans are acceptable,
why not private-pay primary care?
Private-pay imaging is an anomaly in Canada: unlike other
physicians, radiologists may bill the government for a service in one
setting, and bill patients directly, setting their own fee, for the same

service in another. The acceptability of this practice in Alberta turns

on the distinction that Medicare covers imaging in hospitals, not in
the community. The same service is insured in the hospital, but
uninsured in the communitymuch like prescription drugs. But
unlike prescription drugs, with imaging physicians can work both
sides of the system. Romanow recommended a decade ago that
this loophole be closed, to no effect.
Although the Colleges proposal can be seen as fallout from the
Preferential Access Inquiry, Commissioner Vertes declined in his
report to make recommendations pertaining to private imaging and
concierge medicine. He nonetheless commented that they are
ethically troubling. If his side-comments have this much effect, we
should take note of his twelve official recommendations on access,
referral practices, wait list management, and the proper exercise of
the discretion physicians have as gatekeepers to the system.
The Colleges proposal is important for physicians, health care
policy makers, and citizens across the country. A two-month
consultation period starts Sept 15. It could fail under pressure from
the segment of the public that is used to paying for expedited
access. It could, despite its intentions, return patients to a public
system that has the worst wait times for public MRIs among
provinces reporting this data to CIHI, without fundamental
transformation of referral practices and wait list management. It
could simply loosen the public purse strings for medically
inappropriate imaging and boost the profits of private facilities
owners. All of these questions must be addressed in the coming
months.

Those who care about equity, the future of Medicare, and good
medical practice should be watching closely and contributing their
views and their expertise, whether as consumers, providers, or
researchers. We now have decades of international learning on
improving wait times and wait list management; the movement for
appropriate testing is gaining force. These are powerful allies in the
work to secure the future of Medicare.
Lynette Reid is an associate professor in the Department of
Bioethics, Faculty of Medicine, Dalhousie University. She was
commissioned and paid as an expert opinion witness to prepare a
report for the Inquiry and to testify on its research panel. She blogs
at Biocitizen. Follow Lynette on Twitter @lynreid