Archive for the ‘integration’ category

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

March 27, 2014

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.

Private Hospitals in Specialty Clinic Clothing

September 6, 2013

The provincial government’s mid-summer announcement that regulations under the Independent Health Facilities (IHF) Act will be drafted to permit “specialty clinics” raises some serious concerns. Changes in the LHINS enabling legislation will also be required. While the details are sparse the government’s stated goal is to permit the LHINs, Ontario’s regional health authorities, and Cancer Care Ontario to establish and fund clinics to provide services currently delivered in public hospitals. The government is committing that these new clinics will not harm a hospital’s ability to deliver services.

The official proposals are this general. Some best-guess inferences are: the IHF administration will be responsible for licensing and quality of the new clinics, and they will be paid under some form of global budget-facility-fee-fee-for-service hybrid probably determined through a competitive request for proposals (RFP) process. This is how democracy works these days: in lieu of accountability and transparency, the public has to read the tea leaves.

The proposal for specialty clinics continues trends that move services out of hospitals and shift planning to the regional organizations. These developments have been slow and erratic but seem destined to cut health care expenses, especially for publicly protected services, expand the power of the Ministry at the expense of both doctors – good – and the community – bad, and increase for-profit delivery and market competition in Ontario’s health care system.

These specialty clinics require new regulations because, unlike other IHFs which also take work from hospitals, they will be established and funded by organizations other than the Ministry of Health. The LHINs and Cancer Care Ontario will then be in a position to decide if they should use their money to fund hospital based services or community clinics, some of which will look like private hospitals.

There is reason to be skeptical of the claim that these clinics will only be set up if they do not harm a public hospital’s ability to deliver a service. Currently, in Ontario, there are over 900 IHFs all of which perform work that could be done in hospitals. Not all of it should be done in hospital’s but there are many instances, especially in smaller communities, where centralizing laboratory work and diagnostic services in hospital facilities would increase the hospital’s ability to provide care for its in-patients, increase access for community patients and cut overall costs. The government has opposed all proposals that would help achieve these goals.

The intent of the government to dogmatically limit the scope of all hospitals is reinforced by the 2006 changes to the definition of a hospital in the Public Hospitals Act. Formerly hospitals were institutions to improve the health of the community, under the new definition hospitals are only to provide services to acute care in-patients. This change in definition has already been used in many smaller communities to cut back or close hospital laboratory and radiology services often limiting access to community patients where is limited or no community alternatives. Almost all this previous hospitals work, to the extent that it is still done, has gone to private corporations. Unless the government’s one-size-fits-all limited approach to hospitals, symbolized by the new legal definition, is changed any commitments to safe guard hospital care need to be taken with a grain of salt.

The most reasonable interpretation of how the new speciality clinics will work is that the LHINs and Cancer Care Ontario will decide which ambulatory hospitals services will be moved to IHFs which are primarily for-profit. The decision on who should provide services will be primarily determined through a competitive RFP process, which is the method enshrined in the IHF Act: public hospitals will end up bidding against private speciality clinics/hospitals to deliver services. This outcome is a logical extension of the competitive approach the government has been using between hospitals for some services. The LHINs and Cancer Care Ontario will pay for these new services primarily by taking money from hospital budgets further increasing the threat to hospitals and public health care.

There are some potential positive benefits from the Specialty Clinics proposal. Following the recent physiotherapy changes it seems likely that these new clinics will be paid on something other than simple fee-for – service, which is helpful. Similarly moving some work in some communities to stand-alone community clinics and shifting more services to the regional planning process could make for a more sustainable and accessible health care system. To achieve these desired goals, these new clinics would need to be public non-profit and preferably run under existing hospital or Community Health Centers administrative structures. This formal linking will allow for better use of staff, greater integration and permit the government to achieve its formal goal of expanding non-profit public health care. The capital expenses required would come from the public purse making them part of the overall public planning process and reducing cost.

These new specialty clinics can only benefit our public health care as non-profit entities within a non-profit system. For these regulations to gain public support they need these guarantees as part of the proposals. Unfortunately the government’s pig-headed commitment to increasing for-profit delivery and market competition will only increase cost, and undermine integration, accessibility and quality.

Fragmentation, Private Profit and Home Phlebotomy

December 20, 2012

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 19th’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.

Health Facility License Auction Health Cost Driver

October 19, 2012

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.

 

Missed Opportunity: Corporate Conglomerate Buys Shouldice Center

September 10, 2012

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.

Health Integration: Not in Ontario

April 12, 2012

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.

Ottawa’s Integrated Hospital Laboratory Service Takes the Next Step

March 29, 2012

The Ottawa Citizen announced the start of the Ottawa area hospitals integrated laboratory service.  The Citizen somehow links this development to Don Drummond. It has nothing to do with Drummond.  This particular project dates back to 1996, is fully within the public sector and continues a long tradition, back to 1967, of Ontario’s hospitals cooperating to improve laboratory services for both inpatients and community patients.

Whether this initiative will improve laboratory services, especially for the smaller area hospitals, depends on the details, but there is potential.  This development is also not the real story.

The real story is the regulatory limitation on Ottawa’s new laboratory.  Drummond called for more integration and yet Ministry of Health’s policy is to divide the laboratory sector between inpatients and community patients. The two shall never cooperate even if it would work better.  There is no wiggle room only bureaucratic order.  So the new Ottawa project, which could integrate hospital laboratory work  with community laboratory work, and make the whole system more efficient and provide a more complete service to all patients, cannot.  Calgary Laboratory Services, where the CEO of the new lab worked before Ottawa, does just that.  It is a public sector operation that integrates all laboratory services in the Calgary area.

I look forward to seeing the details of the Ottawa operation.  One historical detail that is missing is how much money was paid to Gamma-Dynacare as a consultant on the project before 2006 and a full accounting of its influence.

While we need to wait and see how the Eastern Ontario Regional Laboratory Association works, it once again reminds us that, in the history of Canadian health care, the best solutions have come from the public sector and often involve the integration of many services.  Unfortunately in Ontario, the Ministry is bound and determined to protect the multinational laboratory companies so we are denied the best laboratory services.