Sujit Choudhry and colleagues1 are to be congratulated for raising the troubling issues of physician kickbacks and self-referrals.1 The Medical Reform Group, of which I am a member, agrees that these practices are ethically dubious and ought to be much more closely regulated.
One simple way to limit kickbacks and self-referrals would be to ban investor-owned independent health facilities from operating within the publicly funded health care system. Kickbacks and self-referrals exist chiefly to increase profit. Disallow profit, and these practices would probably wither away.
There is another reason to consider banning investor-owned independent health facilities: quality. In the United States at least, investor-owned hospitals2 and dialysis centres3 are associated with higher mortality rates than private, nonprofit facilities. Similarly, in a study comparing for-profit and nonprofit health maintenance organizations in the United States, the nonprofit organizations outperformed the for-profit ones on all of the 14 quality-of-care indicators that were assessed.4 In the Canadian context, for-profit independent health facilities are most common in the diagnostic services (e.g., laboratory testing and imaging) and rehabilitation (e.g., physiotherapy) sectors. Given the US data (there are none from Canada), there is no reason to assume that the services they provide are as good as those provided by nonprofit operators.
As one highly respected health care analyst has written in CMAJ, “Canadians [should] re-embrace the core concept of a universal health care system in which the vast majority of services are provided by non-profit institutions with public accountability.”5
So yes, we should ban kickbacks and limit self-referrals. But if we really want to get to the root of the problem (and perhaps improve quality at the same time), we should encourage policy-makers to prohibit for-profit independent health facilities from providing medically necessary care.
Irfan Dhalla Medical Reform Group Toronto, Ont.
Footnotes
Competing interests: None declared.
References
- 1.Choudhry S, Choudhry NK, Brown AD. Unregulated private markets for health care in Canada? Rules of professional misconduct, physician kickbacks and physician self-referral [editorial]. CMAJ 2004;170(7):1115-8. [DOI] [PMC free article] [PubMed]
- 2.Devereaux PJ, Choi PTL, Lacchetti C, Weaver B, Schünemann HJ, Haines T, et al. A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals. CMAJ 2002;166 (11): 1399-406. [PMC free article] [PubMed]
- 3.Devereaux PJ, Schünemann HJ, Ravindran N, Bhandari M, Garg AX, Choi PT, et al. Comparison of mortality between private for-profit and private not-for-profit hemodialysis centers: a systematic review and meta-analysis. JAMA 2002; 288(19):2449-57. [DOI] [PubMed]
- 4.Himmelstein DU, Woolhandler S, Hellander I, Wolfe SM. Quality of care in investor-owned vs not-for-profit HMOs. JAMA 1999;282(2):159-63. [DOI] [PubMed]
- 5.Naylor CD. Your money and/or your life? [editorial]. CMAJ 2002;166(11):1416-7. [PMC free article] [PubMed]