Wednesday, September 01, 2010

Who's going to launch Ontario's first lawsuit over access to bariatric surgery?

Note the question is, "who's" going to launch, not, "will someone" launch a suit.

I think it's inevitable.


Because Ontario, with much fanfare, over the course of the past year has revamped the process which used to allow for a 4-6 month start to finish process for the provision of bariatric surgery resulting in 2 year waits and lengthening wait lists.

The reason a lawsuit's inevitable isn't the simple fact that Ontario's new process has more than quadrupled the wait time for surgery, the reason a lawsuit's inevitable is because Ontario announced that the purpose of its revisions were,

"keeping Ontarians healthy, reducing wait times and providing better access to doctors and nurses."
And that,
"Bariatric surgery can help resolve several health conditions, such as diabetes, hypertension and dyslipidemias. Dyslipidemias is a condition that can lead to atherosclerosis, the hardening of the artery walls, which can restrict blood flow to the heart. Bariatric surgery can also reduce other obesity-related conditions, such as hypertension (high blood pressure), osteoarthritis (a painful joint disease), ischemic heart disease, stroke and some cancers"
So instead of reducing wait times, they've dramatically increased them, for a procedure that they themselves admit resolves multiple medical comorbidities which in turn cause permanent, cumulative damage.

And the wait lists just keep getting longer. In less than a year, the wait time for surgery at the Ottawa hospital has nearly quadrupled, increasing from a minimum of 6 months to a wait of closer to 2 years, this despite their ramping up of their surgical program, and given the nature of health care in Ontario, the lack of OR time and the fact that there simply aren't resources to build new hospitals within the publicly funded system, the likelihood is for these lists to continue to grow, not to shrink.

Couple those facts with the fact that the complication and mortality rates for bariatric surgery are currently dramatically higher in Canadian hospitals and I'd say it'd be a damn good case to take to the courts. Important too to note that the increased risks here in Canada aren't because our doctors are any less skilled, but rather because our doctors have fewer operating room hours available to them and the learning curve for this surgery is steep and unforgiving. My calculations for one centre here in Ontario include death rates at least 3x higher than the American centres I used to be able to access for my patients (the two centres we used in the States both had death rates lower than 0.2%, with one reporting a 0.08% death rate on 3,640 surgeries) and while over time I expect Ontario's complication rates to eventually decrease to those of the States, somehow that's not immediately reassuring.

Finally, for whatever lawyer eventually reads this post, the argument that costs matter is a fair one here in socialized medical Canada, but a faulty one. It's faulty because while it is possible that the actual sticker price for the day of the surgery is lower here in Canada, that's not the whole cost. There's the cost of having these patients sit on waiting lists for two years where Canadian data have demonstrated markedly increased health care utilization for these patients and where one estimate put the average health care cost at $900/month/patient on the wait list (therefore a two year wait list here in Ontario increases costs to Ontario by $16,200 per patient - roughly the cost of the surgery in the States to begin with), there's the cost for the ancillary testing that seems to be the standard of care here in Ontario which isn't the standard of care in the surgical centres of excellence in the States (endoscopies, ultrasounds, etc.), then there's the cost of the team of educators (a cost factored into the American sticker price), the cost of the lost productivity of these individuals for the 2 years they wait, and the cost of dealing with higher rates of complications and deaths. All told I'd guess that the cost of bariatric surgery in Ontario, with it's now 2 year wait, is triple what it used to be when the cases were expedited to American centres of excellence.

As I've posted before, the decision to put the cork in the bottleneck of out of country bariatric surgery approvals was almost certainly a wholly financial decision and even though surgeries in Canada likely cost our system triple those performed in the States, and even though each surgery has been proven to pay for itself here in Canada by means of decreased health care costs in just 3.5 years, if there's not enough money up front to pay for the demand, we simply can't offer it.

Of course that's not what the government said when they explained the new system, and that's why when the lawsuits inevitably come, and mark my words they will, Ontario's going to lose.