Dr. Danielle Martin looks uncomfortable discussing the government’s recent plan to move hospital services into so-called specialty clinics.
On the one hand the VP of Toronto’s Women’s College Hospital sees patients every day who she believes could be better served in a community-based setting. On the other, this transfer of services out of hospitals to local clinics runs many risks, including what Martin acknowledges could be “an erosion of Medicare.”
Speaking Wednesday night at a forum organized by the Medical Reform Group at OPSEU’s Toronto Wellesley Membership Centre, Martin admits that in many ways “the horse is already out of the barn.”
That is not in dispute.
Ontario already has 939 independent health facilities; of which 904 provide specific diagnostic tests such as diagnostic imaging and nuclear medicine tests. The remaining 35 provide surgical or therapeutic procedures such as abortions, laser dermatology, and opthamology. Almost all of these independent health facilities are run on a for-profit basis.
In addition, there are another 276 “out of hospital premises” that provide everything from cosmetic surgery and endoscopies to pain management. Some of these, such as the Kensington Eye Institute, are not-for-profits, but most would be for-profit enterprises.
As part of the government’s Action Plan, Health Minister Deb Matthews intends to shift more services – diagnostics, high-volume surgical procedures and clinical assessments — out of hospital even though there is at best mixed evidence to suggest it will either save money or improve quality of care. While the stated policy is to transfer these services to not-for-profit providers, there is nothing in the regulations that limits that option.
With the sector overwhelmingly in for-profit hands, the question is, does a not-for-profit entity within a for-profit structure count? Otherwise, who exactly is going to be doing this work?
Martin is particularly concerned around the extra fees that often accompany a trip to one of these speciality clinics, whether that involves “up-selling” of services that possess little clinical value or the implementation of mandatory facility fees on unsuspecting patients who believe their procedure to be entirely covered by OHIP.
Despite the risks, Martin says that just because certain services have always been in hospitals doesn’t mean it must always be that way.
“One hundred and five per cent (hospital) occupancy — this can’t be as good as it gets for those who could be treated on an ambulatory basis,” says Martin.
Dr. John Lavis, who was commissioned to write an evidence brief last year for the Ministry of Health, says the potential is there to impact hospital budgets by as much as 30 per cent.
Lavis says he’s neither for or against the idea of such transfers, but admits there are significant risks and mixed evidence.
In his report it is particularly noted that “comparisons of costs in hospitals and costs in speciality clinics have not been subjected to a systematic review of the research literature.”
The fact that Lavis was commissioned to do this work long after the Ministry had made the decision to transfer services in its action plan raises the question of just what was the basis for that plan? Asking for evidence after the fact is more than a little suspicious.
Lavis points out that the regulatory framework is in itself diverse. The Public Hospital Act places very strict controls over public hospitals. The framework for independent health facilities is far less rigorous. For procedures done in physicians’ offices, there is absolutely no inspection of the facilities. Only the physician’s behaviour is governed by the professional college.
In his evidence brief, Lavis also raises the question, but never answers, how this shift in services is to take place “while not imperilling the hospitals that have historically provided them.”
That is a good question, especially with hospitals made fragile by years of deliberate underfunding the government claims is part of this plan to shift services.
Lavis notes in his evidence review that full-time speciality clinics could end up taking out of the public hospitals specialists who provide in-patient coverage, consultation, education and emergency room coverage.
It could also impact the critical mass that hospitals need to maintain services. The activities the private clinics could siphon off would very much leave hospitals with the more complex cases at a much higher cost — or what experts refer to as “cream skimming.”
This whole notion of community versus hospital is an interesting dichotomy, especially when several hospitals – such as Kingston’s Hotel Dieu and Martin’s own Women’s College Hospital – would be themselves defined as “community-based” for simply not having an emergency room.
Natalie Mehra, fresh off an Ontario Health Coalition campaign that has yielded more than 55,000 signed postcards opposing the further transfer of hospital services, says it could come down to equity of access.
Mehra makes the point that these clinics will be clustered in large urban centers mostly in the south. She pointed to a battle raging in Midland where local ophthalmology services are threatened by such a competition for services. That means Georgian Bay residents could have to travel to Barrie or beyond for cataract surgery. It also impacts on the ability of local doctors to make referrals.
Lavis says a similar movement in the United States led to most specialty clinics being located in mostly white middle class neighborhoods, disenfranchising many African-Americans. However, he does not think the same situation would necessarily follow in Canada.
There is also the question of what happens to patients that are not well-suited to these speciality clinics, such as high risk patients or those with multiple co-morbidities. If hospitals are divesting themselves of services they also rely upon, how far will these patients have to travel to access reasonable and safe care?
Mehra says that community governance is virtually non-existent in the private clinics, noting that even the not-for-profit Kensington Eye Clinic does not open its annual general meeting or board to the public – the kind of transparency one would expect in a public hospital.
“It’s not community governance as we understand it,” said Mehra.
Mehra fears that the transfer of such services to the community is setting us up for all-out privatization of our health system.
Procedures such as chiropody, speech-language pathology and physiotherapy are already subjecting Ontarians to significant fees outside of a hospital setting.
Martin says that hospital governance of not-for-profit facilities may be the way to go, assuring the public that there is transparency and community oversight.
Lavis says opposition to community-based care is inconsistent – we appear to be okay with stand-alone private abortion and birthing clinics, but less so with other forms of privately-organized care.
Martin says Canadian Doctors for Medicare has developed a set of principles that could be applied to the decision-making around this issue. The Health Care Delivery Assessment Toolkit is intended to help policy-makers in defining whether a model of care is in the patient’s and public’s interest.
To see the CDM’s Toolkit, click here.