Canadian hospitals profiting from foreign patients raises questions of ethics

Could a for-profit sector that allows foreign patients to be cared for in Canadian hospitals be the financial cure for this country's cash-strapped universal health care system?

That is the question being posed by a series of programs that have taken place, or continue to operate in Canadian hospitals.

Critics think that treating medical tourists for cash will open the door to a two-tiered system and are calling for a ban on the practise. Others say the money could benefit the system as a whole.

Here are two sides of the argument, edited for clarity from an interview with Brent Bambury. Calling for a ban is Doris Grinspun, CEO of the Registered Nurses Association of Ontario. Dr. Matthew Stanbrook, Deputy Editor of the Canadian Medical Association Journal and respirologist at the University Health Network represents the other side of the argument.

POINT / Ban the treatment of medical tourists in Canadian hospitals

Brent Bambury: Canada is becoming a destination for medical tourism. Paint us a picture. Who are the patients coming to Canada for treatment? 

Doris Grinspun: Either their countries have agreements with our country, like for example the Libyan government with University Health Network to bring patients from Libya for orthopedic surgeries. And also there is another agreement with Princess Margaret [Hospital] for cancer treatment, and there were patients coming at one point to Sunnybrook [Hospital] for other conditions and to [Mount] Sinai they were coming to deliver babies. My understanding is that Sunnybrook and Sinai are not doing this any longer. 

Is this happening just in Ontario or is it happening in other provinces as well? 

Well these started a few years ago. In 2012 we became aware that also Quebec was doing this, but the Quebec minister right away way jumped to the stage and said basically 'We're not open for business on medical tourism. Our system is for the people of Quebec.' 

You're calling on Ontario Premier Kathleen Wynne for a legislative ban - a law - that would ban medical tourism in this province Why do you want that? 

That is correct. We formed a coalition with Ontario Midwives and the Ontario Community Health Centers and with Doctors for Medicare. And we are asking for a legislative ban because when we have a legislative ban then every doctor in the province, every hospital in the province, will know that accepting people for money - to put them ahead of the line, from other countries - is simply prohibited.

If I come to Canada from Libya or somewhere else and I want chemotherapy who do I make the check out to who gets the money?

Well this is a very good question because so far we haven't been able to find out. We did the freedom of information [requests asking] where the thirty million dollars that University Health Network says they have made in revenues is. We do know, because we got from the CEO at the time that met with me, that some of that money goes to doctors' pockets because simply they make more money to do a case from abroad than what they make to do an orthopedic surgery on you if you're in need that care. So some of that money is simply in doctors' pockets we want to know actually where the rest of the money is. But even still if it is to make money and to bring it back to the system it will challenge the issue that Ontarians who have the means will also want to get ahead of the line to get the services and the great majority of Ontarians will need to be waiting in the back. 

You're a health care professional you know that the system that we have has pressures that are brought up my costs, the rising costs of health care in Ontario. People may disagree on the funding methods but they generally agree that the cost of health care is a strain on the system. Why could this not be an innovation? What is the solution to health care costs if this isn't one of them. 

Excellent question because this type of innovation will destroy universality for everybody in the country not just in Ontario we will set the precedent for the rest. There are many types of innovations that our government is looking at, that we are engaged with, that we are proposing. Like moving more care to primary care, moving more care to home care, allowing and enabling people to stay healthy and to delay chronic conditions and delay the complications. That's where you want to save money. Also for example full scope of practice, nurses working to their full scope. Right now that's not happening. Our nurse practitioners working to full scope. Right now that's not happening everywhere. So there are many innovations that the government is engaged [with]. We will encourage the government not to get distracted by the noise with medical tourism that is producing little money by destroying the system and distracting us from the real agenda of system transformation. 

Counterpoint / Treating foreign patients for cash could be the fix our cash-strapped system needs.

Brent Bambury: Doris Grinspun, feels very strongly that there the needs to be a legislative ban against Canadian hospitals treating international patients. You don't agree with her, why not? 

Dr. Matthew Stanbrook: Although I think she puts forward some valid concerns, I think a ban is a little silly and goes a little far to an ideological degree, I think, in rejecting some of the ideas that are being talked about. It's certainly valid to have concerns about the possible impact of this in our health care system and to want transparency and further information before we allow this to proceed, but to say 'We can never do this, we want government to forbid this!' I think is a bit of a silly extreme to take things to. 

So of all the arguments put forward, which do you most disagree with? 

I think the inevitability of it all. That this must violate universality, that this must destroy the principles of the Canada Health Act, which I also support and agree must be respected. It is quite legitimate to be concerned about the potential of this to do it, depending on how it's rolled out, but I think it's fair that if there are institutions that want to experiment with this who genuinely feel that this could be implemented in a way that would preserve the principles of public health care in Canada and might in fact benefit the health care system, it would be reasonable to allow them the opportunity to demonstrate that. 

Okay so ideally in a perfect world, draw us a picture of how that would work. What would the ideal system be for you?

I'm not sure I would call it an ideal system, I think an ideal system is one where we would solve all these problems and have no concerns about that but I think we're a long way from talking about ideals. Let's start with talking about an improvement on the serious problems we have. I think a system like that would be when would you bring in enough revenue that you can expand the capacity of the present system to deliver more care to Canadians who presently have to wait for it, who presently don't have access to it in a timely fashion and to do so equitably. I think it is conceivable that this could be one way to do it and I think it's fair to let those who are motivated to demonstrate that, to try to do so.

The place where you work, the University Health Network here in Toronto, has an ongoing international patients program. Doris said that UHN made $30-million from the program and that she placed access to information requests through her group to find out where the money went and she couldn't find out, so there wasn't transparency there. Where did the money go?

I'm not sure I know much more than what's publicly known even though I work there and I must say I haven't been involved.

But isn't that a problem, that's there's no transparency?

Yup, I agree completely. I think absolutely. Canadian taxpayers pay for hospitals, they're entitled to know what they're getting for that service, they're entitled to know if services are being used in a way that doesn't benefit them. I think it's not as nefarious as she might make it portray, I think it's obvious it goes into the global budget of the hospital. Some of it does go to pay physicians and yes it's true that we as doctors can make more money billing outside the system than we do inside but that's always been true. I mean if an American gets sick while they are here and comes to me for treatment I get to charge them at a different rate, that's always been the case.

But if we have a parallel system then doesn't that put pressure, doesn't that take doctors away from the Canadian health care system? 

That's a legitimate concern so we would need to know that that wasn't luring physicians away from delivering care at the same rate and frequency, if not more so, to Canadians and making them wait. That is a valid concern, it doesn't mean that's inevitable though.

You think a system can be made that is transparent? How are you going to figure out how to build that system?

It's certainly possibly to be more transparent, that's where you start. The place to start is not saying okay let's go crazy anyone who wants to do this, it's to pilot it out. Let the people who want to do this demonstrate that it can work the way they say it will and it's appropriate to be skeptical until they prove that, the onus is on those institutions to do it. But if they want to do that, let's let them try on an experimental basis, provided it's transparent, which I agree it's not now. Let's run that experiment, let's let the public see everything that that impacts including not only the services used locally but the affects in the broader health system and then let's see what we find. And if it turns out that yes indeed this is not impairing Canadians' access to care, perhaps even is opening up, then it would be hard to argue so stringently against it. On the other hand we might well find no this isn't possible, we don't have the resources, and that would be important to know as well but we only know if we look.

What about the legal argument? Doris' primary concern is that the development of a foreign patient program will ultimately set a legal precedent and then Canadians will see a system that they want access too. They'll press for it legally and then we have a two-tiered system in Canada. Do you share in that concern? 

I'm not a lawyer and those who are could speak more to the reality of that scenario. It seems to me though that it's the wrong analogy. It's not Canadians getting access here compared to patients coming outside the country here for care. It's 'does one have the right to go to another country to seek care?' If that's where the equity has to be I would argue Canadians already have that. Canadians already have the right to go to other countries. This is merely other people doing the same thing it's not the right comparison to compare that to Canadian seeking care in their own country. It seems to me a false analogy but it perhaps a lawyer would argue differently. 

Do you think that we will ever see a ban on foreign patients for revenue, for profit? 

I think that's a political question and as political questions go it's possible that if that were politically favourable that's what would happen. 

I sense that you don't think that we've done enough exploration to warrant a ban at this point. 

I am troubled jumping to conclusions about new models of health care in the absence of evidence. I agree with all the theoretical concerns that are being argued about. I agree with some of the benefits that have been touted. But until we actually look we don't really have much to base our conclusions on. And I'm a scientist I prefer to have data to base my conclusions on so I'm a little more liberal than Ms. Grinspun and allowing some exploration of this just so we know what we're talking about.