THUNDER BAY, ON ---- February 21, 2014 ---- Public opinion polls show many Canadians worry about surgical wait times. Anecdotal media reports and heated political debates encourage this worry. Government reports often feature wait time improvements. Some experts claim solutions are within reach and inexpensive, while others call for increased privatization as a solution.
Prepared for EvidenceNetwork.ca by Neeta Das McMurtry
In the midst of all of the data collection and debate, the question remains: Are Canadians waiting too long for surgery?
Who is waiting? What are they waiting for?
Canada still cannot answer either of these questions very well. There are not enough province-wide databases to inform our national wait-time worry.
Most healthcare facilities maintain their own lists. Some provinces have launched centralized lists for some procedures. These databases help minimize surgical wait times because patients from a busy facility can be offered care in other facilities with shorter waiting lists. (See How do we solve the problem?) The Canadian Institutes of Health Information has launched a web database collating regional and facility health data across the country, including surgical wait times.
Not all surgical wait times are the same
One way to evaluate surgical wait times is by number of days, but Canada has no consensus on when wait times start. Some institutions start measuring wait times when patients get referrals from their family physicians; others start when patients begin seeing medical specialists; still others start when patients are put on hospital waiting lists. Broad statements about national wait times are problematic when they are based on comparisons of data that are measured inconsistently.
Another way to evaluate surgical wait times is by urgency. For example, a few extra weeks of waiting for elective surgeries such as cataract removal does not impact the health of most patients. However, for many types of surgery, rating cases by urgency launches a complex process of sorting and re-sorting patient cases, without necessarily improving upon a shortage of resources whether that be operating times or number of surgeons. More useful is to simply have specialists determine where elective surgeries are appropriate and then organize the system to deliver the surgeries without delay.
Studies show that Canadians generally have rapid access to cardiac and cancer care, but access to less-urgent, or elective, surgeries could be improved. Again, data here are problematic because there are no guidelines for identifying “elective procedures” beyond the subjective assessments of patients and healthcare professionals.
When waiting lists are reviewed in detail, it has been found that surgical wait time numbers are inflated by patients being put on multiple waiting lists for different hospitals.
In addition, one study found that up to 1/3 of patients should have been removed from the list because:
§ the patient has already had the procedure done elsewhere
§ the patient was already admitted into hospital as an emergency case
§ the patient no longer wants the procedure, or it is not medically necessary
§ the patient is deceased from other causes
§ the patient was called for the procedure, but asked to be put back on the list to wait for a more convenient time slot.1
How do we solve the problem?
An important first step for shrinking surgical wait times is keeping track of them. A basic database can monitor wait times for different treatments. The next step is to use relatively inexpensive management tools to redirect patients from lengthy waiting lists to shorter ones, while still allowing patients to wait for the provider of their choice if the situation is not urgent.2
Evidence indicates some patients are waiting for care that they don’t necessarily need, such as diagnostic tests. Procedures such as MRIs are often cited as examples here. But doing hip replacement surgery on younger patients or the very old is not necessarily the best thing for patients. Sweden and the UK have started measuring patient-reported outcomes in an attempt to figure out what types of patients benefit and who are harmed by different procedures. Also, in some cases, patients waiting for medical specialists could have their issues addressed by other types of healthcare staff — from dieticians, to nurse practitioners, to social workers.
Sometimes having more resources helps. Resources can include facilities, equipment, or staff — and cash isn’t the only factor determining these resources. For example, the number of physicians in Canada is mainly influenced by the size of medical school classes, but also by immigration rules and by the rate at which physicians move to practice in the U.S. Significant increases in medical school class sizes have steeply increased the number of physicians across Canada. In most provinces this has meant a significant increase in physician supply, but Ontario saw a real decline in the 1990s.
One frequent suggestion for addressing surgical wait times is allowing more for-profit, healthcare facilities. (See What does “private” mean in Canada’s healthcare?) In practical terms, this would mean that some patients would wait for treatment in a not-for-profit facility, while patients with more cash, or with private insurance, would wait for the same treatment in a for-profit facility. At first glance, this would appear to divide one long line-up into several, thus shortening wait times for all. However, research from around the world shows that parallel private systems actually make wait times in publicly-funded healthcare facilities worse. (See Privatization and longer waiting times).
Many healthcare providers across the country have already launched successful strategies for addressing wait times in various healthcare settings that have nothing to do with privatization. In fact, wait times for some procedures are already improving in
Canada, with 75 per cent or more of provinces meeting benchmarks for some procedures.
§ The Saskatoon Community Clinic implemented an Advanced Access model of booking patients with its family doctors and nurse practitioners in 2004. Now most patients are seen the day they want to be seen and many are seen the same day. The Community Clinic is now working with the Saskatchewan government to spread this efficient model across the province.
§ In Hamilton, Ontario, the Mental Health and Nutrition Program models a strategy for eliminating delays for specialty care. The program coordinates 17 psychiatrists, 20 dietitians and 80 counselors (social workers) and 100 family practices.
As part of the program, patients with mental health issues are immediately connected with counselors working as part of the family practice team. Referrals to the psychiatry specialty clinic have dropped by 70 per cent. At the same time, 1100 per cent more patients are having mental health issues addressed without delay from their family physicians’ office. What is more, the program has documented improvements in patient depression scores as well as general health and functioning.
§ The Ontario Wait Times Strategy has had some success in reducing wait times for priority areas including cancer surgery, cataract surgery, hip and knee replacement, and diagnostic imaging. This strategy has focused on reducing waits between a specialist’s treatment recommendation and the resultant medical procedure, such as an operation.
§ The Alberta Bone and Joint Health Demonstration project used a variety of different processes to reduce wait times from referral to first visit with surgeon. Waits dropped 80 per cent, from 35 weeks to 6 weeks. Wait times from the first visit with surgeon to surgery date plummeted 90 per cent, from 47 weeks to 4.7 weeks. Patients’ length of stay in hospital fell 30 per cent, from 6 days to 4 days. What is more, patients surveyed expressed increased satisfaction.
What does “private” mean in Canada’s healthcare?
More private healthcare is often presented as a logical solution for Canada’s waiting time issues. However, the question isn’t really whether privatization should exist or not in Canada; the question is how far should privatization be allowed to go?
From the outset, publicly funded healthcare in Canada has included elements of private health delivery. More succinctly, Canada has public financing, but private delivery models:
§ Canadian hospitals are not-for-profit businesses that bill public health plans for services rendered to patients.
§ Most physicians in Canada work as independent business owners, paying for their own offices and support staff, setting their own hours and location, but billing public plans — hence the term private practices.
§ The same goes for many laboratories providing services such as ultrasounds or blood tests, which function as independent businesses that bill the public health plan.
But things aren’t quite that simple:
§ There are also for-profit facilities working alongside not-for-profit facilities, supported by a mix of public funding and private fees.
§ Many subsectors, including outpatient drugs, rehabilitation, dentistry, ophthalmology, etc. are largely paid for privately (that is, out of pocket or through private insurance) outside of hospitals.
When people argue for or against privatization in healthcare, what they are actually debating is the development of for-profit hospitals, clinics and physicians that can charge fees not just to the public sector, but also directly to patients, or to private insurance policies. In other words, allowing for individual physicians to bill patients privately for healthcare services alongside or parallel to public billing. Currently, physicians have to choose between either billing private fees, or billing public insurance — but they can’t do both.
Proponents of private healthcare say it allows wealthy patients to fast-track services, thereby increasing the total funding available for healthcare, and freeing up space in public systems so that everyone can get faster treatment. Critics of privatization say it encourages a two-tier healthcare system, which goes against core principles of universality and accessibility in the Canada Health Act.
In many parts of Canada, healthcare providers are not allowed to bill private fees for services already covered by public plans. Public plans vary among provinces, but typically cover physician and hospital services deemed medically necessary by the respective provincial governments and in keeping with federal guidelines. But many permissible private health services do still exist in Canada and the public health plans do not always cover everything.
Many Canadians already supplement healthcare costs by paying for care out-of-pocket or through private insurance plans. These costs can include everything from prescription drugs, to orthotics, to dental surgery. In fact, only 70 per cent of Canadian health expenditures are from public sources.
This model has many Canadians wondering whether more private payments could allow patients to shop around for better medical services — particularly when they perceive significant wait times in the public system. However, examples across North America show that healthcare is not a commodity that necessarily improves with more private alternatives. Related data shows that more healthcare spending does not necessarily result in more healthcare service, and that more healthcare interventions can sometimes do more harm than good. (See Privatization and longer waiting times and Staffing Issues in Parallel Care)
Privatization and longer wait times
Parallel public and private healthcare is when the same range of medical treatments is offered in institutions that bill public insurance as in institutions that bill private insurance.
In a parallel system, private institutions can provide faster care — to patients who can pay — but they seriously compromise access for those waiting for care in the public system by luring staff away from public facilities, and creating financial incentives for professionals who generate income through private care.3 There is also evidence suggesting that private healthcare encourages overuse and that wait times in publicly funded systems get longer in part to create demand for paying more in the private sector.
Another issue is that private healthcare providers may leave expensive cases to the public systems and “cherry pick” patients who are healthier and younger, or who have conditions that are easier and cheaper to treat.
Until 1999, Manitoba patients waiting for cataract removal could line up in the public system, or pay a surcharge to go to a private facility. The surgery itself was fully covered by the provincial health plan in both public and private facilities, but the private facilities charged patients an additional user fee. Yet even with private treatment options, cataract patients in Manitoba did not see a shortening of wait times except for those who could pay the surcharge (See Staffing issues in Parallel care).
In 2006, Quebec created more room for more private healthcare delivery alongside the public system. The change was part of a provincial strategy to address wait times for cataract removal, hip replacement and knee replacement. So far, province-wide data shows the new regulations have had no impact on wait times for those particular surgeries. Quebec has expanded private healthcare delivery to other services, but is struggling with a legislative grey-zone where private services are mushrooming ahead of provincial guidelines.
Countries with parallel healthcare systems have the longest public wait times. For example, England and New Zealand, which have parallel private hospital systems, experience larger waiting lists and longer wait times in the public system than countries with only one publicly-funded hospital system, such as Canada.
Since 2000, England’s National Health Service (NHS) has set clear wait time goals, published data on hospital wait times, imposed sanctions against poor performing hospital managers, invested in more public hospital capacity and better patient management, purchased additional capacity from private clinics when needed, and placed restrictions on consultants’ private practices. These measures have shortened public hospital wait times, but the direct causes of improvement and the consequences on quality of care are still under debate. However, what the situation in England does illustrate well is that strategic government policy and funding may lessen the service gap in healthcare systems where both private and public hospitals are already in operation.
Researchers have also looked at the variation in waiting times within countries with parallel care. Studies in both Australia and England find the more care provided in the private sector in a given region, the longer the waiting times for public hospital patients.
To minimize impact on public waiting times, the Netherlands does not allow patients using the separate private hospital system to also use the public system. This has shortened wait times in Netherlands’ public system relative to those in England and New Zealand.
Staffing issues in parallel care
Parallel healthcare divides healthcare staffing between two systems. Since healthcare practitioners can’t be in more than one place at the same time, this takes doctors and nurses out of the public system, potentially increasing wait times for the population relying on public care.
Also, doctors can earn significantly more in the private sector by setting their own fees for services or increasing profit margins on treatments or tests that they prescribe. In countries where this is allowed, economists have identified a “perverse incentive” in parallel care, where doctors benefit financially by keeping public waiting lists long and encouraging patients to pay for private care.
Manitoba used to have a parallel healthcare model for cataract surgery. During this time, public wait times increased. The parallel model created a financial incentive for physicians who were permitted to work in both public and private systems to limit their work in the public system and direct patients to their more lucrative private-pay practices:
§ patients waited approximately 5 weeks for private sector cataract surgeries offered for a $1000 fee
§ patients waited approximately 8-10 weeks for cataract surgeries performed by surgeons operating exclusively in public hospitals
§ patients waited approximately 16-25 weeks for cataract surgeries performed in public hospitals by surgeons operating in both the public and private sectors
A 1998 survey in Alberta compared wait times in three of its cities. In Edmonton and Lethbridge, where the vast majority of surgeons were in public hospitals, average wait times were between four and seven weeks. But in Calgary, which had the most surgeons per capita and where all surgeons operated out of privately owned day-surgery facilities, average wait times were between 16 to 24 weeks. This study also found that many of the private clinics were aggressively marketing “upgraded” lens implants to patients at significantly marked up prices.
Experts available for interview
Eric Bohm, MD, FRCSC
University of Manitoba
Orthopedic Surgery, Standards and Practices
204-926-1212 | email@example.com
Ben Chan, MD, MPH, MPA
University of Toronto
Patient Safety and Quality/Rural Primary Care
416-978-8622 | firstname.lastname@example.org
Malcolm Doupe, PhD
University of Manitoba
Aging Population, Nursing Homes, Home Care
204-975-7759 | email@example.com
Cy Frank, MD, FRCSC
University of Calgary
403-220-6881 | firstname.lastname@example.org
Alan Katz, MBChB, MSc, CCFP
University of Manitoba
Primary Care Delivery and Disease Prevention
204-789-3442 | email@example.com
Robert McMurtry, MD, FRCSC
University of Western Ontario
Wait Times, Surgical Policy and Delivery
519-646-6287 | firstname.lastname@example.org
Marie-Pascale Pomey, MD, PhD
Department of Health Administration, Université de Montréal
Quality & Safety of Care, Waiting Time Strategy, Pharmaceutical Policy
514-343-6111 ext. 1364 | email@example.com
(Available for interviews in French/English)
Michael Schull, MD, MSc, FRCPC
University of Toronto
Health System Integration/Emergency Department
416-480-6100 ext. 3793 | firstname.lastname@example.org
Amardeep Thind, MD, PhD
University of Western Ontario
Wait Times to See a Specialist
519-858-5028 | email@example.com
 Waiting list lengths
§ Tomlinson M, Cullen J., A clinical audit of patients on an orthopaedic waiting list for greater than two years, The New Zealand Medical Journal [1992, 105(937):266
§ Goldacre M, Lee A, Don B. Waiting list statistics. I: Relation between admissions from waiting list and length of waiting list. BMJ 1987;295:(6606):1105-1108
§ Lee A, Don B, Goldacre, MJ. Waiting list statistics II: An estimate of inflation of waiting list length. BMJ 1987;295:1197
§ Dalton KJ., Surgical waiting lists, BMJ 1984;289:495
 Management tools to reduce wait times
§ Amar C, Pomey, M-P, et al. Sustainability of Wait Time Management Strategies for Orthopaedic Surgeries. Soumis et accepté avec révision International journal of healthcare quality assurance. (IJHCQA-11-2013-0131). Resoumis le 25 février 2014. Accepté le 14 juillet 2014.
 Public and private healthcare in Canada
§ Backgrounder: Court Challenges to the Canada Health Accord
Prepared for EvidenceNetwork.ca by Neeta Das McMurtry
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