Health Integration: Not in Ontario

I am sure there is a plan to improve health care. There must be: Ontario’s recent budget says it wants to improve integration, control costs and increase access.  Yet Ontario’s provincial budget just does not do it.

The section heading says “Providing the right care, at the right time, in the right place”. Praise worthy sentiments.  The regional governments, the LHINs, responsible for meeting this goal are going to be reformed again to increase their power. But the next point says that routine procedures in hospitals will be shifted to non-profit community based clinics.

The problem is that these clinics don’t come under the LHIN’s mandate; they are not part of the services the LHIN’s integrate.  These clinics are legislated under the Independent Health facilities’ Act and funded directly from the Ministry of Health.  When these services move from hospitals they will join doctors, medical laboratories and over 900 other, mostly for-profit clinics, already outside the LHINs.

So the government is shifting money from hospitals, which are part of an integrated system, making that system smaller, and increasing funding to another separate system of clinics.  The divisions will become deeper and stronger.  Hospitals and the regional governments will become weaker. I do not follow the logic, which means there may be none.

The “poster child” for this strategy is the Kensington Eye Clinic.  This center has worked because it is in downtown Toronto. There is a large local population requiring enough simple eye procedures to support one clinic performing standardized procedures.  But it is an example of how this strategy does not work for Ontario or for health care integration.

The Eye Clinic is outside the regional organizing structure. It does not provide for the movement of staff, or purchasing, or patient records, or money between institutions.   The Doctors in these clinics are among the highest paid in Ontario. And this structure will not work for most communities in Ontario: they are too small. In most communities not integrating all their service in local facilities, usually a hospital, will deprive these communities of needed services.

The one-size-fits-all approach further undermines the LHINs which are supposed to integrate local heath care to fit the needs of each region.  Having a dedicated building for one service may make sense in Toronto and maybe in Ottawa and London. Even in these communities a separate building does not necessarily mean an entity separate from other services.  It could be administratively integrated with a local hospital.  It could be located in unused hospital space and dedicated to that purpose.  There are many options all of which could work in certain situations.  But the province wants it done in only one way, a way that only works for a minority of large communities in Ontario.  This approach does not make sense.

These separate silos with different funding sources force services out of hospitals. This is how it works: the government tightens budgets for hospitals and LHINs so these organizations need to dump expenses.  Then they provide incentives and misleading information to support organizations that fall under a different ministry budget, in this case the Independent Health Facilities’ budget and fee-for-service OHIP payments.  So, like a strong osmotic pressure, work is pulled from hospitals into clinics.  The system further disintegrates.  The ability of local communities to develop the most cost efficient and effective options for their circumstances is diminished.

Part of the political cover for this restructuring is the myth that it is cheaper.  This statement is, at best, misleading. These clinics will do only the simplest cases.  That is there stated mandate. The cost per procedure compared to the average cost per case in a hospital, which includes all the difficult cases, could possibly be cheaper.  But a recent government document found that hip and knee surgeries in a for-profit clinic in Alberta were more expensive than in the public hospitals, so clinics are by no means always less expensive.  Regardless, equating clinics to hospitals is an apple and orange comparison.

If Ontario’s goal is to provide the best local health care and integrated services then the budget does not make sense.

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