More Private Care is the Wrong Prescription for MRIs
The recent stories on MRI in Calgary raise important issues, and expose some views that are simply detached from reality.
Let's start with the facts. MRI wait times for outpatients are posted on the Alberta Wait Times website - waitimes.alberta.ca - for 3 levels: 1 urgent; 2 semi-urgent; 3 non-urgent. The latest data, for June 2016, shows the average wait in Calgary for levels 1 and 2 combined was 8 weeks, down from 9 weeks in June 2015. The wait times for urgent scans are shorter, not longer. The increase in wait times is only in non-urgent scans, where the average wait has gone up from 21 weeks a year ago to nearly 30 weeks.
Is there a shortage? The Herald has reported that MRI volume has increased 17% since 2011. But that’s for Alberta as a whole. The question is, has Calgary been short-changed? AHS’s 2015-16 annual report shows Calgary has actually had an even bigger increase than the province overall: AHS funded 20% more MRIs in Calgary last year than in 2012-13. The increase in Edmonton was only 6%, yet there’s been only a small increase in non-urgent waits there. If we look at the other 3 zones outside Calgary and Edmonton, their increase was less than 6%.
MRIs are over-used: a 2013 study found more than a quarter of MRIs of the lower back were clearly inappropriate, they should never have been ordered, and another quarter were questionable. Alberta has a Clinical Practice Guideline whose main purpose is to discourage doctors from ordering MRI and other imaging scans of the lower back. A former U of C Dean of Medicine and one of the authors of the 2013 study argues the guideline isn’t enough; the over-use of MRI is so obvious that we need hard limits on it.
What’s Jason Kenney’s answer? More MRIs, but not from our public hospitals, from private clinics of course! Earth to Jason: you’ve misdiagnosed the problem, and your prescription has serious side effects! The issue isn’t a shortage of MRIs in Calgary, it’s the opposite. AHS in the past 4 years has poured resources into MRIs in Calgary, and now they’re shocked to report that it seems to have driven demand for non-urgent MRIs through the roof, including almost certainly a lot of unnecessary ones. The issue is that AHS has totally lost control of the service in Calgary.
It’s not a coincidence that radiology is the most entrepreneurial of all the specialties; that they’re the highest billers to the public system; and inadequately addresses the needs of that system. Radiologists have moved out of hospitals into their own private facilities, serving the public system as just another client. The result is that hospitals struggle to get on-site coverage and coordinate services. Meanwhile the public system pays more and more, due to the pressure of the private market next door where radiologists can charge whatever the market will bear. On top of that, upward pressure is generated on physician pay across the board, because the others argue their compensation should be comparable. With physician pay a major driver of our Health budget, we should not be looking at costly private delivery which takes resources out of the more affordable public system.
Another area with an equivalent private market and perhaps the most disturbing of all is continuing care. Seniors care in Alberta has been the focus for private health care in recent years. AHS funded 16% more continuing care placements last year in Calgary than in 2012-13. Yet the percentage of beds in Calgary hospitals occupied by patients awaiting placement (“Alternate Level of Care”) jumped from 11.7% to 16.6% in the same period. That’s fully one in 6 hospital beds occupied by patients who shouldn’t be there. This is a systemic-level failure that makes the system more vulnerable to a breakdown if there is sudden demand like a bad flu season. Many believe this is happening because the shift to for-profit “assisted living” has failed to provide the long-term care beds we need for sick patients waiting in hospitals. This is another failure of reliance on private delivery that we can start reversing by making good on the Alberta NDP promise to open 2,000 public long-term care beds.
The MRI story is important because it shines another light on how private health care has become the tail wagging the dog in Alberta. It drives decisions by AHS that ignore patient needs and drive costs up for no evident benefit to the public system. When you turn health care into a consumer product, you get a system dedicated to selling more of it and paying providers instead of caring for the sick. Eventually you get a system like the American one, so distorted by competition among private insurers and providers that spending more can actually make outcomes worse. We’re not there yet but we’re pointed that way. The Ministry of Health has made wise decisions in putting the brakes on laboratory privatization in Edmonton and laundry services in Medicine Hat. We hope to see progress on MRIs and other private clinics being brought back under public delivery with improved patient outcomes as the ultimate goal.