Archive for the ‘Ontario Government Policy’ 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.

Ontario Budget Debate Ignores Taxes and Billions Transferred to For-Profit Corporations

March 2, 2014

Ontario’s budget debate may be high profile, but it misses two essential points.

With the NDP signaling NO TAX INCREASES (on the middle class) a serious discussion about taxes, particularly the need to increase corporate and wealth taxes, will not take place. It is hard to have any serious budget discussion without considering the income side. Many commentators have made this point.

At the same time, the expanding use of for-profit companies, often multinational conglomerates, to deliver and finance public services, is being ignored. The negative impact of private delivery on cost, quality, accessibility and democratic control of public services has been well documented and may be the most destructive government expense.

The exact amount transferred to for-profit corporations is unknown. This secrecy, by itself, is a strong democratic argument against the use of private companies. Yet, a quick look at the public accounts for the Ministry of Health shows well over one quarter of that budget is paid directly to private for-profit companies. The easy pickings for large payments to for-profit providers in health care are:

Pharmaceuticals – 4.6 Billion Dollars

Only about 2% of the Ontario Drug Programs budget is used for administration. The rest is transferred to large drug store chains and then much from there to the pharmaceutical conglomerates. The $4.6 billion figure includes $414.5 million that is paid to hospitals, Cancer Care Ontario and the Trillium drug plan which is also primarily transferred to ‘Big Pharma’.

Long Term Care (LTC) – 2 Billion Dollars

The Canadian Union of Public Employees estimates that in 2010 fifty-three percent of LTC beds were in for-profit facilities. $2 billion is low because some of the non-profit homes contract services like food preparation, cleaning and maintenance to private health care conglomerates.

Capital expenses – 1.3 Billion Dollars

Most of the $1.46 billion in the Health Capital account to build, finance, maintain, operate and/or renovate hospitals will be transferred to consortiums of multinational companies or to large private contractors.

Home care – 1.2 Billion Dollars

The Ontario Association of Community Care Access Centers says that 91.3% of the home care budget is spent on direct patient care of which the Ontario Health Coalition estimates 58% of nursing care and 64% of personal support services are provided by for-profit companies.

Medical laboratories – 680 Million Dollars

Over 93% of the medical laboratory services outside of hospitals in Ontario are provided by three multinational corporations. Ontario based for-profit companies provide the rest.

Independent Health Facilities (IHF) – 396 Million Dollars

97% of IHFs in Ontario are for-profit companies.

Physiotherapy, Assisted Devices and Home O2 – 598 Million Dollars

Community physiotherapy services, the Assisted Devices Program and home oxygen providers are primarily for-profit.

eHealth – 291 Million Dollars

The 2010-11 eHealth Annual Report says that 80% of their budget is transferred to public-private-partnerships, in other words paid to large for-profit companies.

Hospitals, Primary Care and Multimillion Dollar Incidentals

Hospitals and primary care are still nominally non-profit. However, significant portions of both their expenses go to for-profit corporations (usually very large ones). Hospitals often contract out cleaning, security, food services, information technology and maintenance. Temporary agencies supply nurses. Consultants and management services are regularly hired.

For-profit chains increasingly provide urgent care services and physician offices. These chains are paid from a percentage of the physician’s billings to the government. Management companies, IT firms and temporary help agencies also receive money from the primary care budget.

Then there are a variety of isolated payments from the Ministry of Health to private corporations: for example, the $56 million paid to IBM and the $35.6 million paid to Sykes International. The Community and Priority Services Program, with a $638 million budget, uses a number of private corporations. And the list could go on – the Ministry of Health’s budget is large and complicated.

In addition to the $11.1 billion itemized above, hospitals, primary care and incidentals probably account for billions more public health care dollars transferred annually to for-profit companies.

The use of for-profit companies is not a small problem even in this single case of the Ministry of Health. Two provincial budget provisions would increase accountability, limit further damage and require no party to directly confront the existing problem of for-profit provision.

1) Detail and publish all payments to private-for-profit corporations, and,

2) Prohibit new use of for-profit providers.

A serious debate on these suggestions would help bring the current budget bargaining back to the big issues facing Ontario’s finances: taxes and private delivery of essential services.

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.

Privatising Preventive Care – the For-Profit Flu Fight

November 9, 2012

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

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.

 

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

October 14, 2012

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