A recent Supreme Court of Canada ruling may require employers to pay for medical procedures usually covered by the public health-care system, says an executive with one of Canada's leading human-relations companies.

Joseph Ricciuti, national group and health-care practice director for Toronto-based Watson Wyatt Worldwide, says the court's conclusion that excessive waiting times infringe on individual rights could lead to a greater burden falling on group benefit plans.

The ruling - which now applies only in Quebec - boils down to whether patients can seek treatment for medically necessary procedures at private hospitals and clinics if they face unacceptably long waiting times in the public system.

"You've got this big debate over what is medically necessary," says Ricciuti, whose firm helps companies design employee benefits packages.

Bayne Stanley, Business Edge
Dr. Brian Day, centre, performs a shoulder operation at the private Cambie Surgery Centre in Vancouver.

"It's a controversial placeholder, from my perspective."

He predicts the Supreme Court decision, which found a Quebec man's rights were violated under provincial guidelines because he had to wait too long to receive a new hip, will change the way health care is delivered in Canada.

André Piché, national affairs director for the Canadian Federation of Independent Business, which represents small and medium-sized businesses across the country, says a 2004 CFIB survey showed Canadians want more private-sector involvement in health matters.

Piché says he believes the ruling has the potential to offer a greater role for the private sector in support services such as cafeterias and laundries. "The private sector has tended to be more efficient in providing these services and, therefore, can save (the health-care system) money that way," says Piché from his Ottawa office.

The decision also shows a need for more public debate, he says. Every province may react differently, but an examination of European public-private models would advance the discussion.

"We probably need to have a made-in-Canada solution to the problem," says Piché. "But having (information on) these models would be a useful thing to do."

Len Crispino, president and CEO of the Ontario Chamber of Commerce, says the ruling has reopened the health-care debate. "We all know health care is a sacred cow for Canada," he says. "At the same time, we all know the reality, that is, the system is not sustainable as is."

There is already private'-sector involvement in clinics and other ventures across the country. But Crispino says Canada needs to find ways to improve the health system "so that it doesn't just become a machine that gobbles money."

"In our opinion, we've got to give politicians permission to open up the dialogue," he says.

The Ontario Chamber of Commerce would like to see a series of discussions involving politicians, medical personnel, business leaders and health-care experts, possibly from other countries, to move the debate forward.

Many Ontario businesses are also likely interested in business opportunities that may result from the Supreme Court decision.

"If there's a role for the private sector, fine," says Crispino. "I'm not saying the private sector wants to run the system."

Stephen Chapman, president of the Progressive Group of Independent Business, whose members include chiropractors, says the court's decision will provide business opportunities for its members and others while improving the system.

"The overall system can work better if we get rid of bottlenecks by using additional resources that the private sector can bring to the table," says Chapman.

He adds private-sector involvement will speed up delivery and put more money into the system. Currently, patients on long waiting lists can choose to travel to the U.S. for surgery, but the money they pay there could be invested back in private services here for the benefit of average Canadians who require publicly funded treatment.

"It's funny. People complain all the time about the current system, but now that something's on the table, they're afraid," says Chapman. "They want (the health-care system) to get better, but they don't want to change."

Dr. Brian Day, an orthopedic surgeon who operates the private Cambie Surgery Centre in Vancouver, says the decision will spur new opportunities for insurers and equipment and technology suppliers while leading to the construction of new facilities.

"It's a very good decision for Canadians and the economy," says Day, estimating the decision will generate $12-$40 billion in new investment in health'-related sectors.

Day says he may launch a new insurance company with an established insurer and open a traditional full-scale hospital.

If his group doesn't, he says, someone else will.

"From our perspective, (the Supreme Court decision) might not be that great," says Day.

"We might actually face open competition. But you can't be entrepreneurial and say no to competition. We'll have to stay at the cutting edge of what we do."

The Cambie Surgery Centre treats Workers' Compensation Board patients and others whose bills are paid by medicare, as well as those who pay $800-$18,000 out of their own pockets depending on the procedure. The 125 doctors working out of Cambie provide treatment in the areas of joints and bones, general surgery, gynecology, urology and plastic surgery as well as partial hip replacements and total ankle, elbow and shoulder replacements.

Day, a specialist in arthroscopic surgery who privately treats National Hockey League, National Basketball Association and English soccer players, among others, says patients do not come to him because he operates a private facility. Rather, he says, they seek his services because of his expertise and the lack of operating rooms at traditional facilities.

The surgeon opened Cambie in 1996 because he could not get enough operating room hours - only six per week - at UBC Hospital in accordance with his professional licensing standards.

The Supreme Court decision, he predicts, will result in "a reverse braindrain" as B.C.-trained orthopedic surgeons come home from the U.S. The province is losing 50 per cent of its new orthopedic surgeons, he notes, because B.C. hospitals do not have enough operating room capacity. "The biggest beneficiary here is going to be the B.C. health-care system," says Day.

Meanwhile, Watson Wyatt's Ricciuti says procedures that are delisted from the public system - such as physiotherapy, eye exams and chiropractic aid - "default" to private insurers to cover. Employees who face excessive waiting times at publicly funded facilities may challenge insurers to provide coverage for services obtained from private health-care centres.

Ricciuti urges employers to examine the wording of their employee benefit-plan contracts and collective agreements to ensure they are not vulnerable to unexpected claims, and to ensure that the plan is meeting its original intentions.

"I haven't seen anything yet where the health ministers are looking at (the decision) from a plan-sponsorship point of view," says Ricciuti. "They've only looked at it from their own wallet point of view."

Ricciuti and other insurance industry insiders, doctors and health-care analysts speculate that other provinces - particularly Alberta and Ontario - will soon challenge it as they try to deliver private services.

Employers should have a choice of what they want to cover, he adds. Some plans now split the bill for certain procedures, such as dental surgery, between the employer and employee.

However, co-insurance and deductibles on medically necessary procedures would contravene the Canada Health Act and effectively create a two-tiered health-care system - one for the rich and another one for the poor.

"At the end, I hope the debate is not (about) one system over the other, but a blending of the two," says Ricciuti. "And, I hope people realize the third option."

But retired University of Alberta health-care economist Richard Plain says private health facilities won't be able to compete with public hospitals because of high overhead. He predicts all the different forms of insurance and all the related applications that need to be completed will result in more expenses that will be "lost in this morass of paper shuffling."

Traditionally, he says, children and seniors require the most medical services. Most patients, outside of unions and professional organizations that have coverage through employment agreements, will not be able to afford the expanded insurance programs.

"Who would be able to get this type of insurance?" he asks. "The 85-year-old with multiple treatments?" But Plain says the Supreme Court decision is a wake-up call for provinces to improve health care. He predicts a national study on wait times will better serve patients, while an Alberta effort to reduce waiting lists at different facilities will give consumers more choice.