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

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

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.

More Local Lab Service Cuts

It seems that the government is now using changes in the OHIP fee schedule give more work to the for-profit laboratory corporations.  This reduction in patient access is documented by Rita Marshall in the June 22 edition of the Mitchell Advocate.  Mitchell is a town in the Municipality of West Perth near Stratford Ontario.

Don’t like the fact that Mitchell Family Doctors send patients out-of-town for blood work now? Blame the province, says the office.

“Blood work is an important diagnostic tool and we were pleased to provide that service to our patients so they did not have to leave our community,” wrote office manager Sherry Kraemer in an email.

“It is unfortunate the government does not see value in that.”

The practice stopped performing blood work on patients about three weeks ago after learning about funding changes to the OHIP Schedule of Benefits effective April 1, 2012. Kraemer noted that the province unilaterally imposed the cuts.

“It’s just no longer feasible for us to offer that service,” Kraemer said in a phone interview. “The doctors are upset about it as well but it just seems to be the direction that the government is heading.

“It wasn’t an easy decision and I don’t think anyone’s thrilled about it, but it is what it is.”

Patients who require blood work must now go out-of-town, either to Lifelabs at Stratford’s Jenny Trout Centre or Stratford General Hospital, Seaforth Community Hospital or Clinton Public Hospital.

Kraemer said the waits at Lifelabs may be shorter if patients book an appointment online. Patients can book an appointment through www.lifelabs.com.

Medical Journal Kills For-Profit Lab Debate

I was surprised when the Canadian Medical Association Journal (CMAJ) asked me to write an analysis piece on Canada’s medical laboratories. My book, False Positive, clearly lays out my position that for-profit labs have no place in our health care system, which is at odds with the close, and profitable, relationship between the labs and many doctors. And I am a well-known critic of private health care delivery in general, a policy option that many doctors organizations have not supported.

Regardless, I was interested because an article in the CMAJ would reach a different audience than I had already reached with the book and spin-off speeches and articles. The CMAJ also wanted an international component. I know little about international laboratory services and was interested in learning. So I spent the summer investigating lab services in the United Kingdom and Australia.

When I submitted my first draft the editor said there was too much international content and what they really wanted was a focus onCanada’s services. Oh well, information and perspective gained, and the rewrite was easy, after all most of the data came from my own research.

The next draft was accepted for peer review. Two of the three reviews came back quite positive including comments such as, “a well written and researched paper. The results are interesting and worth disseminating.” The third reviewer felt that the article was too biased against for-profit labs, but provided nothing to refute the core evidence. A third draft was submitted based on the comments of the three reviewers.

So far the process had been fairly normal, but now it moved into the unusual. My rewrite, which met many of the concerns of the reviewers, was now deemed to be too biased by the editors but good enough to print as long as an article in favour of the private labs was included as well. They felt a need for balance. Again, they did not dispute the claims made in the article, including facts that have been used to support for-profit laboratories, only its perspective.

If the CMAJ is suggesting that to be publishable articles must incorporate more than one perspective almost none would be published. The research and analysis must be rigorous and defensible on peer review, criteria the article seemed to have met. The editors suggested, I guess to try and preserve some sense of integrity, that they would solicit another article supporting private labs and print both articles.

While I thought this was strange, I had no objection and agreed to this approach. Three months later I received a letter stating that the editors had, “not been able to attract the appropriate author to write [a paper in favour of private laboratories],” so my article was rejected. My first thought was that maybe they could not find an appropriate, I assume academic, author because there is a lack of credible evidence supporting the use of private labs. Those involved in the private laboratory industry would also not have agreed to engage in the debate because they prefer to “fly below the radar.” This is a political strategy that has been very profitable for them and it is a shame that the CMAJ would enable this lack of accountability.

As well as the organized medical profession’s intimate relationship with the private medical laboratories in four provinces the Canadian Medical Association (CMA) has been accused of trying to influence the CMAJ’s editorial policy. Five years ago the CMA relationship with the CMAJ came under intense international scrutiny after the firing of editors and resignations from the editorial board following allegations to this effect. Both the very unusual path my article took and the CMAJ’s history again call into question the journal’s independence.

My position that for-profit corporations should not be involved in the delivery of publicly funded health care is controversial but not unreasonable. It is defensible, has strong factual support and is part of an important debate on the future of our health care system. It is unfortunate if the CMAJ lets fears about upsetting the private interests of sections of the medical community override its mandate to present solid information and discussion on health care policy.

Drummond and For-Profit Health Care

Considering the 1,500 dollars a day Don Drummond was paid and the research staff at his disposal you would figure that his analysis would be more subtle and better informed.

It is not news that Don Drummond supports for-profit health care but his rationale is shockingly simplistic. The following is the key paragraph from his report supporting more private health care:

There should not be an a priori or ideological bias towards public- or private-sector service delivery. Both options should be fully tested to see which provides the best service. This should not be defined simply with respect to cost, but be quality-adjusted. As long as government remains the payer for all covered services, it should allow for a role to be played by both the public and private sectors. After all, family physicians are for the most part private-sector operators paid by OHIP for their services. And we seem to have no trouble with the idea that private companies now provide publicly funded laboratory work for health care providers. This should be extended where it is the superior model.

Mike Harris in 1999 also uses the private labs as an example of how well “the private sector has been delivering medical laboratory service for years more efficiently and effectively than hospitals.”

We should certainly be examining for-profit laboratory services, it is the largest and longest standing example of private delivery of an essential medical service, but unfortunately for Drummond and Harris any close examination shows that using private labs is an inferior model.

The residents in Thessalon, Wallaceburg, Perth, Bracebridge, and dozens of other smaller towns in Ontario would tell Drummond they are not happy with the switch to the private labs.

Similarly, many big city patients have been inconvenienced by the loss of access to their local hospital,

Many doctors report longer turnaround times with increased private delivery.

And there is the increased cost.  It is a reasonable estimate that Ontario health care system could save 175 to 200 million dollars per year by integrating community and hospital laboratory services with hospital laboratories at the center of the system.

Drummond’s other example of good for-profit health care is as misleading.  To glibly equate independent family physicians with corporate health care, like the AIM Health Group owned by the venture capital corporation, Imperial Capital Group, or diagnostic multinational CML, shows that Drummond knows more about ideological correctness than health care or economics.  Sorry Don, the overview of health care in your report would not have passed as a fourth year policy paper.

Update on Thessalon and St. Joseph Island

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.

LHINs Undercut Integration

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.

No Legal Requirement to Cut Lab Services

Residents around Thessalon and on St. Joseph Island, both east of Sault St. Marie in northern Ontario, have been recently told that their community hospitals will no longer be taking blood samples ordered by their family doctors. This follows a trend across Ontario to force all non-hospital patients to use for-profit laboratories, even if, as it is in the Algoma region, it is much more inconvenient for patients and more expensive.

The communications officer for the Sault Area Hospital, the mother ship of these two local hospitals, gave as the reason for cutting lab services that conditions of their laboratory’s licence and provisions of the Public Hospitals Act prohibited hospitals from servicing community patients.  According to a newspaper column in the Sault Star this information had been given to the hospital by a spokesperson for the Laboratory Licensing Branch of Ontario’s Ministry of Health.  Nothing about this story rings true.

I can find nothing in the laboratory’s licence, found on-line at http://www.qmpls.org, that restricts what patient’s provide the samples to be tested and it would be very much out of line for the quality assurance service to make this ruling.  Their job is to ensure that the tests results are accurate, not who can provide the blood.  Also, I can find no prohibitions against performing community patients’ tests in the Public Hospitals Act or its regulations.

I also read the current Hospital Service Accountability Agreement between the Sault Area Hospital and the North East Local Health Integration Network (LHIN) and could find no reference to who can use hospital faculties to have their samples taken or restrictions on what tests can be performed in the hospital’s laboratory.

The story from the Ministry of Health also does not ring true because hospitals in Ontario take requisitions from family doctors for diagnostic imaging on a daily basis.  Hospitals in Ontario have been performing tests on community patients since their inception, many since the middle of the last century, and I can find no recent substantive legislative changes that would restrict these activities.

All of these factors point to the conclusion that the hospital’s spokesperson was given misleading information to justify reducing access to needed laboratory services.  The real question is where did this order come from?

The coordination of these service cuts across Ontario strongly suggests that it is a Ministry of Health directive, but so far no one has come forward and provided the evidence.  Until this happens local hospital executives will continue to take the flack and provide stories to cover someone’s butt, probably the Minister of Health’s. So much for openness, accountability, strengthening the public healthcare system and improving access, all stated goals of the Ministry of Health.

British P3 Lab Looses Money

The flagship public-private lab partnership in Britain between Kings College Hospital Trust, Guys and St. Thomas Hospital Trust and Serco, a multinational government services company, lost money in its first half-year of operation.

The audited financial statements for the first six months show that Kings College, which owns 33% of the partnership, lost 217,000 pounds on the venture.  Frank Wood, a biochemist and Union steward, reports that this is a dramatic  turnaround for a pathology service that used to make money for the hospital.  Historically, the hospital’s labs have successfully competed for, and profited from, selling services to private hospital and other trusts.

While it is early in the history of this public-private business, similar attempts in  Calgary and Toronto in Canada all eventually dissolved with the work going back into the public system.  The ventures were not profitable enough for the private business and two cumbersome and costly for the public system with little added value.

In the spirit of Edmund Burke’s words, “those who don’t know history are destined to repeat it,” perhaps Britain’s National Health System would be better off trying to improve its public laboratory services rather than repeat failed public-private approaches.