Posted tagged ‘integration’

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.

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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.

Independent Health Facilities and For-Profit Delivery: Reassuring Words, Troubling Results

May 22, 2012

Who said these words and when?

We have three broad objectives: to develop a more community-based health care system to ensure that patients receive quality medical care as close to home as possible; that the procedures are carried out in a safe, effective manner; and to regulate facilities so that they are appropriately located and established in a planned way.

What we want to see is the freeing up of hospitals to do what they do best: provide the patient care and the patient care services that require a hospital setting. As a result, our institutions will be free to direct their expert care to those most in need, which in turn will result in substantial savings and efficiencies in our hospital sector.

For community-based facilities, the Ministry [of Health] will give preference to Canadian and not-for-profit groups. (minor editing was done to improve word flow)

You could be excused if you guessed Deb Mathews, Ontario’s current Minister of Health, or Dwight Duncan, the Minister of Finance. Either could have used these exact words when describing the 2012 changes in funding to health care.  But you would be wrong.

Elinor Caplan, Minister of Health in 1988, made these comments when she introduced the Independent Health Facilities Act (IHFA).  The IHFA legalized and structured the market for non-hospital facilities that provide medically necessary procedures, much the same as the Laboratory and Specimen Collection Center Licensing Act did for private laboratories.

Both of these pieces of legislation created separate silos for private providers further dividing health care provision.  A fact reinforced by Ontario’s recent initiatives to move more hospital services into the community.

I know that Caplan, presaging recent comments by Minister Mathews, said that preference would be given to non-profit providers, but what is the result of her government’s actions?

Twenty-five years after the introduction of the IHFA the ten largest for-profit chains governed by the IHFA account for 2% of all the providers yet hold 38% of all the licences and control 24% of the locations.  Two companies, CML Healthcare and Medical Imaging Centers have 23% of the licences. Limitations on public data provided by the Ministry of Health make more interesting comparisons, like income, corporate interlinks, volume of patients and quality records, of these publicly funded health care providers difficult, if not impossible, to obtain.

The words that Caplan and Mathews use are reassuring but the outcomes of their actions are troubling. One consistent fact has been the disconnect between what they say and the continued expansion of the for-profit sector to the detriment of public services and patient care.

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.

Update on Thessalon and St. Joseph Island

February 10, 2012

The facts as we now know them:

Despite what the hospital web site says there are no lab facilities at the Mathews Memorial Hospital or the Thessalon Hospital. Neither has a laboratory license.

Blood is taken at these facilities by hospital staff and sent to the main lab at the Sault Area Hospital for processing.

Both hospitals have been taking blood from community patients for years under these conditions.

If there is now a concern about the legality of this service there is a simple solution: the Sault Area Hospital could apply for a specimen collection center license at the Mathews Memorial and Thessalon sites.  It is an easy process, with minimal cost – less than the cost of gas paid by all the patients that will now be forced to drive to the Sault each year for their blood taking.  The buildings are all ready there, the equipment is there, the skilled staff is there and the transportation network back to the Sault is in place.  It seems like a no-brainer.

If some solution using the hospitals is not found we could end up with one of those “fact is stranger than fiction” situations.  What we could have in these northern Ontario communities is laboratory specimens being drawn in Mathews Memorial and Thessalon hospitals and being driven numerous times a day back to the main Sault hospital laboratory for processing.  Simultaneously, community patients from these same communities are being expected to get in their cars and drive 80+ kilometres to the Sault so they can have their blood taken at a private lab. And, to add to the traffic on the highway 17, the new best interim solution is that Lifelabs will set up a one hour clinic once a week in these communities and drive the blood to the Sault.

On the way back to the Sault the Lifelabs drivers will probably pass the vehicle driving the blood from the patients in the satellite hospitals as well as all the community patients who were not able to make it to the one hour clinic. The big winners are the oil and gas companies and the private labs.  It is craziness for public resources, patient’s time and access to an essential medical service.

The Silo Strategy –Part 1

January 31, 2012

How did the for-profit labs become the sole providers of laboratory services for all non-hospital patients in Ontario?  These patients, often called community patients, usually need a lab test that is ordered by their family doctor or a nurse practitioner.  In Ontario multinational corporations have achieved a feat unparalleled in any other province in Canada.  They have complete domination of the community laboratory market.  All other provinces use public non-profit facilities to serve rural and northern areas and most, if not all, urban community patients.

In 2000 the Ontario Association of Medical Laboratories, the lobby group for the private laboratories, argued that government policy should recognize hospitals and commercial laboratories as the primary providers in the sectors they controlled. This silo strategy emerged from the failure of the for-profit laboratories to successfully expand into providing inpatient services in the 1990’s.  Since then the for-profits have actively opposed integration, fearing that integration would bring about their decline, as it did in Alberta and Saskatchewan after the private labs were bought under the control of those provinces regional health authorities. Opposing integration also improved their chances of increasing their share of the community market: which they have done, with help from their government friends.

We may never know the back story behind this result.  But a couple of recent legislative changes were important. The 2006 change in the definition of a hospital in the Public Hospitals Act helped compete their anti-integration-silo strategy.  This amendment was tacked onto the legislation that brought in Ontario’s regional health authorities, the LHINS.  Section 52 of the LHINs legislation changed a hospital from a place that can care for all people who are ill, to one focused on those admitted to hospital. The change limits access for community patients to all those services that hospitals provide.

By legislatively narrowing the scope of hospitals the government has limited the possibilities for integration.  If each region is to make maximum use of all its health care resources in the way that best suits that region, precluding hospitals from being used in certain ways undermines the their best use: it takes away options. Narrowing the role of hospitals increases the potential market for-profit companies even if it decreases access for community patients and increases health care costs.  The limited definition of a hospital not only affects laboratories services, but other services like imaging and rehabilitation, that patients are finding increasingly hard to access in a hospital.

It is not clear what back room dealing brought about this change but the winners are Lifelabs, Gamma Dynacare, and CML.

Changes in a second piece of legislation, the Commitment to Medicare Act of 2004, were a complementary precursor to the changes in the definition of a hospital and also favoured the for-profit silo approach: that is the story in next week’s blog.

LHINs Undercut Integration

January 26, 2012

Even though I have not met the CEO of the Sault Hospital in northern Ontario I expect he is an honorable person with a difficult task: to justify the unjustifiable.  It is on his orders that the Thessalon Hospital and Mathew’s Memorial Hospital, small rural hospitals, closed their doors to the local community for blood taking. Residents now have to drive 85 kilometers to a for-profit specimen collection center in Sault Ste. Marie.

A column in the Sault Star reports that the CEO said that the Laboratory Licensing Act somehow restricts hospitals from collecting specimens from community patients.  The fact is facilities with laboratories, like hospitals, are explicitly excluded from specimen collection center licensing.  It is this exclusion that has allowed hospitals to collect blood samples from community patients since licensing began in 1973.

The second reason given is that the hospitals need to focus their resources on providing acute care in line with the Public Hospitals Act. I initially thought the reference to the Public Hospitals Act was as much of a red herring as the Laboratory Act reference.  Many hospitals in Ontario still provide x-rays, CT scans and MRIs to community patients and public hospitals have provided lab access for decades. In the many discussions about hospital lab closings around Ontario no one had given a new directive, regulation or legislation as a reason.

It seems, after some more research, that the reference to the Public Hospitals Act has some basis. Ironically, section 52 of the 2006 legislation that established the Local Health Integration Networks (LHIN)(emphasis added) also changed the definition of a hospital.*  Hospitals used to be facilities set up for “the treatment of persons afflicted with or suffering from sickness, disease or injury”: simple enough and broad enough to be of maximum benefit of the community.  In 2006, the Liberal government changed the “purpose” of a hospital to serving inpatients and outpatients registered with the hospital.

I can find nothing in the Act that prohibits hospitals from serving community patients.  Hospitals still do serve many community patients who need a variety of diagnostic and other procedures.  Under whatever provision this work is done it would seem that a similar rule could be applied to lab services.  The Public Hospitals Act also allows the government to make directives in the public interest, for instance, to improve access.  The government could use this very reasonable provision and direct hospitals to provide needed services to their local populations.  This is particularly important in smaller communities where there are no other specimen collection centers.  If all else fails doctors could register all the local residents as outpatients or patients could simply go the emergency and register as patients: a much more expensive but workable option.

But all these machinations miss the point.  The LHINs were set up to integrate, rationalize, amalgamate and restructure health care and it is incongruous that tagged onto the LHIN legislation were restrictions on what services hospitals can provide.  This section reinforces silos within health care and undercuts integration efforts.  For example, community patients must use an out-of-town for-profit lab while hospitals have a local laboratory for inpatients that the community could use.

There is also a broader issue.  To make best use of all our health care resources, we need flexibility to use our core facilities, like hospitals, to maximum advantage and this is inhibited by the change in the definition of a hospital.

The Public Hospitals Act explanation may not be a total red herring, maybe just a little pink, but it still is not justifiable.  It does not pass the smell test.  It is rank that our government restricts the use of a public facility forcing residents to drive 85 kilometers to go to a for-profit lab to have their blood taken.  It may work for the labs shareholders, but the residents of Thessalon, St.  Joseph Island and dozens of other communities in Ontario probably feel differently.

*An Act to Provide for the Integration of the Local System for the Delivery of Health Services, assented to March 28, 2006.  The sections amending other pieces of legislation are left out of further amended acts on the LHINS.