Two-Tier Healthcare; Two-Tier Privacy

“Let me tell you about the very rich. They are different from you and me.”
F. Scott Fitzgerald, “The Rich Boy”, 1926

In healthcare, they have more privacy.

“Two-tier healthcare” refers to the existence of for-profit diagnostic, surgical, and “boutique physician” clinics and hospitals, separate and distinct from the “publicly funded” healthcare system in Canada. The aspect that I find interesting – and possibly worthy of study by a Ph.D candidate looking for a topic – is the “privacy” implications associated with its existence.

Many countries accept the co-existence of “publicly” and “privately” funded health care providers and institutions. In Canada, there is a political dimension associated with any such co-existence, which has a sensitivity all its own. Also clouding any discussion of whether such co-existence is a “good thing” or not is the fact that we have a “for profit” healthcare system next door in the United States, which Canadians do use from time to time. While one study calls it a “tip without an iceberg” it is periodically brought to our attention (e.g. the “Danny Williams case” of Newfoundland’s Premier going to the US for heart surgery). Whatever trends exist for Canadian use of American healthcare, there is evidence that the “for-profit” healthcare sector is growing in Canada.

Who uses such “privately-funded” services? Aside from those who receive government reimbursement for services not available (or not available in a timely manner) in Canada, it’s likely the wealthier segments of society. Why? Because income and income distribution is a major determinant of health. Don’t take my word on it. The report Social Determinants of Health: The Canadian Facts notes starkly:

  • Men in the wealthiest 20% of neighbourhoods in Canada live on average more than four years longer than men in the poorest 20% of neighbourhoods. For women, the difference was found to be almost two years.
  • Those living in the most deprived neighbourhoods had death rates that were 28% higher than the least deprived neighbourhoods.

So what’s this got to do with privacy?

One might argue that those with access to “private” healthcare may also have greater control over the means to preserve the privacy of the sensitive personal information flowing from that care. If you pay for your healthcare directly, it’s plausible to demand that such information remain confidential. No billing the government means no need to submit information to the government. No submission of information means more privacy.

This may not be the case with respect to “publicly funded” healthcare. One need only consider the recent example of Ontario’s Baseline Diabetes Database Initiative and the use of billing information for a non-billing-related purpose  (see “Ontario’s Diabetes Initiative: Big Brother Carries a Stethoscope” for more details).

Another example is Ontario’s Drug Profile Viewer (DPV), which is an electronic information system that allows the Ministry of Health and Long Term Care to share the prescription drug claim histories of Ontario Drug Benefit (ODB) recipients with healthcare providers in hospital emergency departments. Who are ODB recipients? Generally, seniors, residents of long-term care or special care homes, social assistance recipients and those with chronic conditions requiring expensive and rigorous drug therapy (e.g. persons with HIV/AIDS) represent the majority of Ontarians whose drug histories are collected and shared through this program. In other words, people who commonly occupy the poorer, potentially marginalized, stigmatized and more vulnerable segments of society.

The expansion of the DPV to other groups of people is a logical step and a similar program exists in British Columbia with PharmaNet, which permits pharmacists and physicians (e.g. emergency department physicians; dispensing physicians in remote communities) as well as hospitals and regulatory colleges to have broad access to drug data.

We’ve not had a good debate in Ontario (and perhaps other parts of Canada) as to just what secondary uses government may make of such data. It can be argued that the government’s role in health care is simply the management/dispensation of funds  – this being the only real legitimate authority for the collection, use and disclosure of personal health information in individually identifiable form. However, recent developments which reveal the government’s approach to implementing eHealth initiatives leaves one with the sense that the government may wish to enact legislation for the submission of personal health information into government held databases, for purposes unrelated to the funding/billing function.

The potential for withholding and withdrawing funding to compel health organizations to “play” with government in terms of information sharing, despite conflicts with medical ethics or data protection laws, is very real.

Given this potential for secondary uses, I can’t help but wonder if those who use private healthcare services may be able to shield what they consider to be highly sensitive personal information better than those who can’t afford such services.

As for some practical tips, if you live in Ontario and want to exercise your rights to restrict access to your personal information in the Ontario Lab Information System then go here. There’s not much on this site but you do get a telephone number and an email address. To restrict access to your prescription history, go here.

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