Posted tagged ‘Ontario’

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.


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.

Public Interest Duty Should Stop Shouldice Sale

September 26, 2012

Can Ontario’s Minister of Health, Deb Mathews, stop the transfer of the Shouldice Clinic to the health care conglomerate, Centric?  Absolutely, it is within her powers under the Private Hospitals Act: as a friend of mine said, “they wrote better laws 50 years ago.”

The Private Hospitals Act mandates that the Minister stop the transfer of a private hospital where the new owners do not have the “good character and fitness” to manage and operate a private hospital.  The Minister, if she was to do due diligence, something all ministers should do, could also use wording which says that each director and officer of the corporation has to have the character to manage, operate and be associated with a private hospital. The Ministry’s staff would be ideally suited to undertake the research, including delving into the pasts of the directors with international backgrounds.

The easiest and most responsible grounds for the Minister to refuse to transfer Shouldice’s license to Centric is her obligation under the Act to protect the public interest.  The Private Hospitals Act includes in the public interest, “the proper management of the health care system in general and the availability of financial resources for the management of the health care system and for the delivery of health care services.”

This definition is broad enough to base a decision on the evidence that the use of for-profit companies costs more, increases mortality, adds to the complexity of the system and hinders integration: problems compounded by the fact that Centric is linked to an international health conglomerate whose primary corporate strategy is growth through acquisitions and mergers.

There are numerous legal options available to the Minister to stop the transfer of the Shouldice Clinic to Centric: a questionable corporation, dubious directors and/or the public interest. The best would be if she defended the public’s interest in having a strong public health care system, a fact recognized by the liberals in their election commitment to limit for-profit community hospital services.

A copy of the Private Hospitals Act can be found at:

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.

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.

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.