Dr. Brian Day wants more private health care

Oh hi there, it's me Gavin Crawford, host of Because News, the show where I gather three panelists and quiz them about the news in front of a live studio audience. This week we host comedians Miguel Rivas, Emma Hunter, as well as comic book and book book author Ryan North. I'll find out who really read Mark Carney's new budget and who fell asleep before the ending. Also, we'll try to figure out why traffic lights are getting an extra signal. Join me in my pals as we move on from the blue jays and finally talk about anything else. Subscribe to the show on Spotify, Apple Podcast, or anywhere that shares podcasts for free. This is a CBC Podcast. I'm Dr. Brian Goldman. This is White Co. Black Art. The history of publicly funded healthcare in Canada was written by people like Tommy Douglas and Emmett Hall. The history and possible future of private healthcare in this country may well be written by the guy we're about to meet. So tell me about the protests. When did they start? So it's quite a few years and we had two series of protests. When I became president of the CMA, we had another protest and they had placards and signs and universal healthcare and not more healthcare. What shocked me was that two of the 15 or so protesters had had surgery at our clinic. One of them was even speaking against private healthcare. They paid for private surgery at this clinic. That's what we're dealing with. Dr. Brian Day has been dealing with that since he opened the Canby Surgery Center in Vancouver nearly 30 years ago, Canada's first freestanding private hospital. The clinic sits on a quiet residential street in the city's Falls Creek neighborhood. No protest today, but it wasn't always that way. Day, an orthopedic surgeon, former Canadian Medical Association president and early proponent of private healthcare, led a 14-year unsuccessful battle through the courts to legalize private pay healthcare in BC. Through it all, Day has been a lightning rod for critics who say he wants to destroy Medicare, earning nicknames like Darth Vader and Dr. Prophet. But these days, some are celebrating Day as a different kind of profit. Someone who early on predicted the collapse of Canada's healthcare system and thinks he knows how to fix it, which is why I've come to the clinic, Day Belt. It's 7am and this compact clinic is buzzing with patients having knee replacements, laser eye procedures, spine surgery for slip discs, bus surgery for hernias, gallbladders, all on three floors and six operating rooms. So they're not here yet because children don't like having surgery at 7 o'clock in the morning. But this is where children have their very young children who need a general anesthetic have their dental surgery. And not just adults. Canby treats kids as well. Most patients have same-day surgery with a few beds on the top floor for those who stay overnight. They've done 90,000 procedures here. Some are private pay and some are services provided under WorkSafeBC, the province's workers' compensation program. This private clinic is but one of Day's innovations. He also pioneered robotic orthopedic surgery. Ten years from now, we'll sit in the office and the robot will bring us in. Actually, we want to be here. The robot will actually do the surgery. Well, what will we do when the robot does the surgery? Maybe 15 years. Okay. Now, I think you do know that in 1983, I was the clinical lead in the development with the UBC engineers of the world's first surgical robot. 1983, it's in the Guinness Book of Records and Wikipedia and all that stuff. Back then, robots, it was done with research grants, but it was very expensive. So maybe when it comes to injecting some private health care into a Canada system, you were ahead of your time as well. Maybe, yeah. I'm sure I was. And Day has a new book published in May, Might Fight for Canadian Health Care, a 30-year battle to put patients first, and a provocative article in McLean's. Now, more than ever, Canadians may be ready to examine Day's prescription for what ails Medicare. So tell me, what types of patients do you see the most here at this clinic? So the commerce type patient we see is an injured worker. The injured workers are one of the many groups who are exempt from those restrictions on private health care. And the workers' compensation board is an example of private health insurance and what it does. And what it does is it gets people treated more quickly. And the reason the workers' compensation board is anxious to get patients treated quickly is they have the data and we have the data that shows if you treat patients quickly, they get better quickly, and their long-term outlook is much better. If you keep someone who's injured and disabled or in pain waiting for a year or so, many bad things happen. They deteriorate, their muscles atrophy, they become dependent on medications and drugs, sometimes narcotics. You can never get them back to where they were. But most importantly, and most significantly, this is one of the things I talk about quite often, is that governments don't care about costs 20 years from now. It's cheaper to treat patients quickly in the long term. We'll get into all that in a few moments, but you are also doing private surgeries here. You're doing private joint replacements, hip and knee replacements. We just got approved to do private joint replacements. We were doing private ankle replacements and elbow replacements. We used to do shoulder replacements, and the government stopped us doing shoulder replacements. But now we've just been given permission again to do them. The restrictions are that we will only be able to do them on non-residents and on injured workers, on other exempted groups like prisoners and judges. These are all armed forces. These are all exempt from the restrictions. But to me, as we sure will discuss, it's the out-of-province patients that make the system appear as it is, which is silly and unfair to the residents of a province. So you see a lot of patients from Alberta? Yeah, a couple of months ago, there was one day I was operating on five Albertans here, and a colleague in Alberta was operating on six British Columbians. And I thought, this is a movie. This should be a Monty Python movie, with a shuttle bus going between the two provinces. When you cross the provincial boundary, the laws don't apply to you. This is, again, part of the Python-esque situation we're in in healthcare. Do you do publicly funded surgery here? We used to, but once we got into litigation with the government, they stopped sending us patients. And the strange paradox is that we opened, under a right smack in the middle of a 10-year rule of the NDP. You've had NDP leaders come here as patients? Yeah, too. We had two NDP leaders come here as patients. There's so many threads here, but we're getting there. And take me back to the beginning, nearly 30 years ago, what were you intending to do by opening this clinic? So my colleagues and I at UBC and VGH, we were experiencing cutbacks in our operating time, because we were cost items. So there was an incentive when the hospital's running out of money, there's an incentive in Canada to not treat patients because patients are the cost factors. People need to understand that. And sometimes, occasionally, I'm going to slow down to make sure that people listening to this conversation understand this. If the government paid surgeons or the hospital per patient, then they would have enough money by definition to manage all their patients. But instead, you have a fixed global budget. It means that every patient who is using services in that hospital is actually drawing down on the budget. And so if this hospital gets really successful and has hotshot surgeons who are really good and are attracting a lot of patients, what happens then? Then the Chief Financial Officer says, "Stop. You're using up our money." And so in other socialized countries even, the public system pays the hospital when they do a hip replacement or when a patient comes into the emergency. In Canada, when a patient goes into the emergency department or goes into hospital for a procedure, they are using up that hospital's budget as opposed to supplementing the budget, which is what happens in other developed countries. So back then, 30 years ago, you were already beginning to realize that this global budget idea was constraining your ability to do all the surgeries per the demand from patients. And so you came up with the idea for this clinic. Yes. And to be fair, it wasn't original. I mean, we knew in other countries, they called it activity-based funding. We have to make the public system in Canada such that a hospital is rewarded for the number of patients and the quality of its care. I've received letters from hospital administration telling me that they will not get this new equipment because it might attract too many patients and use up their budget. You've actually told you that. Yes, in writing, yes. So in essence, what you were trying to do was create capacity. You're trying to increase the capacity to do more procedures. Yeah, I use the analogy. Here we were. I mean, imagine if all of the automobile repair units in a country were run by the government and the mechanics had hundreds of cars waiting to be repaired, but the government said, you know, we can't afford to open, let you into our garages. We decided we'll build our own garage and fix up, fix the cars for our customers and our patients. And how successful has the concept been? Well, it's been very successful in terms of the fact that we despite all of the problems we've been through with the government, we're still standing, but a lot of private centers like ours have closed. So how much is it cost to have surgery here? Well, it depends. So there are minor, relatively, I don't like the term minor surgery, but there are less extensive surgeries like cataracts and dental surgery on children that we do. And they might cost in the low, you know, low thousands the more expensive joint replacements that we'd be doing may cost tens of thousands of dollars because the implants cost thousands of dollars. And then we've got to keep them overnight. So there is a cost factor. And of course, there's quite a business in medical tourism where Canadians are going to other countries, the United States, India, just to name two countries for surgeries. And you're saying let's do the opposite. Let's make Canada a mecca for medical tourism where people want to come to Canada. Exactly. I think medical tourism could be one of Canada's biggest industries. It's a massively growing multi-billion dollar industry worldwide. And what happens in Europe and elsewhere in other countries that the public hospitals even, rather than closing at five o'clock, they keep going and they treat patients and use the profits, dirty word profits, to buy new equipment and fund the treatment of public patients in their own jurisdictions. I had a recent visiting orthopedic surgeon from Germany and I kind of jokingly asked him a population in the public system of healthcare, 10% are private. And I asked him what the wait for a hip or knee replacement was in the public system. And he says, oh, it's a long time. I said, well, how long is it three or four weeks? And I said, I said in the private system, only one week. It's not equal, but it's an awful lot better than what we have. In Canada, the benchmark wait time for new joints is not three to four weeks, as it is in Germany, but half a year. The Canadian Institute for Health Information says that in 2024, 32% of Canadians waited longer than half a year for a new hip, 39% waited longer than half a year for a new knee. Clearly, we have a long way to go to catch up to Germany. We'll be right back. Welcome to Decoding Women's Health. I'm Dr. Elizabeth Pointer, Chair of Women's Health and Gynecology at the Atria Health Institute in New York City. I'll be talking to top researchers and clinicians and bringing vital information about midlife women's health directly to you. 100% of women go through menopause. Even if it's natural, why should we suffer through it? Listen to Decoding Women's Health with Dr. Elizabeth Pointer wherever you get your podcasts. You're listening to White Coat Black Art. This week, a conversation with Dr. Brian Day, a veteran orthopedic surgeon and steadfast proponent of bringing private pay into Canada's health care system. Now, here's part two of my conversation with Dr. Day. You have never wavered in your belief that Canada needs some degree of private health care. Make your pitch. Why do we need it? It's not rocket science. This is something that every top-performing country allows. Also, we're near the top of the OECD in costs and near the bottom in quality outcome and efficiency. Just a quick note. Day mentions the OECD, which stands for the Organization for Economic Cooperation and Development. The organization collects data from member countries, which allows us to see how Canada's health care system ranks compared to other nations. So, I use the sports analogy that if I were a coach of a hockey team or soccer team, and I was spending more on my club than the top three, I would look at what the top three or four clubs were doing and try and learn from what's different. The two biggest differences are one, that they allow some competition, and the second is in having fixed global budgets for our hospitals so that patients are the last thing the Chief Financial Officer wants or the administration for that matter. The other thing we haven't discussed is what's happened with this government monopoly is it has exploded into a massive bureaucracy. Lack of competition, a monopoly, bloated bureaucracy, and a fixed budget that doesn't reward hospitals that do better and see patients more efficiently, and rules. For instance, you can get private procedures, but you have to travel to another province to be able to get them. I want to put this into the modern context. The health care system, as it exists today, for instance, I'm in a merged position. We've seen massive increases in ER wait times, and we've heard media reports that some patients are dying in part because of how long they wait. Who's to blame for that? The government, absolutely the government. To be fair, the public, because the public elect the government. People outside of the country can't believe what we do, that we are literally allowing tens of thousands of Canadians to die on public wait lists with no way out other than leaving their own jurisdiction. So all of these things that we've talked about, people dying on wait lists, waiting for cancer surgery, people waiting inordinate amounts of time for joint replacement, people waiting many hours, sometimes even a day or two, in the emergency department, no matter how sick they are. How might private health care deal with all of that? So don't get me wrong. I believe in a strong public system. So I think the emergency department is where the public system has to be strong. And I think that what happens in other jurisdictions in emergency departments, patient goes into an ER, they carry with them revenue from the public system so that the hospital that doesn't have an efficient ER where you're having to wait hours doesn't get the revenue. So how can the infusion of private health care begin to address that? Well, on a global scale, it addresses it by ending a monopoly. And there is no monopoly. I've asked anyone who opposes this concept to name me a monopoly that serves the consumer well. And there is none. By definition, you need competition. We must end the state monopoly on health care. We don't have it in education, for instance. You know, no one is saying, oh, the private schools have taken and the independent schools, the religious schools have taken all the good teachers away from the public system. Explain to me why we need a federal ministry of health. It's a provincial jurisdiction. We have no federal ministry of education. We don't need a minister of education federally, and we don't have one. We don't need a minister of health federally, but we do have one. Eliminate them and let the provinces take care of their own. Let the provinces compete with one another. Let them have initiatives to experiment and look at the best around the world. And let's end the monopoly. You are proposing not 80 percent private care. You're proposing something like 10 percent private care. I would say, you know, that I would say we're in a position to now go out and study the top three or four health systems, and let's learn from what they're doing. That that's not that complicated. Which countries are you looking to the most? Holland, France, these countries, Sweden, these are not right-wing radical countries I'm naming. They all allow some competition in the belief that a small element of competition improves the public system. Let's cut the bureaucracy and let competition improve efficiency. You've tried several ways to make your case to Canadians. You were president of the Canadian Medical Association. How successful was that? Well, it raised the problem for a year, but it raised the issues. But the problem with positions like that is you come, you're gone, there's hype, and then a year or two later you're gone. And then you're past it. Everyone wants to keep fixing this without realizing that there's a monopoly going on here that's wrong in my book that I just published recently. There's a chapter called "The Hippocritical Oath," and it's about this. And I've been in debates and arguments and public debates with people who weeks or months later have phoned me to, "Oh, I want this. Can I come privately? My brother needs this. Can we get to see you privately?" So critics, people who are publicly critical, phoned you a few weeks later and asked if they can get somebody in to have surgery at Canby. Yes, and as I say, we've treated two leaders of the NDP in this clinic. We've been exposed to this hypocrisy since we opened. It's normal human behavior. When it's me, things change. More famously, you took BC to court. What was the legal argument you were trying to make? The main legal argument we were trying to make is that in 2005, the Supreme Court of Canada gave Quebecers who were on waitlist the right to treat themselves and obtain private insurance. And we were basically going to the courts and saying, you know, you've given this right to Quebecers, shouldn't we, the rest of Canadians, have the same legal rights? And this time they refuse to hear it. The British Columbia Supreme Court has dismissed Dr. Brian Day's fight for private health care in Canada. Now, the lower courts in the Chowley case, it's called the Quebec case in 2005, the lower courts had ruled against private insurance. So the Quebec Supreme Court and the appeal court in Quebec did what our courts did. And they were deferring to the highest court. In our case, though, our BC appeal court came out and said, you know, the waitlist largely arises from their concluding statements as a result of rationing of access by the government, and that this was startling, and that patients are dying as a result of this deliberate rationing. And obviously, in my mind, they were just passing the buck to the higher court, the Supreme Court of Canada. But astoundingly, the Supreme Court of Canada refused to consider whether Canadians who live outside of Quebec should have the same rights that Canadians who live in Quebec have. His lawyers argued patients have a constitutional right to pay for private care when wait times in the public system are too long. But lower courts found there was little to suggest that unrestrained private health care would reduce wait times in the public system, and Canada's highest court declined to hear an appeal. And to me, this is astounding. What do you make of the fact that the Supreme Court allowed the provision of private care in Quebec, but didn't want to take the case, hear the appeal of the decision in your case here in British Columbus? So in effect, private for-profit health care is allowed in Quebec and not in British Columbia. I think there's a word that describes this. It's called cowardice. It's called fear of my employer. Some people, after losing a lawsuit and seeing protesters and hearing from politicians that won't move forward with this issue, would be discouraged. What keeps you going? Well, I'm just angry at the hypocrisy mostly. It's so unfair. I came from a very low-income working class family in post-war Liverpool. The last thing I want is for low-income groups to suffer in health care. I think the solution to that is for the government to fund their premiums and make it so that low-income groups get the same coverage and the same benefits. This is an unfair system and we need to fix it. We've reached the point in our health care system where a lot of noted observers of health care, people inside the system have started to talk about the health care system collapsing, which is something we didn't talk about 15 or 20 years ago. Are we at a crunch point? How optimistic are you that the public system reaches a crisis point and moves forward with some reforms that you think are necessary? I think it's up to the people. As I said earlier, I think the people now need to take control and they need to exert that control. You mean the voters? Yes, the voters. This is now affecting everyone. We have a massively aging population. The thing is, in the '60s when our system was designed, there was no stem cell therapy, no transplants. The same with complex cancer and heart surgeries. Combine that with the futures of gene therapy, stem cell therapy, the drugs that cost millions of dollars a year. We're not going to be able to afford equality in health care, but we can at least strive to give everyone a good standard of health care. Things are getting worse. It's my age group, the aging baby boomers, who are hitting on this system. This isn't the end of the deterioration. It's going to get worse. We need politicians to accept that and understand that. Am I optimistic? I was optimistic 25 years ago and that proved to be wrong, so who knows? Dr. Brian Day, it's been a pleasure speaking with you. Thank you, Brian. This week's show is part of our season-long coverage of the growth of private health care in Canada. If you have a story you want to share with us, write to [email protected]. That is our show this week, but we're looking for feedback about another program we're doing in the weeks ahead. Have you ever complained about the care you or a loved one received in hospital or at a clinic? We're looking for complaints that were successful and ones that weren't. Email us at [email protected], giving your name, where you live, the complaint and the response you got. Better still, attach a voice memo to your email. We'll put the best responses to an expert on patient complaints. Whitecoat Blackheart was produced this week by Stephanie Dubois with help from Jennifer Warren and Samir Chabra. Our digital producer is Ruby Buiza and our senior producer is Colleen Ross. I am Brian Goldman and I'm proud to bring you stories from the Canadian side of the gurney. See you next week.