Sunday, July 4, 2010

Private CT clinics: Cornucopia or Juggernaut?

Get your reading glasses on. And get ready to rumble. It’s time for health policy cagefighting! In this corner – the Advanced Access Afficionado. In the other corner – politicians, bureaucrats and political commentators. Guess who’s wearing black?

Last month, the Saskatchewan government announced that it was looking for a 3rd party supplier to provide CT scan services (1). The intent is to reduce wait times. Of course, that got my attention.

(Note: Because some links to media sources seem to vanish unpredictably, I’ve included the text of all the stories referenced in this post in an appendix. If you try a link and it doesn’t lead anywhere, scroll down to the end of the post. P.S. July12,2010 -because of some concerns about copyright, have removed the text that was initially pasted at the end of this post. So, sorry if the links to op-eds turn into deadends. KV)

The article focused on the response from the opposition NDP party, namely that this was a step toward the piece-by-piece privatization of health care. Commentary by the Leader-Post’s Murray Mandryk (2) lambasted the NDP for being hypocritical and dogmatic in their opposition to privately-operated CT clinics.

Whether or not the NDP is hypocritical in opposing this CT clinic is beside the point. The clinic has been portrayed as necessary because Saskatchewan needs more CT scanning capacity. Fans of wait time reduction strategies should smell a rat. Healthcare wait times sometimes result from inadequate capacity, but more often result from a mismatch between demand and capacity. Over time, backlog builds, even when demand and capacity are balanced.

Adding permanent capacity to manage backlog will be successful, but in the end, is wasteful. Once the backlog is dealt with, you need to mothball that extra capacity. Expensive CT scanners, professional staff and clinic investors don’t like mothballs. That’s the point I tried to make in an op-ed response (3), giving our clinic’s experience with Advanced Access as an example of ways to cut wait times without permanently adding capacity.

Weighing in on the same issue was Steven Lewis who, in addition to providing some analysis around safety and appropriateness of CT scans (4), called for open discussion around the risks and benefits of a privately-operated clinic. Stan Rice expressed his skepticism (5) with a financial analysis of private vs public CT scanners.

Mandryk responded to the op-ed pieces with “Informed health debate overdue” (6). While his statement “Like me, many of you might be troubled by the underlying premise that we can somehow turn back the clock by performing fewer diagnostic tests” puts him firmly in the “more is better” camp, I agree with his call for debate around this issue. I don’t think it’s going to happen, though.

The government has already stated its intention to support the privately-operated CT clinic, and has called for proposals. Sask Health doesn’t lack expertise around wait time reduction strategies, so I can’t imagine that this decision was made without full (internal) discussion of alternatives. If I were in the decision-maker’s shoes, I can see the appeal of the private option. It’s actually easier to take this approach than opt for the drawn out process of increasing efficiency and appropriateness of testing. To saying nothing of having to change the culture of “more is better”!

I don’t doubt that this strategy is going to work. Wait times will drop. It will make for some very satisfying headlines. And, as long as that’s as deep as the analysis goes, certain skeptics will be invited to eat their words.

It’s very tempting to wonder why “they just don’t get it”. Why can’t “they” see this issue as clearly as me? But, as soon as I start thinking that way, I play the Switch game in my head. What is it in this situation that I’m missing? If I’m truly convinced that Advanced Access methods can reduce wait times and provide appropriate, timely testing for Saskatchewan, and that building privately-operated capacity is not the answer, what’s the appropriate forum for debate? What’s the best way to illustrate the admittedly counterintuitive principles of Advanced Access so that policy-makers will embrace them over the more expeditious solution?

If politicians are driven by the belief that citizens need the quick fix afforded by an extra CT scanner, maybe the audience to be convinced is the entire (voting) population of Saskatchewan. I think I’m in over my head.

In answer to the question in the title of this post, it’s both. It’s a juggernaut because it seems unstoppable. It’s a cornucopia because many patients will benefit from the bounty of increased capacity.

But, can you have such a bountiful harvest without some of the fruit going to waste? How much goes to waste, and whether anyone bothers to keep track, remains to be seen.

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