Tuesday, March 01, 2011

Lying about bariatric surgery isn't the way to fix the system.

On Friday the Ontario Liberals put out a press release detailing the “savings” garnered by their $75 million investment in bariatric surgery. They report a “savings” of $10,000 for every patient who receives bariatric surgery in Ontario versus out-of-country, and that in 2010/11 they will have “saved” $45 million and in 2011/2012 an additional $21 million.

Those numbers, and their enthusiasm, are a farce.

Prior to November 2009 and the establishment of Ontario’s bariatric registry program, a two-page application was required of physicians to access out-of-country bariatric surgery for their patients. A committee at the Ministry of Health would review the application and if a patient met appropriate surgical criteria they would be approved for out-of-country consultation. From start to surgery this process took 6 months and the total price tag for the province, including both pre-operative and post-operative appointments and management of complications, along with the surgery and resulting hospital stay, was exactly $18,050 US dollars.

Therefore, according to their reported, “savings” of $10,000 per patient that ought to mean that per procedure surgical cost in Ontario is $8,000, yet the true cost was recently reported by the Ministry of Health to be $17,200.

Suddenly that $10,000 per patient "savings" has been reduced to $850.

Sadly, that’s not the whole story. Demand for bariatric surgery in Ontario greatly outstrips supply. In Ottawa since the establishment of the bariatric registry and the denial of out-of-country requests, patients I have referred have been waiting between 7-12 months to receive their surgical orientations following which they will likely be required to wait an additional 9-12 months for surgery. All told wait lists are now between 1-1.5 years longer than when out-of-country surgeries were an option. To truly discuss cost “savings” the cost of waiting needs to be taken into account.

A 2004 Canadian study did just that and looked at the direct medical costs attributable to bariatric surgical waits. That study concluded that an additional 1.5 years of waiting costs the Canadian health care system $5,900 in direct health care costs, with each year of waiting thereafter costing $4,500. It’s important too to point out that the study did not even try to account for the substantial indirect costs associated with decreased productivity and increased disability also seen in pre-operative patients.

So how many patients are currently awaiting surgery?

At a family medicine conference in November 2010, Dr. Mehran Anvari, the co-leader of Ontario’s bariatric registry, reported that the average number of monthly referrals for bariatric surgery in Ontario had reached nearly 900 , reflecting an unanticipated and rapid rise in demand. Therefore even were demand to stay the same, given the Ministry’s prediction of 2011 seeing 2,085 Ontario surgeries, every 2.3 months the wait list will grow by an additional year.

So back to the “savings”.

Taking even a conservative estimate of an additional 1.5 years of waiting for an Ontario surgery rather than an expedited out-of-country procedure, despite a “savings” of $850 per patient in surgical costs and follow ups, the 3,000 waiting patients won’t save one dime of taxpayer money. Instead their surgeries will ultimately cost Ontarians an additional $15.3 million in direct health care expenditures and many more in indirect costs. Were wait times to grow to 2.5 years due to growing demand, those additional direct health care costs would reach $48 million.

The thing about surgery in Ontario is that we only have so many operating rooms. There simply isn't a way to markedly increase access to one type of surgery without either spending more money on more operating rooms, or bumping other surgeries. Given we don't have the funds to build new hospitals, given there are in the neighbourhood of 360,000 surgically eligible Ontarians, and given a rapidly rising demand, within the current Ontario framework, waits can go nowhere but up.

Here in Ottawa I've heard a third surgeon has been brought on board and that instead of operating 2 days a week the bariatric surgeons will be operating 3 days a week. I've also heard that they're ramping up the number of orientation sessions. Of course I've also been told that Ottawa's backlog is the worst in the Province.

Hopeful folks may read into this that things are going to happen much faster and that the wait lists here will decrease.

Cynical folks may read into this that getting people into orientation sessions quickly may simply increase the wait from orientation to surgery.

Certifiably cynical folks like me wonder if more rapid access to orientation will be used as a means to cook the books by suggesting that patients are no longer "waiting" once they've been oriented.

Frankly I'm rooting for hopeful, but rooted in certified cynicism.

Either way, Ontario should certainly be commended for leading the country in providing access to bariatric surgery; however the premature elimination of the out-of-country option rather than saving money is in fact costing taxpayers tens of millions of dollars a year and is prolonging the suffering of thousands of sick Canadians.

Telling it any different is a downright lie.

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  1. Anonymous6:15 am

    What a disturbing system where a government official gets to decide whether you can have surgery or not. How the Canadian system gets lauded is beyond me.

  2. It disturbs me that people are even being referred by professionals for this kind of surgery. It's so unnatural! No wonder so many people have issues well after the surgery has been completed (not to mention the time/money wasted) People are always looking for a quick fix. What we need is MORE nutritional intervention and less medical quick fixes (pills, surgeries, etc). Ug.

  3. Anonymous2:12 pm

    Until the government and the medical community wakes up and recognizes the problem of hyperinsulinemia, the weight problem will continue. The treatment for hyperinsulinemia is no sugar in any form, no grains and no manufactured oils, and the problem will go away in a couple of years. All it would take is a government statement that states that sugar, grain, and manufactured oils should not be consumed by overweight people.

    Of course, that would reduce the medical field and hurt food manufactures so it is not likely to happen.

    If in doubt, G Taubes, Lustig, Bernstein, Eades, Vernon, and other must all be wrong.

    But what do I know.

  4. Anonymous2:39 pm

    I don't understand why grains would be a problem, or giving them up the answer. Even just 100 years ago everyone ate grains at every meal. They weren't obese.

    And really people do know what they should and shouldn't eat. They also know they are eating far too much.

    Just think about how the majority of people at in 1900: real food, all foods, at the table, no snacking, no ordering in and no panoply of choices: what you see in front of you is what you get.

    The study I'd like to see is one which would examine the advent of colour tv in Canada with obesity.

  5. Anonymous2:43 pm


    No second helpings.
    And: They were very active. We may not all live or work on a farm, but we do have to apply some discipline, leave the table when we've had "enough" and go do something physical as much as possible, throughout the day.

  6. Anonymous2:44 pm

    HA! In BC there is almost no possibility of getting surgery under the medical system, in Canada or outside.

    @thehealthyapron - bariatric surgery is not a quick fix,it is a last resort. What works for you is great , but it does not work for everyone. It is not time and money wasted, it is a life changing positive intervention for most people who undergo it.

  7. Anonymous6:59 pm

    What a disturbing system where a government official gets to decide whether you can have surgery or not. **How the Canadian system gets lauded is beyond me.**


    That's patently obvious. It's not "a government official" that decides.

  8. Anonymous7:55 pm

    Are independent user-pay bariatric surgery clinics allowed in Canada under medicare law?

    If you have been refused bariatric surgery by the Canadian system, meaning bariatric surgery isn't medically necessary for you, but you still wanted it for cosmetic reasons, can you get it privately on a user-pay basis?

    You can get other cosmetic surgery in Canada on a user-pay basis.

    If I want bariatric surgery for cosmetic purposes, (in other words, for me it isn't considered medically necessarily and therefore not part of publicly insured care), are there any places in Canada where I can have it done at my own cost?

    If there is nowhere in Canada, is that because it is illegal to offer cosmetic surgical procedures outside msi, or because it's so expensive there isn't a market to run a clinic?

  9. Anonymous10:29 am

    It is interesting that the savings go down by half from 2010/11 to 2011/12 while the number of surgeries done in province will increase.

    You would expect savings to increase as the number of surgeries increase.

    Clearly the initial savings are higher because patients who would have had surgery in the U.S. didn't get it AT ALL that year!

    The initial high savings indicate just how many people they stacked up like firewood on Ontario wait lists!

  10. Anonymous10:29 pm

    “It is interesting that the savings go down by half from 2010/11 to 2011/12 while the number of surgeries done in province will increase.

    You would expect savings to increase as the number of surgeries increase.

    Clearly the initial savings are higher because patients who would have had surgery in the U.S. didn't get it AT ALL that year!

    The initial high savings indicate just how many people they stacked up like firewood on Ontario wait lists!”

    Wow, very good point and a clear way to look at exactly what is going on within the current Bariatric system.

    Before I take my comment any further I want to point out a couple of things:

    “If I asked you to go into your back yard and dig a hole using nothing but your hands, you will over time be able to dig that hole - it may be a small hole, but a hole all the same…. imagine what you could do if I offered you a shovel”

    Dr Schram, 2009

    Bariatric surgery is a tool, a shovel perhaps and when used with good eating habits, exercise and a healthy lifestyle it can offer new hope and a new life to the obese people in your lives. Bariatric Surgery is not a “quick fix” nor an “easy way out”; it is a second chance and a tool that can be used to provide long term weight loss.

    After research and careful consideration my family doctor and I agreed that I was a good candidate for Bariatric surgery. We also agreed that Ontario wait times were too long and that waiting would cause long term tissue damage and could ultimately result in my death. OHIP agreed, and I was granted out of country coverage in the Spring of 2009. After meeting with my US surgeon he recommended another form of Bariatric surgery and I asked if OHIP would consider revising my surgery from a RNY to a VSG. What did OHIP do, they cancelled my coverage all together of course.

    I have since won my appeal with OHIP and have been granted my out of country coverage once again.

    Since getting in line within the Ontario Bariatric system I have experienced things I never thought I would see:

    First of all let talk savings:

    Ontario Liberals report a “savings” of $10,000 for every patient who receives bariatric surgery in Ontario versus out-of-country:
    I promise you that this number DOES NOT take into account all the “testing” that is part of bariatric surgery. Once you include, blood tests, ecg/ekg, exercise stress tests, abdominal ultra sounds including wall thickness tests and barium swallows, what is the true cost savings?

    I believe there may be a moderate cost savings but it does not come close to $10,000 per patient.

    I have experienced OHIP lying about wait times. They move clients between centres in order to continually start the clocks back at “0”. Keep in mind that each time a client is moved, the wait time clock is reset. For instance in my case, I waited at one “Centre of Excellence” for six months only to be moved to another non-surgical assessment centre, where I followed their testing regime for 8 months. At the end of eight months I was sent back to the original centre and told that because my file was too old they would “like to start fresh”. I have been trying to talk to a Bariatric Surgeon since October 2009 and will not see that surgeon until March 2011... and that is only after Ombudsman Ontario became involved. OHIP will likely say my wait time for surgical consultation was three months.

    There is something clearly wrong with this picture.

  11. Anonymous3:21 pm

    I asked my Dr to refer me for the surgery after 20+ years of dieting, losing 100 lbs 3 times over just to gain it back, due to a hormone imbalace called PCOS. I am 42 and I have a right to be healthy and live a normal life. This is a last resort for me. a friend of mine was referred in Jan 2011 and just had her orientation in May, 11. She was told that it would be 3-4 months wait after the orientation as long as you are not a smoker. We live ouside of Toronto, ON. So far I have heard that the wait times here are not so bad.

  12. TO: One of the Anonymous Commenters,

    Bariatric surgery is not "cosmetic surgery" -- a surgeon would not perform the surgery even if you are self pay unless you needed it.

    You can't just walk in and have bariatric surgery to lose those pesty 40lbs!

    Those type of comments are the reason that so much false information is spread about Weight Loss Surgery. That and the ignorance of people.

    If a surgeon performs WLS on someone who thinks they need it for "cosmetic reasons" then he is a black market surgeon and I feel sorry for your health and end results!