Tuesday, November 30, 2010

Ontario's bariatric surgery strategy reflects monetary realities.

This will be the first of a few posts this week on bariatric surgery including a post detailing one patient's experience in successfully overturning Ontario's Ministry of Health's cancellation of her pre-approved out-of-country gastric bypass.

Today's post though will cover a topic that I've blogged about before - why the changes?

The Ministry of Health, through their press releases and official spokespeople, has stated that the point of shutting the doors to out-of-country surgical access and spending $75 million on increasing access to in-province surgical care was to improve timely access to surgery and to improve the quality of patient care.

Unfortunately to date all they've succeeded in doing is markedly increase wait times and put people at increased risk of surgical mortality. What do I mean? Well prior to shutting the doors to patients accessing the 18 American bariatric surgical centres of excellence (a moniker they earned rather than one they simply awarded themselves) the MOH covered , patients could go from referral to surgery within 4 months of application and surgical mortality was in the order of 1 in 1,000 or better. Since the American corridor has been shut wait times have easily reached 1-2 years with Ontario striving towards the procedure's reported all comers "average" death rate of 1/200, a rate that still isn't the one I'd be striving to hit for as noted, the American centres of excellence, where their high volume gives them a tremendous amount of experience, have death rates markedly better than the 1/200 average and tend to range between 0.5 and 1 in a thousand.

Sure doesn't sound like improved access to better care to me.

So why have they made these changes?

My belief has always been that the primary driver for changes was, is, and always will be, money. And frankly that's a very fair consideration in our single-payer health care system. Problem is, without identifying that as the driver for change, we're obscuring the real problem - the system's failing, and pretending that this is all about delivery of care means that we'll be far less likely to try to fix it.

Well, my belief was confirmed on Saturday when I was sharing a podium with Dr. Mehran Anvari, one of the principle investigators of the new bariatric registry program in Ontario. Between his talk and the answers he was able to provide to my questions, he clarified a few things.

Firstly he commented on how one of the main problems with the out-of-country surgeries wasn't the surgery itself, but rather after-care. A very valid point and one that makes me wish at least some of the $75 million dollars Ontario recently allocated to bariatric surgery was spent on the creation and propagation of educational tools and resources for family physicians and general surgeons that would help instruct them on the needs and common complications of the post-operative patient.

He also said this,
"We simply as a province, we cannot afford to send every patient who requires bariatric surgery to the US"
I believe it. At the end of the day despite having patients "requiring" surgery, the monetary truth is we simply can't offer to pay for everyone, and as I'll be discussing later this week, I don't think we have or will have the funding to do them in Ontario either.

Once again I must point out that money is a fair consideration here in Canada, and perhaps if more people were as up front about it as Dr. Anvari we'd be busier trying to find innovative and creative solutions rather than trying to protect an already broken system from valid criticism.

Of course fair or not I imagine the Ministry of Health will soon find itself in quite a pickle because as far as I'm aware, money may enter the equation of whether or not a procedure should be funded, but I'm not aware of it being a defensible rationale for an approved procedure having an inordinately long wait list. But more on that over the course of the next few days.