One of the assumptions of the Drummond Commission report is that if health care services take place in a hospital, it is going to be more expensive.
As Tony Randall once expounded in an episode of television series The Odd Couple, when you “assume,” underlining parts of the word on a blackboard, you end up making an “ass” out of “u” and “me.”
Under such cost assumptions, Drummond recommends anything that isn’t acute care be delivered somewhere else.
The Commissioner does not say what those services would be, but it would be safe to bet it would include rehab, complex continuing care, mental health, palliative care, outpatient clinics and diagnostics, to name but a few. That’s a lot of service to come out of our public hospitals leaving us to wonder what would be left behind?
This is not entirely news. The present government has been hell-bent about doing this for some time. We have already seen closure of outpatient rehab services across the province. This is just a more direct expression of the government plan.
The reality is hospitals have been doing much better than their community counterparts on many of these fronts. This is our own inconvenient truth.
Lab testing is far more expensive in the large central privatized labs that were supposed to have the advantage of huge province-wide volumes.
The amount transferred by the Local Health Integration Networks to the hospitals for MRIs is not nearly enough to pay for the same service at a private for-profit clinic.
When hospitals started divesting themselves of rehab services, communities were left with no reasonable alternatives and patients were forced to pay out-of-pocket or use private insurance. For patients, this definitely did not represent a savings.
Dr. David Walker, the government’s lead on the ALC (alternate level of care) issue, recognized patients remained in hospital longer in the absence of accessible outpatient rehab. He specifically recommends the McGuinty government revisit OHIP funded community rehabilitation services, particularly for stroke and fracture patients.
As health care hubs in the community, hospitals should have a volume advantage.
While many of these new hospital facilities have empty floors, it is curious how building new bricks and mortar facilities in the community becomes that much more efficient? Is nobody paying for these new buildings?
As more services come out of the hospitals, the less sustainable they become – particularly in rural areas and the north.
Walker points out that if all ALC patients were moved from the hospitals, “the fiscal sustainability of the hospital would be severely challenged.” This is particularly true as the government moves further away from the global funding model. The more “easy” procedures that are taken out, the more expensive the remaining services become.
For labs, by moving community-based work to the private sector, it has also undermined hospital efficiency. When the government sought to wind-up a pilot project where small rural hospitals were paid to process community lab volumes, they found out such work allowed these hospitals to expand their scope of testing, pay for more updated equipment, and maintain round-the-clock shifts. When the testing was withdrawn and sent to the private sector at a higher cost, many of these hospitals were left without an overnight shift and had to use what is regarded as less reliable point-of-care testing.
While Drummond recommends narrowing the focus of hospitals to acute care, he remains strangely silent on the hospital’s performance around cancer care.
Working with Cancer Care Ontario, the hospitals have an admirable record. Your chances of surviving cancer are much better in Ontario than in just about anywhere in the rest of the world.
Does quality not factor into these decisions?
While Drummond would like to expand that model to create a Mental Health Ontario and a Heart and Stroke Ontario, he is reluctant to recognize the role of hospitals in that model.
By undermining the hospitals, Drummond also ignores another of his recommendations – to address labour shortages, including improving retention. Hospitals have been stable employers compared to many of the private agencies doing public work.
What is disappointing about Drummond is he didn’t think outside the box when it came to hospitals. Instead he just accepted a long string of worn assumptions that have little evidence to support them.
Instead of asking if hospitals are efficient, he just assumes they aren’t.
This is ironic given he makes numerous recommendations about more evidence-based policy. Pity he didn’t heed this advice himself.
The other irony is his report toys with the idea of actually using the expertise of the hospitals to replace the less experienced LHINs. He suggests it would be possible to run the health system from a hub of 25 major hospitals.
Regardless of whether this would actually work, it suggests the hospitals may have more merit than Drummond would publicly give them credit for.
This doesn’t mean we can’t or shouldn’t deliver more services in the community. We might want to instead recognized that are hospitals are part of that community.