Laboratory Services Expanded in Huntsville and Bracebridge Hospitals: Point of Care Testing Fails to Meet Expectations

Muskoka Algonquin Healthcare (MAHC) has restored a regular night shift in its medical laboratories at the Huntsville and Bracebridge hospitals. This is a victory for viable community hospitals. It is also another example of the chaos caused by the government’s artificial prohibition on hospital labs performing medical laboratory work for community patients, for example, patients of family doctors.

The Huntsville and Bracebridge sites were on the cusp of a mini trend among small hospitals in Ontario replacing some in-hospital laboratory services with point-of-care-testing (POCT).* After two years’ experience the MAHC is reversing this policy and reinstating a regular laboratory night shift removing the need for most POCT.

MAHC’s Executive Officer for Diagnostic and Ambulatory Services gave two reasons for expanding their laboratory hours: 1) the savings from the switch to POCT were less than anticipated; and 2) the physicians complained about a decrease in quick accurate lab results with the reduced laboratory hours.

The recent increase in hospital mergers, regionalization and budget cuts has accelerated the trend to reduced laboratory hours in small and rural hospitals. Laboratories are often put at the top of the list when hospitals consider what services to cut.

Underlying these pressures is the reduction in laboratory volume, and income, faced by many hospitals due to the government’s decades long drive to ensure that all laboratory work for patients outside of hospitals is done in private for-profit labs. As harmful as this policy has been for all hospitals it is particularly devastating and irrational in smaller communities.

When community lab work is shipped out of these communities to centralized for-profit laboratories many of the smaller hospitals find it hard to justify full laboratory hours and a broad range of tests. As well as reducing access for community patients, cut backs in hospital laboratories have reduced services for inpatients and increased the cost to the overall health care budget.

MAHC was very much at the center of this misguided and ideological Ministry of Health policy. The Bracebridge and Huntsville hospitals were part of a pilot project program that funded small hospitals to process community work. A review of this program found that they performed the work for twenty-two dollars per community patient while the for-profit laboratories cost thirty-three dollars. Yet the government ended the pilot projects in 2007. The main reason given was to bring all hospitals into compliance with the government policy that mandated community work be processed by for-profit corporations. (Reference: RPO Management Consultants, “Laboratory Pilot Projects Review: Final Report,” Ontario Ministry of Health, March 31, 2008.)

It was after the ending of the pilot project program that MAHC attempted to meet decreased revenue by shifting some of the hospitals laboratory work to more POCT testing. It is now clear that that change did not improve patient care or save money.

The message in this story is that vital accessible small and rural hospitals need to maintain necessary medical services. The government needs to fund these services and allow communities the flexibility to maximize their use of health care resources. In this case, it means allowing hospitals to process community lab work, but it extends to all medical services.

Congratulations to MAHC for providing more comprehensive laboratory services to its patients. It is now time for the Ministry of Health to fund this needed hospital program and to change its policies to allow integrated, accessible, cost-effective medical laboratories.

*Point of Care Testing (POCT) is medical diagnostic testing performed outside the clinical laboratory in close proximity to where the patient is receiving care. POCT is typically performed by non-laboratory personnel, usually nurses, and the results are used for clinical decision-making. POCT devices are often ‘hand held’ or may be small portable analyzers. POCT is generally more expensive than in lab testing and quality assurance requires through protocols and skilled maintenance. POCT tests available include blood glucose, urine dipsticks, blood gases, chemistry, hematology, coagulation, cardiac markers, and pregnancy tests.

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.

Response to Toronto Star Pro For-Profit Clinic Opinion Piece

On December 10, Rick Janson, Campaigns Officer, Ontario Public Service Employees Union, published the following post in response to an opinion piece in the Toronto Star:

Who should you trust? Former PC advisor shills in the Star for private health care

Francesca Grosso says she is an established expert in health care policy. A former PC health care policy director, her day job these days is a principal at Grosso McCarthy, a public affairs company for hire… continued at

http://diablogue.org/2012/12/10/who-should-you-trust-former-pc-advisor-shills-in-the-star-for-private-health-care/#more-2618

Will That Be Raspberries With Your Rectal?

The changing face of primary care is on special at Loblaws’.  Primacy, a for-profit chain of primary care clinics, has 112 outlets in Loblaw Stores. Most Loblaws’ also have in-store pharmacies.  The synergies are obvious.  Primacy’s web site says, “an on-site pharmacy provides expert advice and services to our patients.”  A recently signed preferred pharmacy agreement organized by international professional services company Towers Watson is also designed to boost pharmacy sales; and presumably traffic to the Primary clinics, and Loblaws’ vegetable aisles. The preferred pharmacy agreement aims to reduce drug plan costs for the companies covered.  A win-win for Towers Watson, Loblaws’ and the Companies’ benefit costs. Employees using the drug plans get convenience, if they go to Loblaws’, and “enhanced services” offered by the Loblaws’ pharmacies.

Rounding out their current suite of health services many Loblaws’ include a GoodLife fitness center. GoodLife is a different service in that it receives little, if any, public money for its primary business.  Mind you it did just receive a very generous tax credit for a 5 million dollar donation to the University Hospital Network’s Peter Munk Cardiac Center in Toronto.

The existence of the Primacy chain and its association with Loblaws’ is what caught my attention.  In days past, a physician, or a small group of doctors, would rent, sometimes buy, an office space and run their practice.  There were many problems with this model.  Doctors ran the show, there was limited integration of other health professions in patient care, and it was hard to provide after hours or 24 hour primary care.  But at least the public money trail was fairly obvious. Doctors received medicare payments, ran the practice, and paid staff, suppliers and landlords.  Community Health Centers are a non-profit alternative that improves primary care access and local  community control.

Chains like Primacy change some fundamental elements of this service provision. Primacy, with annual revenues of 3 million dollars, has 450 physicians providing services to 3.5 million patients per annum (from company media release).  It was recently purchased by Calian Technologies Ltd. (TSX:CTY). Calian is a diversified Canadian company with a high yield dividend – a good match with Primacy’s assured payments from public insurance.  Primacy is part of Calian’s  Business and Technology Services division which primarily provides staff outsourcing, consulting and contracted management services.

Is there something wrong with these changes?  The Doctor still runs their medical practice and Primacy just makes it easier? Good questions, and since we just starting to see the emergence of these significant for-profit incursions into primary care, the concerns are more extrapolation from past experience and reasonable assumptions until we obtain more information. We don’t even know the extent of for-profit primary care  and no one is monitoring it.

The lack of knowledge is a concern in itself. No matter how you cut it the bulk of the money funding these developments is public money going to provide a core service for Canadians.  And these changes are no longer trivial.  There are many primary care chains all across Canada, employing thousands of doctors and serving millions of individual patients. If nothing else, control is shifting to corporate boardrooms.

Since it is primarily public money providing an essential service, as a minimum we need to know the contractual arrangements between the companies, and between the companies and practitioners.  In the United States, where interlocking corporate structures governing various aspect of care are common, there have been many reports of misuse: over-referring being a central one.  In Canada there has been a long history of for-profit laboratories exchanging various perks, like cheap rent and subsidized staff, for increased or monopolistic referral patterns.

Then there is the cost.  What percentage of this public money is now being used for advertising, profit, and multiple layer of administration?  And what if Calian mandates the use of a proprietary technology in the clinics, or engages its clinic staff in labour practices which the health care providers are worried might affect care?  Are their confidentiality clauses?  Are their restrictions on staff employment patterns, like the one imposed by a private methadone clinic? Are their benefits to staff for referrals to the Loblaws’ pharmacy?

These questions are just the tip of the iceberg of concerns.  The initial step is to shift our gaze onto this changing landscape and determine what these changes mean for access, quality, cost and democratic control of primary care.  Is it really useful to have the long-term stability of frontline medicine determined by the success of the raspberry futures market?

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.

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.

GlaxoSmithKline Sets Record with 3 Billion Dollar Fine

And the list goes on.  It is no secret that many for-profit health companies in the United States are regularly fined for various forms of fraud, usually cheating Medicare or Medicaid, or jeopardizing patients’ health, or both.  This is the second big one I have read about this  week, the other being cardiac surgeons working for the hospital chain HCA performing unnecessary procedures on up  50%  of patients.

The lower level of for-profit involvement in Canada’s health care system has meant less blatant fraud, though there have been prosecutions and legions of questionable practices involving private companies ‘bonusing’ doctors or patients to increase business: activities which both increase cost and jeopardize care.  It just goes with the turf of paying for private profit to provide what should be a collective benefit.

From the August 6, 2012 posting in the The Chronicle of Higher Education:

Academic Researchers Escape Scrutiny in Glaxo Fraud Settlement

By Paul Basken

Federal prosecutors triumphantly announced the nation’s largest-ever health-care-fraud settlement last month, when the pharmaceutical maker GlaxoSmithKline admitted marketing its drugs for unapproved purposes [3 billion dollar fine].

Virtually unpublicized was a key detail: One of the central pieces of evidence in the case was a 2001 scientific journal article listing 22 authors, most of them university researchers, that was actually written by Glaxo-hired authors to overstate the benefits and understate the risks of a highly profitable Glaxo drug.

For years, critics had been pointing out flaws in that study of the drug, the antidepressant Paxil, and warning that the study’s recommendation of the use of Paxil on children had dangerously misrepresented data and hidden information indicating that the drug promoted suicidal behavior among teenagers………

In the settlement announced last month, Glaxo agreed to plead guilty to two counts concerning the false marketing of Paxil and another antidepressant, Wellbutrin, and one count of failing to report safety data about Avandia, a diabetes drug.

To read the full article go to http://chronicle.com/article/Academic-Researchers-Escape/133325/?key=SW53Il9vZXNHYnpgOGtBNW1VYSBrOEt3YCEQbS9zbltcFQ.

For further comment read the post on Fear and Loathing in Bioethics http://loathingbioethics.blogspot.ca/2012/08/gsk-admits-papers-were-fraudulent-but.html.

Public Pay Public Benefits

The new graphic beside this post features logos from five corporations delivering essential medical services in Canada. The represent the reality of a broad range of for-profit companies benefiting from public payment for health services:the new focus of this blog.

For the last year I have written on for-profit delivery in Canada’s medical laboratory services. While this interest will continue, example after example illustrate the continuing threat of private laboratory companies to accessibility and sustainability of health care, they are only part of the problem. The companies depicted in the new graphic indicate the breadth of the private threat.

CML Health Care is one the three multinational corporations that take a billion dollars a year from our public health care system for medical laboratory services. CML was founded by a pathologist who made his initial wealth from the expansion of health services after the introduction of medicare.  Through a strategy of mergers and acquisition his company grew to include pharmaceuticals and a wide range of other diagnostic services.  CML currently provides over 20% of the community radiology and ultrasound services in Ontario.

The Cambie Surgical Center is one of Canada’s most infamous health care facilities.  The corporation was founded by an orthopedic surgeon and past president of the Canadian Medical Association, Dr. Brian Day, known for his ongoing clashes with the public health care system.  Dr.  Day’s clinic is being investigated for extra billing in contravention to the Canada Health Act and he is currently involved in court challenges to the validity of universal health care. Cambie brags that it has more operating rooms than most hospitals, six, and provides a range of surgical procedures, including eye, dental, orthopedic and plastic surgeries, to private pay patients and those insured by British Columbia`s universal health insurance.

The three remaining logos are from for-profit primary care chains.   The AIM Health Group: Integrating Health and Wellness runs a broad range of primary health facilities, including 11 family medicine clinics, 35 infusion therapy centers and 14 rehabilitation clinics.  It was a publicly traded company that was purchased in 2011 by Imperial Capital, a Toronto based private equity firm. AIM’s revenues in 2009 were over 54 million dollars. MCI: The Doctors’ Office, the logo that looks like a Swiss flag, in a privately held corporation that runs a chain of 36 family practice clinics in Ontario, Alberta and B.C.  The red apple is the logo of Appletree Medical Group, a healthy primary care chain with 14 locations in Ottawa and 21 around Toronto.

Sadly CML, Cambie, Appletree, MCI and AIM are a small sample of an expanding number of for-profit firms reaping the benefit of public payment. Even though many provincial governments, including Ontario’s call for moving more services out of hospitals into Independent Health Facilities, favour more private clinics their use is relatively unstudied.  I hope that more discussion and research on these for-profit providers will help in a critical evaluation of their impact.  When the public pays the public should benefit.