Fragmentation, Private Profit and Home Phlebotomy

Every day there are stories of how the fragmentation of health care hurts patients.  A few, when a patient dies, make the media.  Most often fragmentation causes small inconveniences, but there are many and they affect patients in very real ways.

December 19^th’s story is about a patient with a serious chronic illness.  She lives at home and manages her illness fairly well.  Monitoring her condition requires weekly blood work which is taken by a home care nurse through a PIC line, a semi-permanent intravenous access port. She then walks the blood a fairly short distance to a health center where LifeLabs picks it up at the end of day.

On December 19, as usual, the nurse took her blood then, as usual, left: the nurse is not allowed to transport the sample. Unusually, the blood sample stayed in his house because the patient was not able to walk to the clinic due to an exacerbation of her illness.

At this point in the story, it helps to go back 15 years. When I started as a home care nurse, we drew blood and transported it to the lab, often in a hospital.  Around the same time, Ontario formed the Community Care Access Centers to coordinate home care and put all home care services out to tender.  One of the services contracted was blood taking.  In our area, MDS, the precursor to LifeLabs, won the contract.  The new arrangements were that the nurse, now with a contracted agency, would visit for nursing duties, and, when blood was needed, a MDS phlebotomist would take the blood and bring to back to their lab.  Privatized home care coincided with the move away from using hospital labs and worked synergistically to give more work to the for-profit labs. Since MDS drew the blood all the samples went into their laboratory processing system. Most samples were shipped to Belleville, or more likely, Toronto before results were reported back to Kingston.

This system was even more absurd for my specific job.  I worked on the intravenous team servicing rural areas.  I would drive 20 minute s to see a patient and, if they needed urgent blood work I would draw the blood, and, as now required, leave it for an MDS driver who would also drive 20 minutes out to the patient’s house to pick up the blood.  Certainly one solution to this absurdity was to stop the service and make it the patients responsibility.  For the home-bound-cardiac-patients-in–rural-Ontario this was not the best solution. Nonetheless, as a way to reduce expensive duplication this was the one chosen the government.  Most patients are now expected to go to a bleeding station to have their blood taken.  Or, if you wish, you can pay a for-profit lab to come to your house.

Back to December 19, 2012 and our patient at home with a PIC line and her blood samples.  She did call the clinic and ask for help.  Luckily, a staff person was both available to drive to her house and willing to look the other way ignoring various bureaucratic restrictions around the transportation of blood.  The blood was picked up and the patient will get the results she needs.

This is a small story on the impact of fragmentation due to the division of services into components to facilitate the use of for-profit health care companies. Staff flexibility, concern and minor rule-breaking were needed to give this patient the care she needed, though I expect that” best practice” rules would not agree with this approach.  And, it does not address the needs of the hundreds of thousands of patients who daily suffer from a fragmented for-profit home care system.  Rather than rely on serendipity and the good will of staff maybe it is time for an integrated public non-profit home care service.

Privatising Preventive Care – the For-Profit Flu Fight

Flu season is upon us, and it seems that the for-profit-health-care bug is infecting primary and preventative care.  The yearly campaign to increase the number people vaccinated against the flu is coordinated by the public sector though the Ministry of Health and Public Health Units.  After that it gets a bit murky.

Large multinational pharmaceutical companies produce the vaccine.  GlaxoSmithKilne Inc. is Canada’s largest supplier.  Putting the vaccine in the people’s arms has been primarily done by small family practice professionals or public health nurses.  To meet the challenge of increasing immunization rates – over 40% of Ontarians are not receiving the vaccine – the wide network of family practices and community health centers could be given more resources to, as one possibility, hire part-time nurses and nursing students to go into malls, set up tables and administered flu shots. Instead the focus seems to be shifting to for-profit providers.

The for-profit pharmacy chains recently got the nod to administer vaccines.  Also, in malls we have an expanding network of private urgent care clinics and for-profit fee-for-service primary care chains like, MCI: The Doctors Office, which are happy to administer flu shots.  A percent of each shot payment, $4.50 for the vaccination plus an administrative fee-per-visit premium of $5.10, go into the coffers of this for-profit health care management corporation.

The circle is now complete with private multinational corporations producing the vaccine and corporate chains injecting patients.  The yearly repeating cycle provides the opportunity for more and more for-profit involvement.

As a society we make decisions about how we want to organize our affairs.  The policies we adopt develop their own power. There is a political theory, called path dependency, which is based on this phenomenon.  But we really do not need a theory to recognize the strength of existing processes.  The NIMBY syndrome, or the common argument ‘we have always done it this way’ are daily experiences. More profoundly, we have a society based on using fossil fuels and moving to more sustainable energy sources is a major problem.  This does not mean that change cannot happen, it obviously does, but it is much harder when certain structures exist.

The same goes for how we deliver health care. As we allow more private provision the more we are inclined to use it, or for-profit corporations impose themselves on public policy in a way which expands their presence and makes us more reliant on their services. It can be a powerful self-reinforcing spiral.

The muddying of the health care waters with private-profit providers also has implications for reasoned discussion on the benefits of vaccinations. I believe that mass immunization programs have been very important to improving public health, but involving the profit motive in this valuable public policy opens up the programs to legitimate criticism that the need and claims of efficacy come from the drive to make profit and not improve health.  These arguments are at least partially correct and undermine public decision-making. The following post is one of many that make illustrate this muddying of the water: http://www.healingcard.com/politics-profits-pandemic-fear-mongering-national-vaccine-information-center/

Increasing for-profit corporate provision of primary care is a matter of significant concern as we move more services into the community and place more emphasis on prevention programs. Unfortunately we do not even know the extent of these changes, their public cost or their effect on quality or access: and the government, to the extent that it is tracking these developments, is not talking. If nothing else, placing larger swaths of primary care under corporate control removes valuable information from public discourse – business confidentiality – and limits both community control and physician control of primary care.

Health Facility License Auction Health Cost Driver

It seems so obvious in hindsight:  if you want to know what is going on in business-side of community medicine look where doctors look – the classified section of The Medical Post.

After reading all of the articles, during a slow day at work, a big flashy classified ad for MCI: the Doctors Office caught my attention.  It is one of the expanding chains of family practice centers that are the face for-profit primary care in Canada.  The ad provided no further insights into the operations of the chain.

Below this ad was a more interesting offering: the sale of an Independent Health Facility (IHF) license.

Auction of IHF in GTA

A rare multi-modality IHF in Pickering, Ontario is to be auctioned

 The IHF license has the following modalities: Nuclear Medicine; In Vivo – General and SPECT; Diagnostic Ultrasound; General Ultrasound; Vascular Ultrasound; diagnostic radiology; fluoroscopy; Bone Mineral Density; mammography; and, Radiography

No other assets or liabilities to be sold with this.  This is strictly a license only sale.  Non-conditional sealed bids must be received by end of business hours on Thursday Nov. 1, 2012. Closing of the above transaction will take place no later than December 31, 2012.  A minimum reserve bid is in place.

Only serious principals send inquiry to ihfauction@yahoo.ca.

The ad is interesting because it puts no caveats on the sale except that it is a final transaction and that there is a minimum reserve bid:  standard practices in any estate auction. Unfortunately this is a sale of an essential health service.

The bid is to be non-conditional but this seems at odds with the Independent Health Facilities Act. The Minister of Health has the power to refuse the transfer of a license.  She ‘may’ allow the transfer if she is satisfied that the new owner will provide a quality service and “operate competently and with honesty and integrity”.  Now it seems to me it should take the Ministry longer than a few weeks over Christmas to assess whether a new owner meets these criteria.

Then there is also the concern about location.  The license is tied to a location and clearly there is nothing but the license being sold.  Is there a lease on the building?  Is it up?  And there appears to be no equipment or staff.  So the purchaser will be setting up a new business with a non-conditional bid and a closing date of less than two months. If the Minister rejects the transfer than we potentially lose needed services, and certainly the purchaser loses money: pretty high stakes for a non-conditional bid.

The transfer cannot really be non-conditional unless the transfer is relatively free from ministerial interference: somewhat like what happened with the establishment of Specimen Collection Centers (SSC) under the laboratory licensing provisions.  The Ministry simply stopped fulfilling its obligation to protect the public interest in the location of SSCs. The indication is that now the transfer of IHF licenses and location of facilities also operates without any significant Ministry control and outside the LHINs, which were supposed to be integrating health care in Ontario.  This would be a good topic for the auditor when the office next examines IHFs.

The ad also shows that these licenses have a market value independent of quality, quantity or accessibility of care. A market price tied to a license only drives up the cost of care.  The private market in the sale of licensees would also facilitate the corporate consolidation of Independent Health Facilities in Ontario: creating a stronger force for more for-profit health care.

Those who doubt the primary business interests in family medicine should take a good look at The Medical Post’s classifieds and follow the money.

The Independent Health Facilities Act can be found at:

http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90i03_e.htm.  The ihfacution-ad was in the October 9, 2012, print edition of The Medical Post.

 

Canada Health Act used in Zombie Defence of For-Profit Health Care

Andrew Duffy, in an article syndicated by Postmedia, made the logical equivalent of mixing metaphors when he used the Canada Health Act (CHA) to legitimize the use of private clinics. The result, as with mixed metaphors, is a “head-scratching” argument in favour of Centric’s takeover of the Shouldice Clinic.

Duffy uses a confidential government manual found by Jeffery Simpson, author of a recent book on Canada’s health care system, to argue that the CHA was not intended to prohibit the use of for-profit companies to deliver essential medical services.  This expose, complete with grainy pictures, is used to undermine what Duffy sees as a key argument of most who oppose private health care.

Unfortunately for Duffy he is not addressing those who oppose for-profit medicine nor is Jeffery Simpson’s revelation a revelation.  The existence of the manual is an interesting historical footnote but it is only necessary to read the widely distributed Romanow discussion papers to know that the CHA does not prohibit the use of for-profit companies.  As Duffy points out the CHA has been used to penalize provinces for extra billing and user fees, not for using private companies to deliver publicly funded services.

Duffy then mixes his political facts to imply that the opposition to the takeover the Shouldice Clinic by the health care conglomerate, Centric, is based in some misunderstanding of the Canada Health Act.  This is confusing. He has apparently read our letter to Ontario’s Minister of Health objecting to the takeover and it only mentions the CHA in the context that many for-profit companies extra bill, charge user fees, and allow patients to queue jump: all illegal. Duffy seems to think that because the CHA, as all pieces of legislation, is a compromise between different social forces and does not ban private companies, that it condones their use? Andrew, while we are scratching our heads, a quick trip to a logic 101 class might help.

The sale of Shouldice to Centric once again raises the issue of how best to deliver health care. Along with the well researched and documented concerns of increased cost and mortality and decreased quality and access associated with for-profit providers, which have been outlined in this blog and many other more reputable sources, Centric highlights the growing problem of corporate concentration and foreign ties in Canada’s private health care sector.

Centric is nominally a Canadian company but it has strong ties to transnational private equity firms. For-profit primary care chains, such as Appletree, AIM and MCI, are expanding their presence; laboratories and other diagnostic services have for decades been dominated by an oligopoly of multinational corporations; and Saskatchewan’s expansion into publicly paid for-profit surgery uses Surgical Centers Incorporated, a chain with facilities in Alberta and British Columbia.

Do these conglomerate chains increase the problems of for-profit care? Do they open Canada to trade challenges undermining public health care?  Do they place Canadian health care needs below foreign profit concerns?  All good questions which are hard to answer because we do not even have access to simple accountability data like, how much public money is paid to these for-profit companies?

There are problems with the CHA: one is that it does not require public non-profit delivery.

A problem with the health-care-delivery debate is that those who favour the use of for-profit companies tend to rely on fabricated arguments, for example, ‘activists oppose private delivery because they misunderstand the Canada Health Act.’  These fabricated arguments, like all other zombies, are hard to kill because their perpetrators won’t come into the daylight and address the real problems with for-profit delivery.

Duffy’s article can be found at: http://www.canada.com/health/Cabinet+document+shows+Canada+Health+open+private+clinics/7383633/story.html

The Risks of For-Profit Community Care

With the sale of the Shouldice Clinic to a health care conglomerate it is useful to review some of the literature comparing for-profit hospitals to non-profit hospitals. The results show that:

1)      there is a higher risk of death in for-profit hospitals, http://www.cmaj.ca/content/166/11/1399.full :

2)      private for-profit hospitals result in higher payments for care than private not-for-profit hospitals,  http://www.cmaj.ca/content/170/12/1817.full, and:

3)      on average, not-for-profit nursing homes deliver higher quality care than do for-profit nursing homes,  http://www.bmj.com/content/339/bmj.b2732.abstract.

These studies stand-out because of their very large sample sizes.  All of the results are based on multiple peer-reviewed studies ending up with sample sizes of dozens to thousands of hospitals and hundreds of thousands to millions of patients.  While there are individual studies with contrary results the strong trends are clear: deaths and costs increase in for-profit hospitals and in for-profit nursing homes quality decreases. This is not a presumption of problems with private hospitals, as Andre Picard writing in the Globe and Mail recently stated, but a well-researched fact.

While studies with similar breadth have not been done on community health clinics and primary care services, the hospital data is so strongly in favour of public non-profit provision it does beg the question, why experiment with for-profit community services?

Missed Opportunity: Corporate Conglomerate Buys Shouldice Center

The Ontario Government has missed an opportunity with the sale of the Shouldice Clinic to health care conglomerate, Centric Health.  The government could have purchased Shouldice and integrated its services into the public health care system: after all, Shouldice was funded from the public purse.

A good comparator for the missed opportunity is the Kensington Eye Centre, a stand-alone non-profit facility which specializes in eye care. It has become an example of how specialized care can be given within the public system when there is sufficient demand for similar procedures.

Shouldice was established before Medicare and, like many other pre-Medicare private services, it was “grandfathered” and permitted to continue operation.  In part, the good working relationship between the center and the public system, no attempts were made by the Shouldice family to undercut public delivery, a common problem with most for-profit corporations, allowed the arrangement to continue.  Shouldice was an anomaly which by its differences from most for-profit providers shows why for-profit provision is not a desirable addition to our health care system.

Centric Health, the purchaser, is a publicly traded company on the Toronto Stock Exchange. It is pursuing a strategy of “mergers and acquisitions and expansion opportunities” to “create meaningful stakeholder value”.  What this means is that Centric will take public money and use these resources to buy up other health care properties in preference to expanding new services, improving quality or improving access: all primary priorities in a public system.

We will be funding an emerging health care monopoly, as happened in medical laboratory services, not better services. Centric owns Lifemark Health, an elder care service company, a chain of methadone clinics, a orthotics company and MIC which, with CML Health Care, controls 23% of the Ontario’s community diagnostic services.

Also, we will not know most of Centric’s owners, only its directors and operating officers.  This was one of the big changes in the medical laboratory industry in the 1970’s.  The for-profit laboratories were rapidly expanding and the government thought they would control conflict of interest, over use and over charging by keeping track of doctors who were lab owners.  The Ministry of Health sent out a directive that all the companies had to report their owners.  MDS, now Lifelabs, had just become publicly traded and replied with a curt, ‘good luck’: we are public traded, with thousands of shareholders, some of whom will be doctors and you will not be able to track any conflict of interest.

In the end the fortunes of Centric health are determined by its ability to thrive on the stock market, not by how much we need its services, the quality of care, how it influences public policy to enhance the common good, or how it uses excess funds to improve health care.  While all of these will impact its share price, the bottom line is if it does not make a profit for its shareholders it will go out of business.

Centric currently trades at 73 cents a share on the TSX with a 2.3% increase on Sept. 10.  Investors are pleased with the possible acquisition of Shouldice and Centric’s increased access to public funds, but that does not mean the public should be.

The Ontario government has missed a key opportunity.  It could have made a stronger public system instead it seems determined to allow a significant expansion of corporate health care in Ontario.

Methadone Clinic Limits Doctor’s Employment

One of Ontario’s little known private secrets is that most methadone, a staple of opiate addiction treatment, is primarily provided by for-profit clinics. Last week a doctor who works in one of these private clinics casually told me that her contract with the clinic forbade her from working for another methadone provider.

The context for the comment was that a clinic was looking for a part-time physician and she could not apply for the job. I guess her “employer” is concerned that she might steer some of her patients, and their money, to the other clinic.

This artificial barrier to the efficient use of skilled medical professionals increases public cost. Many methadone doctors work part-time.  They undergo an extensive training program to gain their methadone licence and are in short supply.  It is easy to imagine that a doctor working a part-time shift at one clinic might have a schedule that fits a part-time shift at another clinic that needs a physician. There is an obvious solution to this employment mismatch which works for the doctor, the clinic with the  short-staffed shift and the provision of methadone treatment, but is not workable because a chain of methadone clinics wants to protect its business.

And most of the money being played with is public.  OHIP, Ontario’s public health insurer, pays for the doctors’ visits, drug tests and other medical care.  The Ministry of Health covers the cost of the drug and disability insurance, welfare or seniors’ drug plans, all public money, pay most of the dispensing fees, which are in the range of twelve dollars a dose. The bottom line is that this is a publicly funded program primarily delivered for-profit chains who create restrictions that decrease the efficient use of the resources needed to provide a necessary service.

A similar contractual difficulty limiting good quality health care came to light a few years ago when private companies were increasing their presence in the delivery of publicly funded home care. Comcare, a for-profit in the same business conglomerate as Dynacare, one of Canada’s three multinational medical laboratory companies, had an employment contract clause forbidding its employees from talking about their policies and procedures.  This gag clause works against a central safety mechanism in our health care system: the moral obligation, and for registered professions, for example, nurses, doctors and therapists, the legal obligation to report dangerous conditions.

Contracts like these add cost and dysfunction to our heath care system.  Unfortunately I am sure they are only the tip of the iceberg. Rather than uncovering snippets of information over coffee, a basic accountability stipulation would be that companies receiving public money must make all their contracts affecting staff and the provision of care public.  After all we are now posting union contracts, management pay scales and hand washing statistics for public institutions on-line.  Lets level the playing field.

 

Are OHIP Fees to High? – Part 1

Ontario’s recent decisions to cut fees for doctors’ services and move more services from hospitals to community facilities, called independent health facilities (IHF), raise numerous questions about doctors incomes, fee-for-service payment and for-profit clinics.

The Ontario government is arguing that they need to cut many fees because technology has changed making it less costly for doctors to perform certain services.  The government wants “better value for money”.  These arguments leave the impression that there is some measurable process to determine the value of medical services.

Predictably doctors are crying foul.  They argue that the technologies are expensive, staff costs are ongoing and services will need to be cut if fees are cut: once again reinforcing the idea that there is some objective logic to fee setting.  A position supported by doctor’s organizations which for a century have had committees of doctors that determine the value of a service.

The problem for both parties is that the relationship between fees and the actual cost of providing that service is tenuous.  There is a ‘ballpark’ relationship: a visit to a doctor for a sore throat is paid less that a cardiac catheterization.  But below this level of generality the precision falls away dramatically.

This is not a new observation. From my own research, when lab fees in the 1970’s were set by committees of doctors, pathologists earned millions of dollars from their connections to the expanding for-profit laboratory industry. When this became public the resulting political storm – a million dollar income from the public purse was even more outrageous back then – alleged conflict of interest, inflated fees and, if not fraud, highly questionable billing practices.

The Ontario Medical Association (OMA) responded by establishing a new and improved fee structure for laboratory services.  Within two years of the new fees being introduced the Ministry of Health found that there was no reliable data to determine what a fair fee for a laboratory test was. A finding identified again, this time by Ontario’s Auditor General, in 2005.

In 1996 and 2004 Ontario’s Auditor General also found that it was not possible to adequately assess whether the fees paid to independent health facilities reflected their costs.  In 2007 the Ministry of Health said that they were still working with the OMA on solving the problem.

Marketplace, an American TV show, found similar problems in the United States. Marketplaces’ analysis of the Relative Value Update Committee (RUC), the committee of the American Medical Association that recommends fees for medical procedures, detailed how physicians, specifically specialists, can increase the values of certain procedures in their favour.  One commentator said “that if you want to know what is wrong with health care, Google the RUC…a process that for all intensive (sic) purposes isn’t a public process, and doesn’t appear to be accountable to much of anybody.”

I can safely say that these three examples are just the tip of the iceberg of problems with fees paid to medical professionals.  In all instances procedures and technologies change so quickly that, even if fees start out being relatively appropriate to the service, they quickly become obsolete.  There is also the overwhelming problem of conflict of interest with doctors setting their own fees than solely determining what required care is.

So are physician’s fees exorbitant?  Who knows from a technical point of view?  The bottom line is that what we pay doctors is a social decision that reflects technical considerations, training, cultural norms, economic factors and political power. Historically doctors have demanded, and been given the right to set their fees and bill what they want.  Ironically, over the last forty years, as the world has lurched towards greater corporate control, doctors, as private practitioners, have come under greater government control.

At the same time setting prices for medical services through some sort of bidding process in a market environment or administrative procedure has become more common: mechanisms that work well with the private delivery of health care and for-profit medicine.

The recent conflicts between the OMA and the Ontario government raise other issues that will be discussed over the next weeks in an ongoing evaluation of the changes in the fee schedule and the push for more Independent Health Facilities.

More Local Lab Service Cuts

It seems that the government is now using changes in the OHIP fee schedule give more work to the for-profit laboratory corporations.  This reduction in patient access is documented by Rita Marshall in the June 22 edition of the Mitchell Advocate.  Mitchell is a town in the Municipality of West Perth near Stratford Ontario.

Don’t like the fact that Mitchell Family Doctors send patients out-of-town for blood work now? Blame the province, says the office.

“Blood work is an important diagnostic tool and we were pleased to provide that service to our patients so they did not have to leave our community,” wrote office manager Sherry Kraemer in an email.

“It is unfortunate the government does not see value in that.”

The practice stopped performing blood work on patients about three weeks ago after learning about funding changes to the OHIP Schedule of Benefits effective April 1, 2012. Kraemer noted that the province unilaterally imposed the cuts.

“It’s just no longer feasible for us to offer that service,” Kraemer said in a phone interview. “The doctors are upset about it as well but it just seems to be the direction that the government is heading.

“It wasn’t an easy decision and I don’t think anyone’s thrilled about it, but it is what it is.”

Patients who require blood work must now go out-of-town, either to Lifelabs at Stratford’s Jenny Trout Centre or Stratford General Hospital, Seaforth Community Hospital or Clinton Public Hospital.

Kraemer said the waits at Lifelabs may be shorter if patients book an appointment online. Patients can book an appointment through www.lifelabs.com.

Independent Health Facilities and For-Profit Delivery: Reassuring Words, Troubling Results

Who said these words and when?

We have three broad objectives: to develop a more community-based health care system to ensure that patients receive quality medical care as close to home as possible; that the procedures are carried out in a safe, effective manner; and to regulate facilities so that they are appropriately located and established in a planned way.

What we want to see is the freeing up of hospitals to do what they do best: provide the patient care and the patient care services that require a hospital setting. As a result, our institutions will be free to direct their expert care to those most in need, which in turn will result in substantial savings and efficiencies in our hospital sector.

For community-based facilities, the Ministry [of Health] will give preference to Canadian and not-for-profit groups. (minor editing was done to improve word flow)

You could be excused if you guessed Deb Mathews, Ontario’s current Minister of Health, or Dwight Duncan, the Minister of Finance. Either could have used these exact words when describing the 2012 changes in funding to health care.  But you would be wrong.

Elinor Caplan, Minister of Health in 1988, made these comments when she introduced the Independent Health Facilities Act (IHFA).  The IHFA legalized and structured the market for non-hospital facilities that provide medically necessary procedures, much the same as the Laboratory and Specimen Collection Center Licensing Act did for private laboratories.

Both of these pieces of legislation created separate silos for private providers further dividing health care provision.  A fact reinforced by Ontario’s recent initiatives to move more hospital services into the community.

I know that Caplan, presaging recent comments by Minister Mathews, said that preference would be given to non-profit providers, but what is the result of her government’s actions?

Twenty-five years after the introduction of the IHFA the ten largest for-profit chains governed by the IHFA account for 2% of all the providers yet hold 38% of all the licences and control 24% of the locations.  Two companies, CML Healthcare and Medical Imaging Centers have 23% of the licences. Limitations on public data provided by the Ministry of Health make more interesting comparisons, like income, corporate interlinks, volume of patients and quality records, of these publicly funded health care providers difficult, if not impossible, to obtain.

The words that Caplan and Mathews use are reassuring but the outcomes of their actions are troubling. One consistent fact has been the disconnect between what they say and the continued expansion of the for-profit sector to the detriment of public services and patient care.