12/16/15

Performance Problems: 37 Health Care Issues from the Auditor General

The litany of health care problems identified by the Auditor General in her 2015 report is frightening. Here's thirty-seven of them dealing with LHINs, LTC, EMS, Rehab Hospitals, Health Infrastructure, Home Care, and Health Human Resources.

Local Health Integration Networks (LHINs): A Lot of Problems

Rising re admissions in Ontario hospitals

  1. LHINs have not met performance expectations. "Most LHINs performed below expected levels in the year ending March 31, 2015. In that year, LHINs on average achieved their respective local targets for six of the 15 performance areas".  Also: "Based on the provincial results that include all 14 LHINs, only four of the 11 provincial targets that measure long-term goals for LHINs were met."
  2. Performance has not improved. "While province-wide performance in six of the 15 areas measured has improved between the time the LHINs were created and 2015, in the remaining nine areas, performance has either stayed relatively consistent or deteriorated since 2010 or earlier". 
  3. The Auditor also found that the performance gap between LHINs has widened over time in 10 of the 15 performance areas.
  4. There are bigger health care problems in northern and rural areas. The government promised to develop a health care plan in 2007 for rural and northern areas but failed to do so.  Given the ongoing problems, the Auditor General has recommended that the province develop this plan, as promised.
  5. The Auditor recommends that MOHLTC "should determine how best LHINs can manage the primary-care sector." Currently, LHINs do not oversee primary care (except for Community Health Centres).The Ministry says it "accepts this recommendation and will examine ways the LHIN role in primary care can be strengthened".
  6. Neither the Ministry nor the LHINs routinely verify that the information health service providers submit to them is accurate and reliable. "Without such verification, the Ministry and the LHINs cannot be certain that health services are being provided as expected, nor can they be assured that significant errors in reporting has not occurred." The LHINs show no interest in verifying the data, replying: "The LHINs and Ministry acknowledge the importance of high-quality data for decision making. Accountability for reporting accurate and timely data lies with the health service providers."
  7. Processes used to plan and integrate the health system need improvement. Notably, the Auditor notes the "LHINs could do more to define system capacity (that is, how service supply meets current and future demand for service)."The recommendation is for the LHINs to"begin to collect, over a reasonable time period, the data needed to determine the existing capacity of all health services in their regions"
  8. The LHINs should "identify further group-purchasing and back-office integration opportunities in the various health sectors, and implement these cost-saving practices." The LHINs say they will "support" such integration but note that that they will on clinical integration instead: "Consistent with the LHIN mandate, LHINs will continue to lead and focus on service integration (i.e., the integration of service delivery to patients, clients and residents) for the benefit of residents."
  9. The LHINs don't consistently measure the cost savings achieved (or not) by mergers and integration. "Only one of the four LHINs we visited tracked the cost savings that resulted from its integration projects, and then only on merger-type projects." The LHINs response sounds like they will find a measurement system that will prove these integrations are saving money: "LHINs will work toward developing a standard framework in which to identify and measure the impact of these integrations demonstrating overall value for service providers, patients and the system."
  10. The Ministry of Health and Long-Term Care should review existing LHIN boundaries. The Ministry indicated that it will review the existing LHIN boundaries to determine whether changes may be required.
  11. "LHINs are not notified of funding changes on a timely basis, and in turn do not in due course notify the health service providers they fund, resulting in cases where funding originally earmarked for health service providers is returned to the Ministry." (This may help explain the tendency for the MOHLTC to under-spend its budget.)
Comment:  [A] There are significant performance problems. Despite this, the government is reducing resources for health care.  [B] There is scant evidence that the government driven integrations and mergers of health services providers are saving money.  Notably after the Harris government required hospitals to merge, significant evidence arose that this had driven costs up, not down.  [C] There is little attempt to measure the needed capacity of the health care system.  Despite this, the government is systematically reducing the resources available to the health care system, and especially hospitals. [D] The bigger problems for health care in northern and rural Ontario are no doubt connected with the failure of the government to develop a good health care plan for northern and rural Ontario, as it had promised in 2007. We need a solid plan to deal with these issues.  

Problems with LHIN health care performance




Long-Term Care Quality Inspection Program: Repeated Non-Compliance

    Municipal LTC homes in Ontario
  1. The Ministry of Health and LTC (MOHLTC) is not following up on long-term care "situations placing residents at risk. "Specifically two-thirds, or about 380, compliance orders due in 2014 had not been followed up within the Ministry's informal 30 day target."
  2. "The Ministry’s actions are not sufficient to address the repeated non-compliance in certain long-term-care homes—We noted that homes in one region did not comply with almost 40% of the compliance orders issued by the Ministry in 2014, while homes in another region did not comply with about 17% of orders."
  3. The Auditor General notes, "Ontario legislation does not require a minimum front-line-staff-to-resident ratio at long-term-care homes—Home administrators identified insufficient staffing and training as the main reasons for their failure to achieve compliance. In 2014, long-term-care homes provided an average of 3.4 direct care hours per resident per day, while the Ontario Association of Non-Profit Homes and Services for Seniors recommends four hours. Home administrators also said that the provincial funding of $7.87 per resident per day is not sufficient to meet residents’ nutritional needs (three meals plus two snacks)."

Note the ongoing problems in the homes and the connection made to under-staffing.  

Problems in Long-Term Care




Infrastructure: Inadequate hospital funding
  1. Ontario funding is less than the renewal needs for existing hospitals. "The assessments of hospital facilities identified $2.7 billion dollars of renewal needs, requiring annual funding of $392 million to bring assets to what is considered good condition. However, since 2014/15 actual annual provincial funding has been $125 million and prior to that, since 2010/11, only $56 million was provided." 
    Inadequate capital funding for Ontario hospitals and schoools

  2. Hospitals "have had to use operating funds to fund capital" projects. "In the last five years, hospitals spent on average $45 million a year of operating funds on capital and other funding needs."
  3. Funding is less than needed not just for renewal of existing facilities, it is also inadequate for required new facilities. "Existing funding does not address significant pressures faced by ministries for new projects... the Ministry of Health and Long-Term Care has received submissions for 37 major hospital projects totalling $11.9 billion dating back to 2005/06. These submissions were endorsed by Local Health Integration Networks as needed projects requiring funding. However, the Ministry did not put forward these projects for approval to Treasury Board as these initiatives could not be managed from within their existing budget allocation."
  4. There is a bias in funding allocations towards new facilities at the expense of renewing older facilities.
Comment: Earlier reports by the Auditor General's office have documented how privatized public private partnerships (P3s) -- the government's preferred way of developing new facilities -- are wasting billions of dollars of public money.  Now it turns out that the  government is biased towards developing new facilities at the expense of renewing existing facilities. Righting this imbalance by focusing more on renewing existing facilities would put the crimp on those P3 corporate rip-offs.   Spending too much on new P3 facilities is especially bad given that the Auditor also finds that we are not doing enough hospital infrastructure projects to keep up with needs.  With most of Ontario hospital facilities over 31 years old, that spells trouble so we certainly cannot afford to waste what we do spend on privatized P3s.
Most hospitals are over 31 years old

Paramedic Services ("Ambulance"): Improving response
  1. A July 2015 consultants report collected data from 14 of 50 municipal delivery agents. "The consultant concluded that there were limited opportunities for operational efficiencies that would result in cost savings. This was primarily due to all municipalities using unionized staff with relatively similar wages across Ontario. However, the report also noted that improved call triaging could reduce costs overall in urban municipalities. Therefore, the consultant recommended that the province work with municipalities (especially larger urban ones) to increase the accuracy of dispatch systems’ prioritizing of calls. The Ministry is planning to address this recommendation in the Provincial/Municipal Land Ambulance Dispatch Working Group’s report, expected in fall 2015."
  2. The Auditor claimed little progress on minimum service levels and promotion of efficient delivery. "The consultant noted that the Ministry’s current performance measures do not reflect the key outcomes of land ambulance services and recommended that the Ministry review the current measures. The Ministry plans to share the consultant’s report with the OAPC (the paramedic Chiefs) in fall 2015 and then develop processes to promote more efficient land ambulance services by March 31, 2017"

Comment: Improvements in dispatch protocols will help paramedics respond more rapidly to emergency calls.  The other recommendations in the consultant's review, reportedly to be released to the Chiefs in 2015, should be closely followed. 


Rehabilitation hospitals: Rising demand
  1. This sector will expand as the population ages, particularly as the baby boomers turn 75. Still the Auditor notes that "approximately a third of patients admitted to inpatient rehabilitation at the two hospitals we visited with stroke programs had been assessed by an acute-care hospital as having mild functional impairment. This suggested they might have been better served in outpatient programs if these less costly services were available."
  2. There is no co-ordinated rehabilitation system in Ontario.
  3. "There was wide variation in the supply of regular rehabilitation inpatient beds across the province, which could mean that patients had to travel outside their LHIN for services. The number of beds ranged from 57 per 100,000 people in the Toronto Central LHIN to only six per 100,000 in the Central West LHIN. The provincial average is 18 beds per 100,000."
  4. The Ontario Hospital Association reported that, as of March 2013, about 2,300 alternate-level-of-care patients who were ready to be discharged were waiting in acute care hospital beds for arrangements to be made. Of these, 25% were waiting for a regular rehabilitation bed or a complex continuing care (which includes restorative rehabilitation) bed.

Comment: With almost 600 patients waiting in other hospital beds for a rehabilitation bed, more rehabilitation hospital beds will significantly reduce alternate level of care patients in hospitals.  Most of the other patients are waiting for LTC beds -- but there is precious little sign that the government wishes to expand either LTC or Rehab capacity.


Community Care Access Centres (CCACs): Wait lists and varying service
  1. Clients are still put on wait-lists and have to face long wait times to obtain personal support services.
    CCACs are taking too long to assess home care clients
  2. 2. Clients with the same assessed needs still receive different levels of services depending on where they live in Ontario.Unequal access to home care in Ontario
  3.  CCAC funding is predominantly based on what each CCAC received in prior years rather than on actual client needs and priorities.
  4. CCACs are unable to provide personal support services to the maximum levels allowed by law. 
  5. Care co-ordinators’ caseload sizes vary significantly, and some exceed suggested ranges in standard guidelines
  6. Clients may not receive appropriate levels of services as CCAC care co-ordinators did not assess or reassess clients on a timely basis
  7. Not all care co-ordinators maintained their proficiency in, and some were not regularly tested on, the use of assessment tools
  8. CCAC oversight of contracted service providers needs improvement
  9. CCACs do not consistently conduct site visits to ensure service providers are complying with their contract requirements. The lack of site visits to contracted service providers by the CCACs, and the CCAC reliance on self-reporting by contracted providers, does not sufficiently mitigate the risk of under performance or billing inaccuracies. The Auditor consequently recommends the CCACs should conduct routine site visits to monitor quality of care and verify the accuracy and completeness of information reported to CCACs. The CCACs appear to be uninterested in this, noting that they see value in mandatory provincial requirements for automated reporting to the CCACs.
  10. The MOHLTC should expedite diverting low-need clients from CCACs to community support service agencies. The MOHLTC supports this. A phased implementation is going ahead, beginning with four early adopter LHINs. This reform will reduce the CCAC scope of work
  11. CCACs should require that all CCAC care co-ordinators comply with the minimum number of assessments per month and be tested on the use of the assessment tools each year
  12. The Auditor notes that the Ministry only requires contracted service providers to annually self-declare that they have complied with the government’s $4 an hour PSW wage enhancement and so recommends that the CCACs should conduct inspections of service provider records, on a random basis, and share the results with the MOHLTC.
Comment: The Auditor’s report supports some of CUPE’s home care concerns: [1] the CCAC wait lists and the inability of the CCACs to provide the maximum care allowed supports our contention that home care is underfunded; [2] The Auditor’s concerns that the CCAC oversight of contracted providers is inadequate bolsters our contention that, given almost 20 years of CCAC contracting, it is time to consider that contracting-out for vital health care services is the problem.


Per-capita home care funding in Ontario

Human Health Resources
  1. The Auditor General had previously identified that access to health care was a problem for some Ontarians, particularly those who live in rural, remote and northern areas of the province. As of 2011, 95% of physicians in Ontario practised in urban areas and 5% in rural areas. At the same time, 14% of the population lived in rural areas. 
  2. At the end of 2011, 66.7% of nurses were working full-time in Ontario, just slightly under the Ministry’s goal of having 70% of nurses working on a full-time basis.  This percentage dropped to 63.9% in 2014.

Charts: Auditor General 2015

11/26/15

Ontario overestimates deficit -- for the seventh year in a row

Shocker.  The Ontario government is forecasting that it will beat its deficit forecast -- for the seventh year in a row.

The deficit for this year is forecast in the province's Fall Economic Outlook and Fiscal Review to be $1 billion less than forecast in the spring 2015 Budget.  The forecast for next year is already $300 million less than in the 2015 Budget.  That would make eight years in a row.

For this year, the decline in the deficit was driven by higher than expected revenue ($1.245 billion more revenue,  primarily due to an underestimation of revenue from the Hydro sell-off and $600 million higher than forecast revenue from personal income and land transfer taxes).  Lower than expected interest expense on debt ($140 million) has also helped. 

Program spending however is $397 million higher than expected.  The major in-year increases in spending compared with the 2015 Budget are in two areas, the Hydro privatization and the new Green Investment Fund:







The Liberals usually end up with lower than planned spending by the time the next Budget rolls around – so higher than expected spending may sound unusual.  

But they don't usually report lower spending half way through the fiscal year in their Fall Economic Outlook and Fiscal Review.   Instead they wait for the next Budget to make that announcement.  So, despite the report of extra spending in this Fall Economic Outlook and Fiscal Review, we may well see that overspending becomes under-spending by the time of the spring 2016 Budget and the fall 2016 Public Accounts.

Indeed, based on past experience, these deficit forecasts will be revised downwards in next spring's Budget and the fall Public Accounts.   Notably, half way through the fiscal year, the government still hasn't touched its $1 billion reserve. That may well end up reducing the deficit, as it has in the past.

Taking their strategy from legions of middle managers, the plan is to under-promise and over-deliver. For advocates of public services, however, this consistently makes things look  worse than they actually are.

Despite the long record of the government consistently overestimating deficits and then revising them downwards,  many in the corporate-owned media will continue to cast doubt on whether the government will meet its deficit goals.  Just as they have many times in the past -- with remarkable inaccuracy.

Despite the improved deficit, the government is sticking to its spending plans – “Average annual growth in program spending between 2014–15 and 2017–18 is forecast to be 0.9 per cent, in line with the 2015 Budget.” 

In fact, program expense (spending) is forecast to decline from $120.9 billion this year to $120.6 billion next.  In contrast, this year’s program spending is now forecast to have gone up 2.25% compared to last year. With inflation for current government expenditures running at 2.2% in Ontario and population growth of another 1%, we are facing some significant real cuts in public services. 

The government claims it is relying on [1] managing broader provincial public sector compensation (i.e. “net zero” settlements where any modest gain for workers is offset by other measures to create a net zero outcome for government), [2] program review and transformation (where the government cuts costs for existing programs), and [3] addressing the ‘underground’ economy (essentially to increase tax revenue).

The Fall Economic Outlook lists major broader provincial public sector union settlements that are “net zero”and brags of the discrepancy between settlements in the broader provincial public sector and in all other sectors.

Since July 2012, the average annual negotiated wage increase across Ontario’s provincial public sector has been 0.7 per cent. This is lower than Ontario’s municipal public sector (1.9 per cent), federal public sector in Ontario (1.7 per cent) and private sector in Ontario (1.9 per cent).




Real economic growth is forecast at an average of 2.125% over 2015-2018.  This year’s growth is forecast at 1.9%  -- that is quite a bit higher than the Canada-wide forecast of 1.2%, but also significantly lower than the 2.8% forecast in the last Budget.   


Nominal growth (a key driver of government revenue growth) is forecast at 8.8% over the next two years, matching exactly the government's forecast for tax revenue growth. Changes in nominal growth will be key to deficit forecasts.  

Between the Budget and the Fall Economic Outlook, the government revised nominal growth downwards from 4.2% to 2.9% as real growth fell. So the government did well to see tax revenue come in higher than expected.  

Consumer inflation is estimated to run at an average of 1.8% over 2015-18, with inflation at its lowest this year (1.3%) and then hitting 2% for the following three years.


Notably, the government is expecting significant revenue from its “cap and trade” climate change policy -- $300 million next year and $1.3 billion in 2017-18. That can only help.   

11/4/15

Canadian hospital funding now 25% more than Ontario funding

Canadian hospital funding


hospital funding -- Ontario government
Provincial government per capita expenditures on hospitals continue to decline.  This is the third year of absolute decline according to Canadian Institute for Health Information (CIHI) data.

health care inflationOf course hospital services are also affected by inflation, like other services.  One way to measure this is the total health care price index.   CIHI  reports the health care implicit price index over this three year period has increased by approximately 8.3% (160.9/148.6). That is equal to about 2.7% per year.

This inflation means the 2012/13 per capita hospital funding would have to increase to $1,534.95 in 2015/16 just to keep up with increasing health care prices.  Instead the government expended just $1395.73.

In other words, in three short years, the government has reduced real spending on hospital services by 9.1% per person ($1395.73/ $1534.95). If we considered the impact of an aging population on hospital costs (usually put at about 1% per year in extra costs), the real cut in funding would be in excess of 12% in 3 years.

Across Canada (including Ontario) provincial/territorial hospital funding continues to increase on a per person basis.  Over the same period, funding increased across Canada by $27.97 or 1.8%.  Not enough to set off inflation to be sure, but more than the 1.5 percent decrease in Ontario.   Of course Canada-wide average is powerfully  affected by Ontario.  So the rest of Canada excluding Ontario saw a 3.9% increase of $65.23 in hospital funding.

 $
Canada Hospital
Ontario Hospital
TROC Hospital
2005–2006
1,138.74
1,111.69
1,159.43
2006–2007
1,217.65
1,177.95
1,247.23
2007–2008
1,283.57
1,230.78
1,321.68
2008–2009
1,360.87
1,291.74
1,410.25
2009–2010
1,430.05
1,333.31
1,496.70
2010–2011
1,515.58
1,368.71
1,613.66
2011–2012
1,549.05
1,405.52
1,645.36
2012–2013
1,577.46
1,417.31
1,684.46
2013–2014
1,587.17
1,409.70
1,704.93
2014–2015
1,599.12
1,402.00
1,729.07
2015–2016
1,605.43
1,395.73
1,749.69

The rest of Canada (“TROC”), excluding Ontario, spends $1,749.69 per capita. In other words, provincial and territorial governments outside of Ontario spend $353.96 more per person on hospitals than Ontario does. That is a whopping 25.3% more than Ontario. That is up 2% from the 23.3% gap in the previous year.  Ten years ago, in 2005-06 the gap was only 4.3%. 

per-capita hospital funding


In the past, Ontario closely followed Canada-wide funding patterns -- but Ontario has fallen quite a long way behind since the Liberals were elected in 2003 – and especially since the beginning of Liberal austerity in 2010. With hospital funding on a downward track in Ontario, that gap will continue to grow.

Does funding in other sectors make up for hospital under-funding? Funding for "other health care institutions" (e.g. long term care facilities) does not make up for the lack of spending on hospitals in Ontario. Quite the reverse.  Ontario currently (2015-16) funds 7.2% less than the cross-Canada average.


Ontario health institution funding

Overspending on physicians continues, currently at 2.5% more per-capita above the Canada-wide average.  This, however, is a marked improvement from the 12.5% gap that existed in 2008-9.  Indeed in the most recent year reported (2015-16) there was a modest decline in funding per-capita by Ontario on physicians.

Ontario also spends more than the Canada-wide average on drugs. 
 Canadian drug funding

Public health funding had been higher in Ontario for the last decade. But health care administrative funding is low in Ontario compared to Canada. 

Ontario administrative health care funding
Administrative funding has fallen in Ontario from 2.6% of total provincial health care funding in 1974/5 to 0.9% in 2015/16. Across Canada, administrative funding has declined almost as quickly, going from 2.6% to 1.1% over the same period.  

Low health care administrative costs is one of the main ways that public health insurance is more efficient than the  private health insurance system that dominates the USA, and this data suggests that Canada (and Ontario) are gaining even more benefit from this advantage.

Ontario also falls behind Canada in funding the “other health care” category (e.g. home care), funding 14.3% less than Canada as a whole   -- despite all the claims by the Ontario government about investing in home and community care. During the reign of the Liberal government, the gap in funding between Canada and Ontario has remained consistently large.

Ontario home care funding


In total, after many years of closely tracking the health care spending of other provincial governments, Ontario government health care funding is now falling quite far behind the Canadian average – with the the other provincial and territorial governments funding health care 12.7% more per person on average. And the gap is growing. 

Ontario and Canada: health care funding

Ontario health care under-funding is primarily driven by under-funding of hospitals, which accounts for 75% of the under-spending ($353 dollars out of $475). Indeed, total health care under-funding has grown in tandem with the decline in funding for hospitals in recent years.
  
The province of Ontario spends more on drugs,  doctors, and public health, but less on “other health institutions,” health care administration, health care capital projects, “other health care,” and, especially, hospitals.  

For the numbers click here.

9/23/15

The long series of failures of private clinics in Ontario

For many years, OCHU/CUPE has been concerned the Ontario government would transfer public hospital surgeries, procedures and diagnostic tests to private clinics. CUPE began campaigning in earnest against this possibility in the spring of 2007 with a tour of the province by former British Health Secretary, Frank Dobson, who talked about the disastrous British experience with private surgical clinics.

Health care privatization in CanadaThe door opened years ago with the introduction of fee-for-service hospital funding (sometimes called Quality Based Funding). Then in the fall of 2013 the government announced regulatory changes to facilitate this privatization. The government announced Request for Proposals for the summer of 2014 to expand the role of "Independent Health Facilities" (IHFs). 

With mass campaigns to stop the private clinic expansion by the Ontario Health Coalition the process slowed.  

But it seems the provincial Liberal government continues to push the idea.  Following a recent second OCHU tour with Frank Dobson, a ministry spokesperson told the Hamilton Spectator"The province hasn't yet "shifted low-risk procedures to out-of-hospital clinics". However, with the shift, the ministry hopes to provide patients with "quicker access to complex surgeries because hospitals will be able to get to more complex procedures sooner."


Health Quality Ontario (HQO) is conducting a review of oversight programs to improve non-hospital clinics, the Ministry spokesperson noted. "The ministry will review HQO's recommendations to ensure sufficient quality oversight is in place prior to moving low-risk procedures into out-of-hospital clinics."

The ministry's claim that it has not shifted procedures to out of hospital clinics is not exactly true -- we have only slowed down the transfer of work to IHFs, other sorts of private clinics have been taking hospital and other work for years.  The IHF gambit is just the latest attempt to expand the role of privatized health clinics. 

And, as set out below, that history is replete with problems.

The unpromising history:  Hospitals are the main focus of the government’s health care cuts. They do not see community hospitals as providing a broad range of services to the local population, but instead wish to remove an untold range of services from local hospitals and transfer them to specialized private clinics. The proposal would remove the most lucrative, high volume and easiest procedures from community hospitals. The remaining community hospitals would be left with the most difficult services. If they chose to compete with the private clinics, they would have to specialize in a narrow range of services. The government’s plan is the opposite of one-stop, integrated public health care.

This proposed privatization of surgeries and diagnostic tests is in addition to the aggressive attempts to remove non-acute care services from hospitals (e.g. outpatient clinics, complex continuing care, rehabilitation, long-term care, primary care, etc.). As acute care currently accounts for only about 1/3 of current hospital funding, these attacks are a grave threat to the viability of community hospitals, and in fact we are now seeing a wave of hospital shut-downs that is somewhat reminiscent of the Mike Harris era.

Despite the government’s rhetoric about keeping care non-profit, services that are being cut from local hospitals now are being privatized to for-profit owned corporations. Even if the private clinics did start out as non-profit (which has not been the case so far) the whole system of private clinics could be privatized with a stroke of a pen.

Ontario Health Care Privatization: The push for health care privatization in Ontario picked up in 2001 when Ontario Health Minister Tony Clement announced two privatized P3 hospital projects, the Royal Ottawa and the Brampton Civic (part of William Osler Health Centre). Spirited community-based campaigns, including P3 plebiscites in many towns, forced the Liberal government to greatly narrow the scope of the privatization of support jobs (i.e. CUPE jobs) in subsequent P3 hospitals. Nevertheless privatization of the hospital financing continues, despite revelations by the provincial Auditor General that confirmed claims by CUPE and others that the Osler project cost hundreds of millions more due to the P3. A subsequent report from the Auditor General on P3s indicated that billions of dollars have been wasted unnecessarily on these projects, mostly hospitals.

MRI and CT Clinics: The PC government also tried to set up private MRI and CT clinics outside of hospitals. Community/labour campaigns however were able to stop this. A key factor was that, to increase their revenue, the private clinics were allowed to bill private patients for a certain number of hours each week (with the rest of the week dedicated to patients paid for by the public system). As the public insurance system must pay for all ‘medically necessary’ hospital services, the government was left to try to explain why any reputable clinic would allow patients to subject themselves to such tests for medically unnecessary reasons. Since this episode, private clinics have been in the news – but mostly for the wrong reasons.

ORNGE and eHealth Privatization Scandals: Privatization scandals continued with ORNGE and eHealth. In the latter case, the Auditor General revealed rotten contracting out practices. By 2008, the eHealth Program Branch had almost 300 consultants compared to fewer than 30 full-time employees. “Relying too heavily on consultants can be costly,” the Auditor said. “Consultants are generally a lot more expensive than employees, and when they finish a project, they leave, often taking with them the expertise needed to maintain and operate the system they helped develop.” The eHealth contracting-out scandal helped force out the Health Minister David Caplan, along with the CEO of eHealth, and the board chair of eHealth.

With ORNGE, reports from the Auditor General and others revealed how privatization had been used by a nominally public organization to drive up executive salaries to outrageous levels. Those salaries were kept from public scrutiny through the creation of private corporations. The introduction of private corporations into the business obscured legitimate public oversight, with ORNGE sometimes refusing to provide the Auditor General basic information under the excuse of privatization. Ultimately the disgraced former CEO of ORNGE said “I didn’t perceive our salaries would be compared to other public-sector agencies” rather than private sector salaries. “That was an error.”

Private Surgical and Diagnostic Clinics: Shortly after CUPE warned the province of the dangers of private clinics through the tour of the province by the former British Health Secretary (i.e. Minister) Frank Dobson in the spring of 2007, tragedy struck.

On September 20, 2007, Krista Stryland died after undergoing liposuction at a private clinic. Stryland bled excessively following the surgery. The College found that one of the doctors involved delayed calling 911, and when paramedics finally did arrive, they found Stryland lying in a pool of blood with no vital signs. The family doctor who performed the liposuction was ultimately publicly reprimanded and told that her “dangerous” behaviour was an “obvious betrayal of the public trust.” “Emboldened with time and experience, you proceeded to perform more and more invasive procedures and ultimately major surgeries without the benefit of formal surgical training. ...You put your own interests above your patients,” she was told.

The government had let much of the emerging industry slip entirely free of public reporting and oversight.

After the September 2007 death of Krista Stryland, the government was forced to require the industry to face some modest oversight several years later, in 2010. Unfortunately this was not by a public authority, but through self-regulation by the doctors (even though the doctors themselves had lobbied to expand this private industry).

Moreover, problems kept happening.

In the fall of 2011, following disclosure that 6,800 patients would have to be notified that faulty infection control procedures at a private clinic could have exposed them to HIV or hepatitis, the then Health Minister, Deb Matthews, declined to introduce oversight by a public authority, despite public pressure. Instead she comments, “Government can’t do everything. A professional (regulating body) like the College of Physicians and Surgeons, they take responsibility for their members....At this point I am delighted the College is taking that responsibility seriously and has found a problem that we need to fix.”

Eventually, in 2012, the College of Physicians and Surgeons released a report on "out of hospital premises" (one category of private clinics) that mentions that some 29% of the private clinics fall short in some way – but the College would not indicate which ones – or how they fell short. This caused public uproar, with the Toronto Star playing a leading role (as it would continue to do). Again, the government promised improvements.

The Star followed up and revealed that the public reports from the College of Physicians and Surgeons fall far short. They also ran a series of often front page stories on serious quality problems at private clinics, including stories on life-threatening infections during outbreaks at four Toronto pain and colonoscopy clinics. Toronto Public Health investigated the outbreaks and the College of Physicians and Surgeons inspected the clinics, but their reports were kept secret.

The new Health Minister, Eric Hoskins, ultimately responded by promising improvements of the clinics once again. He told the Toronto Star in the fall of 2014 that he has put the province’s public health units and colleges (including the college of Physicians and Surgeons) on notice that he wants investigation and inspection reports made public. “It is clear that our system must become more transparent,” Hoskins said, adding the new measures will allow Ontarians to find out if clinics have had problems with infection control and whether patients have suffered illnesses or died. Hoskins also reportedly asked for advice on this from Health Quality Ontario, an independent government agency that assesses and reports on quality in different parts of the health system.

The College of Physicians and Surgeons responded by releasing in early 2015 a report which called for itself to take over a single system of oversight of Independent Health Facilities, the Out of Hospital Program, and other clinics as well.

To date, the reports on the Out of Hospital Program on the College’s web site remain the same ― with threadbare comments.

Eight years after Krista Stryland’s death and more than eight years after CUPE warning on the problems of private clinics, the government is still trying to establish some semblance of an adequate oversight for private clinics. (For more on college regulation of the clinics, see the CUPE Fact Sheet Briefing Note for OCHU on College Regulation of Private Clinics.)

Time has run out ― the government should stop this failed experiment.

More Private Clinic Problems: Over the summer of 2013, the government got into a messy dispute with private physiotherapy clinics. The government stopped 94 physiotherapy clinics from directly billing OHIP. Ontario Health Minister Deb Matthews said that, over the years, licences to provide these services have been bought up by large corporations. Moreover, she charged, the “existing 94 clinics have had an unlimited ability to bill the government and have become very creative in the way they bill.” The government claimed that an audit of 15,000 records from the clinics found that 58% of them failed to support OHIP billings. Five-minute exercise classes were sometimes billed as physiotherapy, care plans did not measure up, record keeping was incomplete, and physician referrals were sometimes lacking.

“There is extraordinary growth in expenditures and the audit was one of those factors that just demonstrated to me that there were companies who were just taking advantage of the way the program was set out and taking advantage of their unlimited ability to bill,” then Health Minister Deb Matthews told the Star.

By reforming how the money is distributed, the government claimed they will provide physiotherapy, exercising and fall-prevention classes to 218,000 more people, mostly seniors. And they are going to do this while providing less money for physiotherapy than they otherwise would: $16,000,000 less according to the Toronto Star.

Still More Private Clinic Problems: The government was back at war with another group of private clinics in early 2014, this time the newly established private plasma clinics. The government, opposed to their plan to pay people for their plasma, wanted to shut them down.

But the clinics refused. Indeed, they said they need no license from the government to operate. In the face of this open defiance, the then Health Minister Deb Matthews was reduced to calling in inspectors and threatening to get a court order. New legislation was also threatened. “I expect any company operating in Ontario, and especially in the health care sector, to operate within our laws,” Matthews told the Toronto Star. But she admitted it may take time to shut the clinics down.

The private clinics remained unmoved: “Until that act is passed, the legal opinion we have is we don’t need a licence from the provincial government.” Perhaps they were then hoping that with an election coming a Progressive Conservative government would be more friendly. If so, that hope proved unfulfilled.
Nevertheless, the Liberal government has not yet learned its lesson and announced that it will not encourage more private clinics.

Other Private Clinic Issues:

  • Operations can and do go wrong. In contrast with public hospitals, private specialty clinics are unable to handle many emergencies and simply call 911 for EMS. Will ambulances be able to move patients to hospitals when things go wrong? Indeed, private surgical clinics first came to public attention in Ontario when a young mother, Krista Stryland, died following a procedure. After some delay, the doctor called 911. Paramedics arrived at the clinic to find the patient in a pool of blood and with no vital signs. Is it appropriate to establish a system that inherently requires extra time to effectively treat patients who fall into emergency situations? Will the Ontario government establish a requirement that doctors be on site at all times? Will they require that specialty hospitals have emergency capacities (beyond calling 911)? Will they require the private clinics to disclose to patients the limitations of their emergency abilities? 

  • User fees: The Ontario Health Coalition has revealed widespread extra-billing by existing private clinics. There is little doubt that this will intensify with more private clinic delivery. But Ontario already has the highest share of private payment for health care in the country. Private expenditures in Ontario run to 32.3% of total health expenditures, higher than any other province (Saskatchewan is at only 24% private expenditures). In dollars, private payments for health care are 5.3% higher in Ontario than Canada as a whole, almost $100 more per person per year. Notably, increased private payment does not mean a reduction in public spending: governments in the U.S.A. spend far more money on health care than Canadian governments, both in absolute dollars per capita and as a percentage of the economy. This despite the fact that most Americans have no public insurance and private payment for health care in the U.S.A. far exceeds any other country. 

  • Billing problems are also evident in Quebec. In early 2013, the province decided not to renew the contract with Rockland MD, which has provided about 9,000 publicly funded surgeries since 2008 in Quebec. The public health insurer found that Rockland MD was charging people illegal facility fees. The former British Secretary of Health reports that such clinics in Britain were 11% more expensive than a hospital providing similar services. 

  • Doctors’ incomes: Doctors have lobbied for this new delivery form and it will create a new form of payment for doctors. But the introduction of alternate forms of payment for doctors under the Liberal government has gone hand-in-hand with huge payment increases to doctors, not savings. Since the Liberals were elected in 2003, new (or “alternate”) forms of payment to doctors have increased 430% through to 2011/12. With this increase, doctors have driven up their total clinical payments an astonishing 94%. Ontario spends more per capita on doctors than Canadians as a whole. In contrast Ontario spends less per capita on hospitals than Canadians.

8/19/15

Rapid change in public hospital services


hospital inpatient days decrease over last four years
Canadian Institute for Health Information (CIHI) hospital data indicates big changes in hospital activity, particularly in the most recent four years reported. Ontario, especially, is experimenting with hospital cuts and restructuring.  

Hospital inpatient days are now dropping rapidly in Ontario – with a drop of 13.4% in inpatient days over the last four years. This has occurred even as inpatient days continue to increase in the rest of Canada (note: Quebec is excluded from the CIHI report as the data for that province is under review). 

The data suggests a sharp fall in Ontario in 2013/14 compared to 2012/13 (8.9%), a less sharp decline over the previous 3 years, and significant growth over the previous five year period.

Over the 15 years of data reported (1999/00 through 2013/14), Ontario inpatient days have increased 4.6%  -- even while population has increased at almost four times that rate (17.8 %) and the median age increased 4 full years (from 36.2 to 40.2 years). The rest of Canada has seen much faster growth -- 21.1% more inpatient days, despite only 16.8% population growth and somewhat less than 3.8 years growth in median age. 


Despite a more rapidly growing and more rapidly aging population, Ontario hospital inpatient days are falling further behind the rest of Canada.



hospital inpatient days 1999 through 2014

For the sake of comparison between geographic areas like Ontario and the rest of Canada, services can be compared on the basis of service per person (i.e. service per-capita).  

Ontario had 0.68 inpatient days per person (per-capita) in 2013/14 (with a population of 13.55 million). The rest of Canada excluding Quebec (with a slightly smaller population of 13.45 million) had 0.82 inpatient days per-capita.

In other words, the rest of Canada had 20.5% more inpatient days per person. This is a much bigger gap than existed in 1999/2000 when Ontario had  0.77 days per-person while the rest of Canada had 0.79 days per-person.

As a result, in 1999/2000, the rest of Canada had 2.6% more inpatient days per person compared to Ontario; but by 2013
/14 that gap had grown almost 8-fold to 20.5% more inpatient days per person. 


hospital inpatient days per-capita 2013-14


That's quite a change, with much of it occurring in just the last few years during deep cuts to real hospital funding in Ontario.  Clearly, Ontario provides a lot less inpatient days to its population than the rest of Canada and that trend is deepening.

Also note that Ontario inpatient days per-capita have declined almost 12% between 1999/2000 and 2013/14 (going from 0.77 per-capita to 0.68). (This despite a median population age that is now 4 years older than in 1999/2000.) In the rest of Canada, inpatient days per-capita have actually increased 3.7%. 


Hospital emergency department visits 1999-2014




Increasing emergency visits:
Despite  declining hospital inpatient days, Emergency Room visits continue to increase in Ontario. Indeed they are increasing at a faster pace than in the past.  


However, Ontario has far fewer Emergency Room visits per-capita than the rest of Canada: 0.44 visits per person in 2013/14 versus 0.55. In other words, there are 25% more emergency visits per-capita in the rest of Canada than Ontario.   Even with increased use of Emergency Rooms in Ontario, they are much more highly utilized in the rest of Canada. The idea that Ontario Emergency Rooms are over utilized is not borne out by this statistic. 
Emergency department visits 199-2014, Ontario and Canada




Despite the increased absolute number of emergency visits, Ontario has reduced hospital emergency visits per-capita slightly since 1999/2000 (from 0.45 visits per person to 0.44 per person).  However, all of the reduction occurred in the middle of the last decade and there has been an upward trend in more recent years. Unlike Ontario, the rest of Canada has seen increased emergency room visits per-capita (from 0.52 to 0.55). Again, the upwards trend became even more marked in recent years. 


Ontario hospital inpatient admissions this century

Admissions: Total hospital inpatient admissions have been practically static in Ontario and in the rest of Canada since 1999/00.  

However with a rapidly increasing population in Ontario there has been a consistent and rapid downward trend in hospital admissions per-person, with a ten percent drop over the last 14 years reported. This again occurred despite a four year increase in the province's median age over that period. 

Ontario hospital admissions decline sharply

There are 3.3% fewer admissions in Ontario than the rest of Canada (0.089 admissions per-capita in Ontario in 2013/14, versus 0.092 per-capita in the rest of Canada).


hospital ambulatory care visits increase

Hospital Ambulatory Care:  Ambulatory care visits to hospitals in Ontario continue to increase - -but much less quickly than in the past and less rapidly than in the rest of Canada.  

So, Ontario is experiencing both a  dramatic loss of inpatient days and a marked slowdown in the growth of ambulatory care.  Since 2011-12 there has been an actual (albeit modest) decline on a per-capita basis.

Ontario still has more ambulatory care visits than the rest of Canada – 1.4 per person in Ontario in 2013/14 versus 1.24 per person in the rest of Canada. However, in 1999/2000 Ontario had 25% more ambulatory care visits per-capita than the rest of Canada, while now the gap is about half that (12.7%).  So the gap is shrinking quickly. 

hospital ambulatory care visits in Ontario and Canada


This fits with the slowing growth  of ambulatory care in Ontario. On a per person basis, there has been very little growth in ambulatory care visits since 2005-6 in Ontario -- 3.7% (compared to 10.7% growth in the rest of Canada).  As noted, Ontario has actually seen a modest decline in ambulatory care visits per-capita since 2011-12 (from 1.43 to 1.38 per person). 

In sum:
  • In key ways, hospitals provide fewer services in Ontario than in the rest of Canada.
  • Ontario provides far fewer hospital inpatient days compared to the rest of Canada
  • Inpatient days in Ontario are now falling even while they continue to increase in the rest of Canada.
  • The loss of inpatient days in Ontario has increased since government funding cutbacks started at the end of the last decade.
  • Ontario hospitals do provide somewhat more ambulatory care than in the rest of Canada and the amount of ambulatory care in Ontario has increased over the last 14 years.  
  • The growth of ambulatory care however is slowing in Ontario and has recently come to a halt on a per-capita basis. Across Canada, it continues to grow and the gap in ambulatory care between the rest of Canada and Ontario has shrunk markedly.
  • Despite fewer hospital inpatient days to treat patients, more and more patients are showing up at Ontario ER rooms (6.7% more ER visits and 13.4% fewer inpatient days over the last four years). 
  • Emergency rooms are used much less in Ontario than in the rest of Canada.
  • While inpatient admissions are somewhat lower in Ontario than the rest of Canada the gap is not so large as with inpatient days. Accordingly patients must be released more quickly in Ontario than the rest of Canada.
The years 2014/15 and 2015/16 saw real hospital funding cuts in Ontario so it will be interesting to see how they impact hospital service numbers when they are available. 

The data is reported below. 







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