Front Burner - Ford pushes for-profit care amidst healthcare crisis

Episode Date: January 18, 2023

This week, Ontario Premier Doug Ford unveiled a plan to significantly increase the number of surgeries being done outside hospitals, which are struggling with a major backlog of operations. Many of the procedures — including things like cataract, hip and knee operations — will be performed by for-profit clinics. The plan has drawn criticism from several groups, including five major Ontario health care unions, which say it will divert frontline staff and funding away from the public health care system.

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hi, I'm Jamie Poisson. On Monday, Ontario Premier Doug Ford announced his government's plan to significantly increase the number of surgeries that are performed outside hospitals in private facilities. When it comes to your health, the health of all Ontarians, the status quo is no longer acceptable. We need to be bold.

We need to be innovative. We need to be creative. The province is, of course, struggling with a big backlog of surgeries, and hospital capacity is stretched to the limit. But Ford's plan, which will turn many surgeries over to for-profit clinics, is drawing a lot of criticism and accusations that this is a step towards a two-tier, for-profit health care system. Dr. Bob Bell is Ontario's former Deputy Minister of Health under the Liberals, former CEO of the University Health Network, and an orthopedic surgeon by

training. I've got him here today to sort through Ford's plan and criticisms of it. Hi, Dr. Bell. Thank you so much for coming on to FrontBurner. Jamie, it's a real pleasure to be with you. It's great to have you. So it's hard to deny the fact that hospitals in Ontario are not keeping up with the number of surgeries people need move more surgeries out of hospitals into community surgery centers. There's great evidence across Canada and around the world, really, that you can do about 30% more surgeries in the same amount of time if you do the operations and purpose-built community surgery centers. You know, hospitals are designed for complex patients.

centers. You know, hospitals are designed for complex patients. And if you look at community surgery centers that are actually designed to handle high volumes of low intensity surgery, you can simply do more cases in the standard eight hour day. So I totally agree with the Premier that more community surgery is needed in Ontario. And I also agree with him that somewhere between 40 to 50 percent of surgeries being done in hospitals could move to the community. What I really don't agree with is moving these to for-profit centers. Just before we move on, when we're talking about community surgeries, can we just go through what we're talking about here? Like, is it stuff like hernias, cataracts? Yeah, it's a lot of different surgery that are currently done in hospitals.

So cataracts is probably the best example. I'm an orthopedic surgeon, as you mentioned, by background in many orthopedic operations, including arthroscopy, hand, shoulder surgery, even a great number of total knee and total hip replacements, and even spine surgery can be done safely and effectively at lower cost in community surgery centers. Okay. So then let's go back to what you said that really the problem that you see with this is that they're being moved to for-profit community clinics. And why is that such a problem? Well, there are a few reasons here. So if we're going to expand the for-profit surgery sector in Ontario to allow for the volumes of cases the Premier discussed, that's going to mean building a lot of new centers. And if that's going to be done by

for-profit organizations, private equity companies, we're going to have to pay for the return on their equity in the costs that we pay to do the surgery in those centers. Whereas we have hospitals today that could have parts of their operating rooms converted to day surgery centers. That would be much less expensive. The other reason that I'm concerned is that when we look at the staffing that's currently present in hospitals, the limitation to doing more surgery in hospitals right now is that we don't have enough nurses. We probably have enough surgeons, but not enough nurses. And if we're going to do all these extra cases in the community,

we're going to have to recruit those nurses from somewhere. Guess where they're going to come from? Almost certainly from the hospital, especially since nurses working in hospitals today, in addition to doing their daytime jobs, have to agree to be on call for nights and weekend emergency cases. Well, you know, if they're going to leave to go to a daytime job in the community, we may have trouble providing emergency surgery for Ontarians when they need surgery the most. But wouldn't you have a problem with staffing no matter what you did? So even if you built publicly funded clinics connected to a hospital, wouldn't you still have that problem with staffing? The same problem as if they were being recruited to work in private for-profit

clinics? The difference is that if we maintain their employment with not-for-profit entities like hospitals, they would still have to be on call nights and weekends. They could get the benefit of a nine-to-five job most of the time, but they'd still have to have to be on call. Nights and weekends, they could get the benefit of a nine-to-five job most of the time, but they'd still have to agree to be on call. If you look at the recruitment advantage of saying, look, nurses, you come work for us, you're only going to have to work eight to four and then go home. You'll never have to work another night or weekend in your life. Sure, that looks like a pretty advantageous approach. night or weekend in your life. Sure, that looks like a pretty advantageous approach.

Hospitals could avoid having that kind of an inducement to work in the community surgery centers by maintaining their nursing staffing with a requirement to work maybe one night a month on call, as happens today. today. What about the argument that the public system is just not moving fast enough here? You know, this is not a new problem, right? I know that we're in a particularly thorny time right now, but we've been talking about surgery backlogs for basically, I think, my whole life. So what about the argument that the private sector just needs to come in and get this done? Because people are suffering. They need to get these procedures done. They can't wait this long. Well, you know, if you're going to do it with private money, you're going to have to pay for

the private costs. And hospitals have capacity already. The problem is simply money. And there's a lot of money that's being expended on this. If that money were given to existing entities, they could immediately expand the service. The problem has been with surgical wait times in Ontario over the past 10 years is that we've simply underfunded the number of surgeries that we need to do. That's pretty clear. Moving that money into accomplishing surgery now, but giving it to for-profit private operators doesn't make sense to me. It's going to cost more, and it's going to also expose people to the risks of upselling. Sylvia Jones is Ontario's Minister of Health. What is your position as Minister on doctors upselling at private facilities? First of all, I want to reinforce safeguards already exist to ensure no extra charges for

OHIP-funded services occur. However, upgrading of wheelchairs, perhaps choosing a private room over a semi-private room, or as it relates directly to cataract surgery, hospitals offering an upgraded lens as an option that patients can choose but are not obligated to choose. So you support the upselling of services at private facilities? Well, I wouldn't call it upselling of service. I would call it patient options. The premier said that your costs in these for-profit surgery centres would be covered by your OHIP card. We also need to be clear. Ontarians will always access healthcare with their OHIP card, never their credit card. However, in the existing for-profit centres in Ontario today, there are other costs that are uninsured.

And these costs are pretty much unregulated. And believe me, those costs will be substantial in these for-profit centers. Can you give me an example of what some of those costs might be? Yeah, sure. So if we look at a private for-profit facility offering care, supposedly with your OHIP card today, let's look at an example the premier often uses. That's the Shouldice Clinic. Well, you know, if you're going to get your hernia fixed in most hospitals in Ontario today, you come in in the morning and you go home in the afternoon. There's no hospitalization involved. However, at the shoulder ice clinic, you have to be admitted the day before surgery, then stay at least two days after. And guess what?

Those three days of in-hospital care are not paid for by OHIP because they're not really necessary. They're paid for by your out-of-pocket expenses or your workplace insurance. They're paid for by your out-of-pocket expenses or your workplace insurance. That's one example of uninsured services being charged by for-profit providers. The other example is what happens now when cataract surgery is undertaken in for-profit facilities. You know, many people choose to purchase a so-called premium lens after they have cataract surgery to replace the cataract that's removed. This allows people to see without glasses in some instances. And, you know, you can understand that it's valuable to people. Those costs of premium lenses are not covered by OHIP, and they're very carefully regulated in hospitals.

In for-profit facilities, those costs, as the Auditor General of Ontario has stated, are unregulated, highly variable, and we're going to see profits being made in those lenses by for-profit surgery clinic owners, no question. The other criticism I've heard is that the privately run clinics can pick and choose which surgeries they want to do. And just can you flesh that out for me? Why would that be a problem? Because I think there might be an argument for, so what if they pick and choose the surgeries that they want? At least it's taking some pressure off the hospital system to deal with more complex cases. They're going to understand that there's more profit to be made on some patients in some cases than on others. You know, a young person

having an arthroscopy of the knee is pretty straightforward. And the chances are you can do that quickly, get the patient out of the hospital and maximize profit. Another patient whose medical condition may be a little more complex or may have a more complex kind of surgery that's necessary is not necessarily the kind of patient that a private facility looking for profits may choose. So we may see that these for-profit providers carefully select patients to maximize profit rather than moving as many people in general out of hospital as possible. But wouldn't that still do something? I know it might not sound like morally right to a lot of people, but wouldn't that still do something to cut down this backlog? Institute that is a hyper-efficient community center that says it can expand its current services without taking a profit. If you look at community surgery facilities that have been developed by hospitals, places like Riverside in Ottawa, places like the Queensway and Trillium Health Partners in Mississauga, there are lots of examples of hospitals developing community surgery centers,

and hospitals have been asking the government for funding to do this. Now the funding's arriving, but instead of going to the hospitals to develop these community facilities, it's going to the private sector? That simply makes no sense. Why do you think the government, the Ontario government, has made that choice then? Like, why have they done that? Well, you know, the Premier said that he's had lots of advice, he said, from people. Well, in point of fact, the advice he received from the Ontario Medical Association and the College of Physicians and Surgeons of Ontario was, no, don't do this. Don't put the funding into for-profit centers. Put it

into centers connected to hospitals. That's what both those expert organizations said. And the government chose to disregard that advice. So why do it the way he's doing it? Well, you know, he also mentioned perhaps we should copy other provinces that are doing private surgery like Saskatchewan and Alberta. We need to look to other provinces and countries to see what they do differently and borrow the best ideas. Jamie, if you look at the wait times for total hips and total knees, those wait times in Alberta and Saskatchewan are far longer than in Ontario today. So it certainly hasn't helped those Western provinces to open for-profit centers. Their citizens are waiting longer than we are for those total joints. So it seems to me the expert advice is aligned against

the Premier on this one. Why he's chosen to do that, you know, I'm not going to hazard a guess. Many people have suggested that this is the thin end of the wedge to increase privatization of the Ontario health system. I don't want to think that the premier would have that nefarious goal in mind, but it's hard to understand exactly why this is being proposed. He told reporters in that press conference, as you mentioned, he talked about all this advice he was getting. He talked reporters in that press conference, and as you mentioned, he talked about all this advice he was getting. He talked about a hospital CEO. He wouldn't name which one. One CEO, and I won't name him, said, you know what sort of, there's only two places in the world that have the health care that we have, the same system, is Cuba and North Korea.

Like, really? And does that sound like the health care system you're familiar with in this province? Well, I can tell you, I know the hospital sector in Ontario extremely well. And there is no more efficient place in the world to have surgery than in Ontario. The cost per person of health care in Ontario is $1,000 less per capita, per person than it is in Alberta. In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization. Empowering Canada's entrepreneurs through angel investment and industry connections. Hi, it's Ramit Sethi here.

You may have seen my money show on Netflix. I've been talking about money for 20 years. I've talked to millions of people and I have some startling numbers to share with you. Did you know that of the people I speak to, 50% of them do not know their own household income? That's not a typo, 50%. That's because money is confusing. In my new book and podcast, Money for Couples, I help you and your partner create a financial vision together to listen to this podcast. Just search for money for cups. Who do you think stands to benefit from this plan?

Like, of course we've talked about the companies who are going to build these, these private clinics. Of course, there are people that would profit off of that. The companies themselves, but like, just take me through a little bit who stands to benefit the most here from this plan.

First of all, I'm very hopeful that a lot of conversation, both public conversation like this and behind the scenes conversation, is going to convince the government that we need more community surgery in Ontario, but it should be managed by the not-for-profit sector. And, you know, the Premier has talked about receiving proposals. I'm sure he's going to have a lot of proposals from community and hospital not-for-profit groups to say, Premier, let us do this instead of the for-profit sector. And I guarantee you the costs that they're going to propose are going to be lower than the cost brought in by private equity groups to build more facilities. So I'm hopeful in the long run that, you know, that we will see a change in direction. If we get more surgeries happening in this province with the same degree of cost

effectiveness and quality outcomes that we currently have, clearly the patient's going to be the winner. We need more surgery. There's no question about that. But the way we do more surgery is important. And I think it's pretty clear to me that this needs to be cost-effective. It needs to be high quality. It needs to be controlled by the groups that are actually producing high quality results today. Yeah, this concern people have that this is a slippery slope towards increased privatized health care in Ontario. What could that look like here? Like, what is it exactly that people are most concerned about here when we talk about the future?

Yeah. Well, you know, if you've got a substantial part of Ontario health care, medically necessary care being provided by for-profit providers, you know, they've got the government over a barrel. You know, how much are you going to give us? That's not enough. We need more. We need more. The negotiating position for companies that are not controlled by the public, rather controlled by a for-profit motivation, a for-profit CEO on board, let me tell you, they're going to be much tougher to deal with for the government than the hospitals of Ontario are. Hospitals of Ontario are players within a publicly funded system. Private equity investment in our system is going to drive up costs,

and I worry it's also going to turn down quality. I wonder if before we go today, we could try and broaden this out a bit. Of course, you talked about other provinces in this conversation. The federal government took heat after Ford's announcement yesterday. after Ford's announcement yesterday, NDP leader Jagmeet Singh posted online that the feds, as you've talked about, have given Ontario $775 million for surgery backlogs. According to him, Ford passed $24 million of that on to CEOs in what he called for-profit American-style care. But then the prime minister was silent after this announcement. What do you think of that criticism of the feds here? Like, what role do they have to play? Considering so much of our money does actually come from them,

and reports say that we are on the brink of a deal with the provinces where they would see more money. Yeah, well, I think that that deal will come. And I think the federal government is very wise to ask for more data about accountability for how the money is being spent before they increase their contribution through the Canada Health Transfer to the provinces. I mean, you know, this is, you know, we have lots of publicly funded services that are delivered privately. Pharmacies are private for-profit entities, and that seems to work. But they're highly, highly regulated in what they can do and what they can charge. You know, these for-profit surgery centers, the inspector responsible for ensuring that they're doing the right thing is the College of Physicians and Surgeons of Ontario. They're the ones that have

said to the government, don't do this, because they know they don't have the capacity to police the kinds of things that happen in these centers in terms of appropriateness of care, choosing which patient's going to have surgery, and in terms of the uninsured costs that people are going to be charged. So, you know, we have a lot of services that are provided privately. When it comes to surgery, this is one of those essential medical services that I think we need to keep in the publicly funded, not-for-profit Canadian hospital and health care system. And so from the federal perspective, what cards do they have to play here? I mean, obviously, I suppose they could put

conditions around money, but is that all they've got to play here? Well, you know, there are a lot of different roles they can play. The first is, let's let this play out a little bit. I mean, I'm sure the federal government is saying we're not going to create a storm, a firestorm based on what we've heard so far. It's not against the Canada Health Act to have publicly funded services delivered privately. However, medically necessary care requiring surgery is one of those features that needs to be closely followed because people are vulnerable. For goodness sake, when you need something done, you're going to follow what your surgeon tells you, even if it means spending extra

dollars, even if it means having care that may be inappropriate. You're going to listen carefully to what your surgeon says. And, you know, that's part of the reason why the Canada Health Act talks about publicly administered services. So I think we're dealing with a gray zone here. I think the federal government, it's important to create a new FPT accord around the Canada health transfer. But I'm sure the government's watching this carefully. Okay. Dr. Bell, thank you so much for this. Oh, it's a pleasure, Jamie. Thanks for asking. This is an important topic. All right, that is all for today. I'm Jamie Poisson. Thanks so much for listening.

Talk to you tomorrow.