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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