Province needs to look at evidence around hospital mergers

Murray Martin should change his name to Dr. Doom.

Now in retirement, the former CEO of Hamilton Health Sciences is full of swagger about tough choices for health care, suggesting rising interest rates would pressure the government into making big cuts if they don’t make significant adjustments now.

Never mind that the Bank of Canada’s benchmark interest rate of 1 per cent has not budged since 2010. Changing interest rates also take considerable time to work through the system before they impact the rate the government pays on its bond debt. It’s not like the sky is about to fall.

Speaking at a Longwood’s speaker series earlier this week, the Toronto Star reports Martin as promoting BC’s approach – “we are going to make this change, you’ve got three options and if you don’t like any of them that’s too bad.”

Whatever happened to evidence-based decision-making?

Martin wildly believes the province should force more hospital mergers to find savings — this just days after the Scarborough-Rouge Valley hospital merger came to a screeching halt over the high cost of such a merger.

The problem is there is no evidence to suggest mergers save money.

When Mississauga’s Trillium Health Centre merged with the Credit Valley Hospital in 2011, the two CEOs were careful to suggest that it wasn’t about cutting costs.

“This is very much driven by a patient-centred approach and not by cost-cutting,” former CVH CEO Michelle DiEmanuele told the media back then.

In a 2012 story in the London Free Press, Ministry spokesperson David Jensen said “The Ministry of Health and Long-Term Care has not been tracking the money spent on hospital restructuring and mergers.”

Before her mysterious departure as CEO of the Ontario Hospital Association, Pat Campbell also admitted that there has been no recent studies done in Ontario analyzing the impact of mergers.

Maybe the Ministry and OHA should undertake such a study.

If the Ministry and OHA don’t know, why are they pushing hospitals into such mergers under the guise that they do save money?

After the Harris mergers in the late 1990s, the Canadian Health Services Research Foundation published an essay in 2002 busting the myth that bigger is better.

During the 1990s the number of Canadian hospitals declined from 1,231 to 929 – a drop of 25 per cent.

While not all of this can be explained by mergers, it was certainly a major part of the story.

The CHSRF said evidence on cost savings from mergers is largely anecdotal and inconclusive, noting that mergers involving hospitals with more than 400 beds tend to increase the cost of management and administration.

More significant, CHSRF takes issue with DiEmanuele’s assertion that it benefits quality, noting that larger hospital mergers tend to be less responsive to the patient, disadvantage low income patients, do not necessarily improve recruitment and retention and often lead to issues around staff morale and trust.

The essay concluded that “the urge to merge is an astounding, run-away phenomenon given the weak research base to support it, and those who champion mergers should be called upon to prove their case.”

Clearly that has never been done.

A more recent 2012 merger study in the UK noted that “poor financial performance typically continued, with hospitals that merged recording larger deficits post-merger than pre-merger.”

The Bristol University study noted that “the length of time people had to wait for elective treatment rose after the mergers. There was no increase in activity per staff member employed in merged hospitals, and few indications of improvements in clinical quality.”

The Ontario Health Coalition report, Look Before You Leap, also notes a U.S. meta-analysis that concluded most studies pegged the ongoing increased cost of hospital mergers at a minimum of two per cent more, and “sometimes significantly more.”

Mergers in Ontario have frequently resulted in organizational dysfunction.

The Globe and Mail’s Adam Radwanski documented in 2010 the years of in-fighting that resulted from the merger of three hospitals into Quinte Health Care in 1998. Both Trenton and Picton feared that services would consolidate into the more urban Belleville, leading to endless chaos. A 2005 report found the QHC board “unstable, conflicted, divided and excessively political and therefore unable to govern effectively.”

After 11 years of merger and facing an $8.5 million deficit, the government placed QHC under supervision and dismissed the board.

While Radwanski credits QHC CEO Mary Clare Egberts for steering the ship into calmer waters, last year the fighting resumed over the proposed closure of the hospital lab in Trenton. This time, though, the fighting was outside the board structure.

The Niagara Health System is another case of a merger gone wrong.

The NHS factored into the recent by-election after the government revealed plans to build a new South Niagara mega-hospital would correspond with the demise of four other local facilities.

If you looked up dysfunction in the dictionary, you’d likely find a picture of this hospital.

After years of in-fighting, service cuts, significant operating deficits, and finally deaths related to the spread of hospital borne infections, the province also finally appointed a supervisor to calm the situation at the Niagara Health System (NHS).

When we raised the perennial struggles of the NHS, Scarborough’s Biron dismissed the comparison to his own merger plans by suggesting the problem somehow was linked to the mix of rural and urban settings the NHS served.

The irony of all this is that these mergers are also taking place at a time when hospital beds are disappearing.

Last year the OHA acknowledged that there are 38 per cent fewer beds in the province than there were in 1990.

In the capital proposal to replace the four Scarborough Hospitals with one central merged facility, the Scarborough portion of the merger would have declined from 839 beds to 800 despite anticipated increases in demand going forward.

Any study of the effects of hospital mergers in Ontario would be remiss without looking at capacity issues created by such integrations.

While many CEOs like to say their mergers have been a success, the evidence is far less clear.