Andre Picard made some good points in the Globe & Mail two days ago, entitled “Honest talk about private health services is long overdue” – points that need to be made in light of the current debt crisis / austerity hysteria that is overtaking our province.

Perhaps the most important observation is that contrary to what many people believe, Canada does not have a fully publicly funded health care system. For all the people who protest two-tier health care, the truth is, we already have it. Mr. Picard elaborates in more detail in his article, so I don’t have to, but the essence is that some aspects of health care (like physician services) are covered by public insurance, whereas others (like most dental services, and medications for many people) are not.

Mr. Picard observes that there is a problem with the way that “medically necessary” services are covered by public insurance and services that are deemed not medically necessary are not. As he points out, this distinction at times becomes ridiculous.

“Some delineation is positively absurd: Some provinces pay for cancer drugs if you take them in hospital, but not if you take the same drugs at home. Psychiatric care is covered, but most psychological care is not.”

In my field, this absurdity is painfully obvious. A course of psychotherapy from a psychologist for a depressed person would not be medically necessary (even if prescribed by a physician), but the same treatment provided by a medical doctor would be. In practical terms, this means that it in theory it might be possible for me to expand my clinic and provide care for more people by providing counseling through allied professionals under psychiatric supervision – try to leverage my skill set to see more people. However, I would need to fund that privately (so that rich people could access this kind of care, but other people would not), or find some other alternate funding source. However, the province would fully fund me to spend most of my time asking about symptoms and doing counseling that another (probably less expensive) provider could do, because I couldn’t bill for the service if I hired someone to do it under my supervision. Meanwhile, the size of my practice maxes out at 150 patients or so, more or less depending on how frequent the appointments are and how long they are. What is even more absurd is that I could make the same income seeing the same 30 patients every single week for the next 10 years and beyond. Dr. Paul Kurdyak discusses this issue in a study covered by this article in Maclean’s.

I’m not putting down psychoanalysis or long-term psychotherapy. I do a small amount of that kind of work, I’ve seen it help people greatly over time, and yes, I think in some cases it is the best treatment. If psychiatrists want to spend some or all of our time doing that kind of work, more power to them. The decline of psychodynamic thinking and deep self-reflection in our work, in favour of prescribing, is in many ways lamentable (and I prescribe a lot of medications). What I do think, however, is that it does not make sense that some people can access this treatment with public money if they can manage to see a psychiatrist, and the rest of the population cannot. Deciding whether something is medically necessary or not based on who is providing the service is a rather strange way of rationing care. That is not really equal access, but it pretends to be. Everyone who buys a ticket has an equal chance of winning the lottery, but most of them won’t walk away with money in their hands.

It also does not make sense that what might be more efficient models of service delivery may never be incentivized under the current funding model. Also, much of our preventative care is an out-of-pocket luxury while we spend thousands or more to treat someone after their life has completely broken down. I don’t think that type of issue is limited to psychiatry. It also goes far beyond funding – I believe good mental hygiene is not expensive, but it does take a lot of time and effort. This is not something someone can do for you. You have to put in the work.

So, what is medically necessary?

I think this is the kind of thing we should be discussing at a higher level (in addition to other questions, like – how did Ontario become the world’s most indebted sub-sovereign borrower and what does that have to do with health care), but we are deadlocked at the level of squabbling about unilateral action. In our current mental health system, we pay the architect to lay the bricks and build the house himself, and since it costs too much we’re are now trying to pay him less to do it. We’ve totally missed the point, haven’t we?