Ontario's plan to clear its surgical backlog gets the "private" treatment, but is the criticism valid?
A closer look at what backlash is warranted, and what will be required to make this plan a success - regardless of if it is publicly or privately delivered
There are those that can do no wrong, and then there are those that can do no right.
Unfortunately for Premier Doug Ford, people have placed him square into the latter category.
I am by no means a Ford loyalist as I think there is much he has done/is doing that is worthy of major criticism, but the recent healthcare announcement about the province’s focus on scaling up community surgical and diagnostic centres is not one of those things (as of now).
For those that haven’t been following, Ontario announced that the province is going to further leverage surgical and diagnostic centres in the community to reduce our eye-popping surgical backlog. The idea of shifting services out of the hospital has been something we’ve been working towards as a health system for a long time. It is also a trend that the entire international healthcare community has long agreed with.
So why the backlash? Well, inclusive in this announcement was the most dreaded word in Canadian healthcare. The absolutely TRIGGERING P-word.
Private.
As part of this roadmap, there will be increased public funding for private delivery of applicable surgeries, procedures, and diagnostic imaging tests.
And when you put the word “private” directly before the word “healthcare” in Canada, reporters and opposition politicians bring out the hyperbole.
“Doug Ford is introducing American-style healthcare.”
“This is how public healthcare dies.”
“We as Canadians need to reject moves like this, where doctors won’t see you until you hand over your credit card.”
This is politics, the media, and Twitter all at their respective worst. People create sensationalist narratives that are largely inaccurate and do nothing but capture fear-driven attention. And in the process, they further polarize society and reduce the already-shrinking common ground we have across our modern political spectrum.
So with all the negativity and uproar surrounding this news, I decided to take a closer look at some of the common criticism and provide a perspective on what’s valid and what’s not.
1. “There shouldn’t be any private clinics offering these services, only public or not-for-profit.”
A lot of people assume that anything private is instantly bad or evil when it comes to healthcare, or that private healthcare equals American healthcare. This is far from the case, and this is an example of folks conflating private delivery with private payment.
Much of our healthcare is already privately delivered, but publicly paid for. This announcement is just another example of that — no credit card required, just your health card.
The public/private debate is distracting as neither are inherently good or bad. They are tools, but it is the funding, policies, and regulations around them that decide how useful those tools can be.
I believe that these clinics don’t need to be private, but they shouldn’t be restricted from being private either. As long as there is a universal accountability framework in place that ensures quality and consistency across all participating organizations — both public and private — the corporate structure shouldn’t matter. If a clinic can consistently meet a set of process, quality, and experience targets at a competitive reimbursement rate, I don’t care who owns it.
2. “Why not invest this money into untapped hospital capacity instead?”
To me, this argument completely misses the bigger picture.
Long before this backlog and long before the pandemic, there was a growing international sentiment that we need to become less hospital-centric in how we deliver care.
Inclusive in this global shift is the concept of appropriately shifting day surgeries and procedures from hospitals to specialized facilities in the community. Many countries have been doing it (and are looking to do more of it), and there are even multiple Canadian provinces that have been doing it for a few years now, including BC, Alberta, Saskatchewan, and Quebec. In this regard, Ontario is a late adopter province within a late adopter country.
Now, back to the problem at hand — if we just dumped more money into hospital operating room time, that would effectively be doing more of the same and ignoring the broader shift we need to be working towards. Sure, it could maybe help to alleviate some short-term pain, but it would deepen our reliance on hospitals when we need to be doing the opposite.
The hospital of the future should be a place reserved for emergencies and complex surgeries that require hospital-level resources. Lower risk procedures like cataract surgery, hip/knee replacement, colonoscopies, and MRI and CT scans generally don’t need to be done in large acute facilities, but unfortunately the overwhelming majority of them are.
3. “Why are these Independent Health Facilities (IHFs) getting reimbursed a higher amount than the current hospital rates?”
This all stems from some Twitter bickering I came across, but the long-and-short of it is that the ambulatory surgery centres (AKA IHFs) are apparently getting paid more than hospitals for the same procedure. For example, ambulatory centres are getting $605 for each unilateral cataract surgery, while the average rate for this procedure in a hospital — via something called a quality-based procedure (QBP) — is $455.
So the IHFs are getting paid over 30% more per procedure than their hospital counterparts. Now you might be asking yourself, I thought ambulatory centres were supposed to be cheaper, and it is a valid thought.
I am by no means a QBP expert, but I think there are few things to consider here. Firstly, we need to make sure we are comparing apples to apples. A QBP is a pre-set payment that a hospital receives for managing a patient with a specific diagnosis/procedure — like a cataract surgery.
Using cataracts as an example, I’ve seen some say that this hospital QBP payment is meant to cover all direct costs associated with the cataract surgery (i.e., supplies, housekeeping, nursing staff time required for the operation), while I’ve seen others say that the QBP payment is flawed and doesn’t effectively account for some of those things, as they are already covered through the hospital’s global budget.
I tried to find some more detailed information on what goes into a QBP from a bottom-up, line-by-line costing perspective, but it looks like the Ontario Case Costing Initiative (which was used to inform QBP pricing) isn’t publicly accessible — A+ for transparency!
But let’s just say the critics are right and it is an apples-to-apples jump from $455 to $605 for the IHFs. Something to consider is that there is almost always a premium attached when you are trying to change the status quo in healthcare.
If you have a goal of making people do more of something that they currently don’t do, you’ll likely need to dangle a carrot of some sort to overcome that initial change management inertia. This rings true in all parts of society, and it is no different than what we’ve historically seen in healthcare (i.e., high Ontario capitation rates to incentivize primary care providers to join FHTs, higher guarantees in early years for value-based care arrangements in the USA to spark adoption, the massive pay bump that family docs in BC just got to promote recruitment/retention).
All this being said, it would still be helpful to know how the government came up with the $605 figure for cataracts — was there another bottom-up exercise and this was the number they came to? Is it simply a higher amount to incentivize participation? Or is it something else entirely?
These are questions that you’d hope the government would’ve already had addressed, but alas, we are left with nothing but debates on Twitter with no definitive answers (yet). How $605 was decided, how it is meant to be spent, and how it evolves over time all need to be fully transparent so that we can ensure value for money and not further erode trust in public institutions.
4. “This is going to suck more staff out of hospitals when we are already dealing with a health human resource crisis.”
This is a valid concern, and it is probably going to happen to some degree if I had to take a guess.
However, if we were to see a shift of staff from public to private, that would suggest they aren’t happy in the public system to begin with (which based on the rate of burnout/early retirement/career transitions, I think we already know).
Nurses should have the right to find work where they feel safe and valued. Brian Golden, the Sandra Rotman chair in Health Sector Strategy at Rotman, said it best in a recent Healthy Debate article: Why in the world would we feel comfortable restricting the job mobility of nurses? Good question.
A lot of folks tend to get siloed in their evaluation of new initiatives. Yes, in a vacuum, this could take some staff out of hospitals, but that doesn’t mean the government can’t be doing more to prepare for that. Increasing ambulatory surgical capacity is not mutually exclusive from trying to improve working conditions in our hospitals.
To combat this risk, I think there are some things that the government should be doing in tandem, starting with repealing Bill 124 so that nurses and other healthcare workers can be paid more competitively and commensurate with the effort they have been putting in throughout the pandemic.
5. “The private clinics are just going to get all the easy cases to avoid risk and leave the complex cases to the hospitals.”
I don’t know if people are trolling when they say this, but this is literally why you stand up ambulatory surgical centres. As a health system, you want “easy” cases to be handled where they are most cost-effective and least disruptive to the patient’s life. You also want them to be handled in a place where precious OR time doesn’t have to be shared across all acuity and complexity levels.
Right now our hospital ORs are acting like our hospital EDs — they are everything for everyone, and filled with a lot of people that should’ve been able to access care elsewhere. In the ED, that elsewhere is primary care. In our ORs, that elsewhere should be IHFs.
As long as the ambulatory centres are well-integrated with the local hospital to appropriately deal with complications and continuity of care, they should absolutely be relieving our hospitals of the least complex cases — that is what they are there for.
Now, a recipe for success
Like most things, the devil will be in the details.
Ford has already said this is not a temporary solution, which is great, but to minimize any initial flaws that could compound into some of the irreversible issues that critics have flagged, there are items that need to be put in place to make this successful.
1. A comprehensive accountability framework
We have largely abstained from tying reimbursement to metrics, but there need to be strong enough guardrails in place to limit bad actors — either public or private — from abusing this system. As such, there needs to be a framework that holds participating organizations contractually accountable across a variety of categories:
Quality: For example, penalties for higher than expected post-op complications, committing to certain follow-up SLAs, meeting patient reported outcomes and satisfaction goals.
Value: Even though the province has set initial rates, providers should be able to compete on price so we can get more value out of taxpayer dollars, as long as they continue to meet the minimum quality metrics.
Equity: Ensuring access to services are within a reasonable range across income groups and geographies.
Transparency: I don’t think the idea of upselling patients on non-medically necessary features should be prohibited, but there can never be instances of clinics trying to confuse patients or forcing them to purchase some private component to access what is publicly covered. To me, this is where this initiative thrives or dies, and the penalty for any players caught acting in bad faith needs to be swift and severe.
2. Integration with the broader system
The last thing we need is another siloed group in our health system, so it is imperative that these ambulatory centres are better integrated into whatever regional planning is occurring within their geography. This could include having these centres represented at OHT planning committees, centralizing regional waitlist management so folks are more swiftly and accurately matched for surgical/DI services, and integrating pre- and post-op care with the local hospital/primary care to enable better handoffs and continuity.
3. Public and private, not public versus private
The emphasis from this announcement has thus far been on the private sector, but as our overall focus continues to shift towards community and ambulatory services (and we hopefully get out of a pandemic state), we should be striking a balance between building up capacity in the public and NFP sectors, while appropriately encouraging private sector participation at the same time. As I said, the public/private concept is a tool, not a solution, so we shouldn’t give preferred treatment to one tool over the other — or propagate the narrative that they cannot co-exist. We are all working towards the same goal of creating a better, more sustainable health system, so we should be creating an ecosystem where both can play a role in achieving that mission.
At a minimum, it is great that this announcement has at least accelerated the conversation about ramping up ambulatory capacity outside of hospitals — something that is long overdue in Ontario. Given Doug Ford’s reputation, there is ample reason to be skeptical of what’s to come, but nothing that he or anyone else has said thus far raises any major red flags in my mind, perhaps just some yellow ones.
That doesn’t mean we are in the clear.
If done poorly and in secrecy, this could further sour trust and spiral into something resembling the more problematic side of private healthcare.
If done well and in the public eye, this could be a great step towards eliminating longstanding fears around the private sector’s role in healthcare, and also a great step forward for our health system as a whole.