Posted tagged ‘LHINs’

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.


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.

Another Local Lab Service Lost

January 8, 2012

A column in the January 8 Sault Star documents a rural community losing its blood taking services. The Thessalon Hospital, serving Thessalon and area, a satellite hospital of Sault St. Marie Hospital, recently stopped taking blood samples from community patients. Residents in these areas must now drive an extra 85 kilometres to have their blood taken in the Sault. In bad weather conditions this is often a dangerous trip, and it is a long trip for people who are ill, especially cancer patients, kidney patients, heart patients and all others with chronic illnesses that require frequent blood work.

I was struck by a few facts reported in this column. First, Thessalon is being treated unfairly compared to most other rural towns in the province. In most areas, when the community hospital stopped taking blood, one of the for-profit labs opened up close by: at least this is the case in southern Ontario. Often there were reduced hours, but the community still had service.

Second, the columnist, Doug Millroy, argues that the residents of these communities should get use to it because it is happening all over the province. It seems to me that fighting a decision that has increased cost, made it more difficult to provide full services to inpatients and cut services to community patients, should be fought in every community until it is reversed. We should not have to accept ill thought-out changes.

Last, in the article it mentions that this change is mandated by the Public Hospitals Act and the laboratory’s license. Well, I have been researching laboratory policy in Ontario for a few years and this is the first I have heard that hospitals labs are legally barred from taking community patients. Certainly, it has not been mentioned in the many discussions that I have monitored. Nor was it raised in answers to direct questions about the reasons for restricting hospital laboratory services.

It may be that there is a legal requirement though it would have been enacted in the last couple of years. Hospitals have been taking blood from all patients since they were built, in many cases for over 50 years, and no one has been charged or penalized. My understanding was that this development, moving all community blood work to for-profit laboratories, was driven by the Local Health Integration Networks and hospitals which need to save money in tight budget times. Clearly more work is needed to straighten out this story.

In the mean time, good luck to the residents of Thessalon.  As Ontario residents you have a right to reasonable access to essential health services and having your blood taken in your local hospital is reasonable.

Link to Millroy column:

Ontario’s Convoluted Genetic Test Funding

September 26, 2011

I had a discussion with a Ministry of Health employee about funding for genetic testing.  I have not yet been able to verify the details through formal Ministry channels, a process which could take years with their penchant to secrecy. Nonetheless, they are in line with the overall government approach to laboratory testing policy and seem likely.  If they are close to the truth, they are important bits of information for an informed public discussion on genetic testing.

First, when the LHINs were instituted in 2005 genetic testing was made a LHINs responsibility Local Health Integration Networks, LHINs, are Ontario’s regional health authorities.  As a consequence funding was frozen within
the public system for these tests. Few new tests were introduced and it became more difficult to access existing tests.  As with community lab work, did this result in increased use of private labs in Ontario for genetic testing at public expense? This is still unknown, but it did increase use of out of country testing, primarily testing in for-profit  American labs.

The use of the LHINs to save money in their budget by restricting testing in public hospitals is the approach they took lab tests ordered by family doctors.  The LHINs effectively closed all public hospitals in Ontario to processing community laboratory tests shifting that work to more expensive for-profit laboratories.

Using private labs in the States is significantly more expensive than performing the same test in a public hospital in Ontario.  In the last couple of years, to decrease the stress on its budget, the section of Ontario’s Ministry of Health responsible for paying for out of province health care has started to pay Ontario hospitals to do these tests.

What a fine example of silos within one ministry and convoluted policy making.  One section of the Ministry of Health is underfunding hospitals to save money forcing another section to increase its costs and ultimately fund the responsibilities of the first section so it can save money.  I am not sure that sentence makes sense, but neither does the policy.