Monday, November 28, 2016

MRIs: The New Provincial - Federal Grudge Match

SOURCE: CBC News - No Plans to End Private MRIs, Says Sask. Health Minister to Federal Concerns

While there's some interesting things happening with the GTH as of this morning (Wall's Chief of Staff being involved in an e-mail chain, the auditor indicating a police investigation is underway, etc.) we're going to talk about the thing that came out of left field.

Earlier today, the federal Health Minister Jane Philpott sent a letter to Saskatchewan Health Minister Jim Reiter that effectively said it was time to "put an end" to private MRIs within the province. Reiter, and his government colleagues, scoffed at the notion.

Bill 179, the MRI Facilities Licensing Act, passed back in 2015 established private MRI clinics in our province under the system of a "2-for-1" trade off; the idea being that for each private scan conducted in the clinic, that clinic would then be responsible for providing a public scan as well.

Reiter's letter back to Philpott more or less doubles-down on the practice; saying that it has been responsible for more than 2,200 scans and the removal of 1,100 from the wait list. However, these numbers are a little confusing for me.

Back on October 20, 2016 the government released numbers regarding the current "2-for-1" system and the results. Their numbers,from February 2 to September 30, 2016 were as follows:

  • 943 private scans performed in the province
  • 757 public scans performed as part of the "2-for-1" deal
  • 186 public scans in the process of being scheduled
Now,  all of those numbers combined add up to 1,886 scans. Take away the "in-scheduled/not-happened yet" scans and those numbers drop to 1,700. So, where is Reiter getting the 2,200 scans and 1,100 people taken off the wait list numbers from?

Now, that's 241 days being accounted for in the government's October release. In those 241 days, 1,700 scans occurred (Not including the 186 in the "scheduled" portion). That's roughly, if my math can be trusted, about 7 scans a day. At that level, from the period of October 1 until Today, that means we'd have at most 2,113 scans performed in the province.

Yet, Reiter says the system has contributed "more than 2,200" scans. So, I'm not seeing where he's pulling the numbers from on this one...At least, not from the public data that was released a little over a month ago.

But let's bring it back to the basics and talk about the numbers from the release, as opposed to Reiter's numbers that we can't explain. What's the one facet of that that sticks out?

The difference in private scans versus public scans.

At one point or another, the private scans managed to move almost 200 scans ahead of the public scans. That hardly sounds like "2-for-1", given that it shows the scans are not close to parity. And the main reason this is a problem: As far as we know, private clinics have been given no directive to focus on public scans to eliminate the gap.

So, while 186 scans were "in the process of being scheduled" how many scans were added to that backlog?

If private clinics don't have to prioritize ensuring the 2-for-1 ratio is being met, this swap deficit is only going to continue to grow. It doesn't matter if the 186 waiting for a scan to be scheduled eventually get in, if at the same time, 200 more private scans are conducted leading to 200 more people waiting for their swap scan.

So, unless the government issues a directive that private clinics could risk losing their license unless parity is kept and maintained the swap deficit is unlikely to ever actually go away. And that undermines the entire notion of a "2-for-1" swap, when it's painfully clear that the clinics have already placed a greater emphasis on private scans over public ones.

Which brings us to the federal intervention.

One can argue that perhaps this is just desserts for Wall, who has managed to find something new to complain about with regards to the Federal Government pretty much every day. (Don't get me wrong, there's lots wrong with the Federal Government [and we'll talk about that sometime) But as Premier, Wall needs to be diplomatic and receptive, not combative and seeing every Federal action as a personal slight. So, it's not surprising to see the Feds finally kick back on something they can actually do.

On the other hand, Harper had a hands off approach to the Canada Health Act; and one can argue that with tweaks in various provinces, it was only a matter of time until the Trudeau Government did something to try and bring some balance back to the act.

Philpott invoked the ultimate clause in the Canada Health Act: The clawing back of health transfer funds.

As per Article 10 of the Canada Health Act:
In order to satisfy the criterion respecting universality, the health care insurance plan of a province must entitle one hundred per cent of the insured persons of the province to the insured health services provided for by the plan on uniform terms and conditions.
Effectively, provincial governments must ensure that health care services are universal. All people resident in their province should have the same level access to health services as everyone else in the province. If the 2-for-1 trade was at parity, with no discernible deficit for the public scans, you could argue that the province was keeping its end of the bargain.

But, given that we do have this gap between the two, a case can indeed be made that universality is not being maintained under this current system.

Article 19, Section 1 lays out the penalty for breaking universality:
In order that a province may qualify for a full cash contribution referred to in section 5 for a fiscal year, user charges must not be permitted by the province for that fiscal year under the health care insurance plan of the province.
So, what does that mean?

Effectively, Ottawa can decide that the full cost of user fees charged by Saskatchewan should be deducted from their health transfers.

So, if Saskatchewan charged $4 million worth of MRIs in one year; Ottawa could turn around and retract $4 million in health transfers because the province violated the Canada Health Act. And while Saskatchewan receives about $1.6 billion in transfers, $1.1 billion of which is for health transfers,  and a few million less in transfers sounds like a drop in the bucket...Consider the deficits for Saskatoon Health Region and the Regina Qu'Appelle Health Region, where that additional funding could prevent front line layoffs.

If the 2-for-1 system showed promise of working, by which I mean it kept public-private scans at parity with one another, then the SK Party might have had a leg to stand on here. But given that all public data currently available shows that parity has not been achieved, and current practice means striking that balance gets tougher every day with every new private scan conducted, I think the feds are in the right here.

And given that the province plans to expand the system to CT Scans in the near future, it seems increasingly likely that the province is unlikely to blink on this matter.

Which means, of course, that the province will be going to court on it and spending some tax dollars fighting the federal government. At the same time, I'm sure, the feds will invoke the Canada Health Act to claw back Health Transfers to the tune of the private MRI fees. And, sadly, it's the taxpayer who loses here. Since we're either losing money from the federal government, at a time when our health regions need every dime they can get AND that we won't get back unless our side wins a court case (which seems unlikely, in my opinion) OR we're spending money to fight a court case.

Either way, it's money that's being spent or lost that could be making a difference somewhere else in our province.

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