User fees can’t fix complex issue of emergency room wait times

THE QUESTION

The news is full of stories about overcrowded hospital emergency rooms and people waiting a long time for medical treatments. Why don't we charge a reasonable user fee for medical services? That should reduce the number of people going to doctors needlessly while also raising money for our cash-strapped health-care system. It seems like a win-win.

THE ANSWER

You're not the first person to put forward that proposal and you won't likely be the last. However, a large body of scientific evidence suggests that user fees are a bad idea when it comes to health care.

It's true that charging a fee – even a small one – results in fewer people seeking medical care. But it reduces both unnecessary and necessary care – especially among lower-income individuals.

That's a problem because putting off necessary care can lead to worse health down the road. Think of the people who forgo a cancer-screening test because they don't want to pay a fee – or can't afford it.

It's also unrealistic to expect the general public to know what is, or is not, a serious health problem needing prompt attention, says Dr. Michael Schull, an emergency department physician at Sunnybrook Health Sciences Centre in Toronto.

He points out that a pain in the chest might be caused by common indigestion or a potentially deadly heart attack. Sometimes, it takes a visit to a hospital emergency department to make that determination.

And even patients who come with minor complaints, such as a cough or cold or sprained ankle, "doesn't actually affect the wait times for other patients who are sicker," says Schull, who is also a scientist at the Institute for Clinical Evaluative Sciences.

That's because patients are assessed on arrival through a triage process in which those requiring immediate care are seen right away. Many emergency departments also have an additional system to channel patients into separate treatment paths based on the severity of their conditions. "They are in different streams and have virtually no influence on each other's wait time," he says.

In fact, a study co-authored by Schull found that people showing up with minor problems had only a negligible impact on others' care.

The study looked at more than four million patient visits at 110 emergency departments across Ontario. The results revealed that for each low-complexity patient who arrives, the remaining patients experience an increased length of stay of just 32 seconds on average, and an increase in time to be treated by a physician of 13 seconds.

Of course, there are very real concerns about certain wait times in Canada's health-care system. But those issues are complex and relate to serious cases that are not affected by some people going to emergency departments with minor ailments.

Schull says user fees for medical services would simply penalize vulnerable low-income individuals, who often have greater need of health-care services.

Dr. Danielle Martin, a family physician and vice-president at Women's College Hospital in Toronto, agrees with that assessment.

In her recently published book – Better Now: Six Big Ideas to Improve Health Care For All Canadians – she calls user fees "Health Care Zombies" because support for them doesn't seem to die despite ample evidence they don't achieve their desired results.

"When user fees prevent patients from seeking necessary care, people end up suffering complications that are much more expensive to treat," she says.

To make matters worse, they don't actually raise much money, once the administrative costs are taken into account.

"You need someone to collect the fee, someone to chase after the person who still owes the fee and someone to determine who should be exempt from the fee," Martin explains. "By the time you've put in place the army of bean counters, you're running a bureaucracy to pay for itself."

She points to a study that was done in 2010, when the Quebec provincial government was considering a $25 charge per medical visit. It would have been paid as a lump sum when people filed their end-of-year taxes, an approach designed to minimize administrative overhead. (The very poor were exempt.)

The study found that the potential revenue was small – representing less than 1 per cent of the $27-billion public health-care budget in Quebec.

"That shows if you actually want to raise money to pay for the health-care system, you'll need to charge pretty hefty user fees," Martin says.

Over all, a user fee "is a blame-the-patient approach that's based on the assumption people are abusing the health-care system," Schull says.

"I have been doing emergency medicine for 30 years and it's my experience that only a tiny minority of patients inappropriately seek care and that proportion has been getting smaller over time."

In most cases, "patients simply don't know what's wrong" with them or they can't get a timely appointment with a family physician. "I have no problem with these patients coming to my emerg," Schull says.

Paul Taylor is a Patient Navigation Advisor at Sunnybrook Health Sciences Centre. He is a former health editor of The Globe and Mail. You can find him on Twitter @epaultaylor and online at Sunnybrook's Your Health Matters.