Archive for the ‘Quality’ 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.

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Quality Program Fee Increases and IHF Corporate Concentration

October 29, 2012

This year Independent Health Facilities (IHFs) in Ontario will start paying an annual administrative fee to cover the costs of their quality control program plus a new fee for the direct costs of each quality assessment. Prior to June 2012 the Ministry of Health had paid the College of Physicians and Surgeons out of Ministry funds to run the quality program.

The administrative fee per license is set at 860 dollars for the first year. The amount per license is not large but it is continuous.  Many IHFs also have more than one license, for instance, they may be licensed for diagnostic imaging and pulmonary function testing, so their yearly increase will be thousands of dollars. The administrative costs, plus the new fees for each assessment, are on top of increasing costs for electronic medical records, more reporting, more in-depth accreditation and quality control measures, newer technology and a host of costs.

Moving the quality control costs off the government books is a bit of a shell game. IHFs are primarily funded by OHIP payments, or in other words, public revenues. Having IHF operators directly pay for quality programs means they are going to request more money from OHIP. Either way it comes from the public purse.

The government is hoping that the IHF operators will simply absorb the costs.  Under current rules the extra charges cannot be passed onto patients because of the ban on extra billing.  Operators could ask for increased fees-for-services but in the short-term this seems unlikely given the recent fee cuts imposed by the government. Larger corporations with reserves and the ability to reduce costs through multi-site efficiencies will ride out the increases and recoup losses in future fee negotiations. Many smaller operators will simply feel the most pain.

An article in the October 2012 edition of Health Affairs pointed out an increased quality cost on the clinical side.  The authors make the argument that under the fee-for-service payment structure for surgeries in the United States improving quality outcomes can lead to decreased revenues.  Fewer complications from better quality control lead to fewer billing opportunities per surgery plus extra costs in prevention.  The logic underlying this research finding could easily be applied to other fee-for-service health environments, including most IHFs in Ontario.

In case I sound like a defender of millionaire IHF operators that is certainly not my intention. Nor do I think that quality assessment programs are not needed. They obviously are: though it would probably be better if the College did not run them with its conflict of interest – doctors run the College and are responsible for quality in the clinics – and the College’s history of questionable quality practices, at least in the laboratory sector where they are also in charge of quality.

The point is that the long-term provision of for-profit health services by small physician run facilities is a non-starter. As the costs increase to ensure quality it is more challenging for smaller operators.  Smaller operators also pay a disproportionately larger share of their expenses on the process of licensing and maintaining a separate administration to oversee the private market.  It is telling that in the fact sheet outlining the increased fees the last point discusses how IHF operators can give up their licenses. Licenses usually don’t disappear; they are taken over by other operators, more often than not IHF chains which are, in turn, often part of a larger health care conglomerates.

Small physician-run laboratories have long since moved into corporate giants, individual doctors’ practices are quickly becoming an historical artifact and IHF s are  amalgamating into fewer and larger corporations.  The dynamics of quality control and regulation among for-profit providers lead to long-term, non-competitive, corporate domination of these sectors.

The Health Affairs article can be found at: http://content.healthaffairs.org/content/early/2012/10/12/hlthaff.2011.0605

Quality Problems Plague Britain’s Largest Privatized Laboratory

October 1, 2012

The Guardian newspaper reported a decline in quality at the Kings College Hospital trust and the St. Thomas Hospital trust’s recently privatized pathology services.

The report cited in the article found an increase in clinical ”incidents” in the first year of the for-profit laboratories operations, and failure to reach “ agreed targets for the “turnaround times” for processing pathology tests 46 times in 2011, with “critical risk levels” breached 14 times.”

Serco, the multinational outsourcing corporation involved in the private laboratory, promised to upgrade the computer system which has also not gone well.

“In January 2012 a patient was given “inappropriate blood” when their medical history was not “flagged” up by the system. In May 2012 patients’ kidney damage results were calculated incorrectly after a “software fault”. The September 2011 performance review complains of the pre-operative blood transfusion interface failing at the same time every week… (GSTS’, the public –private-partnership running the for-profit lab) annual accounts show £2.7 million had to be written off in 2011 due to “potential clinical uncertainty” caused by its new [computer] system.”

The new for-profit lab has continued to lose money.  The joint venture lost 6 million pounds in 2011 which had to be covered by payments from the public hospitals involved in the partnership.  In other words, funding was taken from other public programs to pay for losses in the privatized laboratory services.

GSTS, the joint venture running the labs, is a partnership between Serco and the two hospital trusts. Serco is a British transnational company with revenues of 4.3 billion pounds, a 2009 profit of 258 million pounds and 70,000 employees. Government contracts account for most of its income.

While it is still early in the process, the largest laboratory privatization in Britain has started out poorly.

The information was uncovered by Corporate Watch, an organization dedicated to critical corporate research and is  “based on Freedom of Information disclosures, leaked documents, interviews with staff and an analysis of the company’s accounts.” Their report and the coverage in The Guardian can be found at:

http://www.corporatewatch.org/?lid=4550

http://www.guardian.co.uk/society/2012/sep/30/pathology-labs-takeover-failures

The Risks of For-Profit Community Care

September 19, 2012

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?

Monitoring Favours For-Profit Health Care

August 30, 2012

A new study by the Health Care Compliance Association (HCCA) in the United States found that non-profit health care institutions are audited by Medicare more often than their for-profit counterparts: 6 times per year compared to 4 for the for-profit facilities.  47% of non-profits were also audited by more than one government agency compared to only 27% of the for-profits.

No explanation was given for these findings, but the authors found the results “surprising”. They are correct: it makes no sense.  Media headlines in the last year include many reports of fraud by major drug companies, hundreds of millions of dollars in fines paid by private laboratory corporations and for-profit hospital chains that have been penalized for a variety of legal indiscretions.

Also, most peer-reviewed studies comparing quality in the two sectors find that you live longer and have fewer complications in non-profit hospitals and that for-profit nursing homes violate regulations more often.

One of the arguments made in support of more private profit in health care is that monitoring will increase.  The corporations will “row” and the state will “steer”.  In the country that invented this metaphor, that clearly is not the case.  The corporations steer, the state pays and it is not clear to many who need health care that anyone is rowing.

Canada also has a playing field tilted towards private firms. For-profit corporations are sheltered by privacy laws while public institutions often have their quality ratings published on web sites. Private corporations use surpluses, derived from public payments, to lobby the government, speak publicly about the value of private health care and fund more private firms.

The HCCA findings add another dimension to our understanding of the negative impact of mixed economies in the provision of essential services.  The uneven monitoring adds extra cost to the public non-profit sector and decreases pressure on corporations most likely to cause a problem.  The promise of monitoring safeguards becomes more than a cover for expanded private provision; it becomes a lever pushing in that direction.

Follow this link to read the full HCCA report:

http://www.hcca-info.org/Resources/View/ArticleId/817/Auditing-the-Auditors.aspx

Methadone Clinic Limits Doctor’s Employment

August 19, 2012

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

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

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

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

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

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

 

GlaxoSmithKline Sets Record with 3 Billion Dollar Fine

August 9, 2012

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.