Informing the Healthcare Debate…or Not

A story on the front page of this Saturday’s Cape Breton Post caught my eye — and apparently caught somebody else’s eye too:

While I sympathize with anyone suffering from the kind of pain Greg Sharpe describes, I had a very different response to this article than did our mayor/PC leadership candidate. For one thing, I didn’t find any evidence in it that “more and more” Nova Scotian patients are traveling to the US for healthcare. In fact, the story notes that the Nova Scotia Health Authority (NSHA) “does not track who, or how many people, travel out of province or the country for private services,” so I must presume Mayor Clarke has compiled his own data. (I also didn’t see the figure $50,000 anywhere in the story, but if it’s true, it’s a good piece of reporting on Clarke’s part.)

 

Back pain

Sharpe fell in his home in January and sustained “a back injury.” What kind of back injury is not specified, but the term could mean an injury to the cervical vertebrae (upper spine), the thoracic vertebrae (between the neck and the lower back), the lumbar vertebrae (between the chest and hips), or the sacrum or coccyx at the base of the spine. I know this is an article in the Post, not a feature in the New Yorker’s Annals of Medicine, but a little more detail would be helpful.

The computer programmer, who was working from home, said his disappointment with the system began after he learned that X-rays, an ultrasound and a CT-scan did not provide an accurate diagnosis. He said he was told he needed an MRI, but that it would [be] in Truro and that he would have to wait until late July.

AP lumbar x-ray of a 34-year-old male (Photo by FitBro [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)], from Wikimedia Commons)

AP lumbar x-ray of a 34-year-old male (Photo by FitBro, CC BY-SA 4.0, from Wikimedia Commons)

So, as part of the treatment that “flabbergasted” Sharpe with its awfulness, he received X-rays, an ultrasound and a CT-scan. Is it the fault of the healthcare system that his injury was such that these diagnostic imaging services failed to identify it, or is it simply the nature of some injuries?

As for the wait time and need to travel for the MRI, that’s a fair complaint — but it’s one the author of the story, David Jala, could have shone some light upon because just two days earlier, he’d had a story in the Post explaining that the Cape Breton Regional Hospital in still in the process of installing its new “state-of-the-art” MRI machine. In the meantime, it is relying on a portable MRI unit “stationed in a hospital parking lot.” In addition, as NSHA spokesperson Greg Boone told Jala, patients can also be sent to Antigonish, New Glasgow or Truro:

“If the wait times are shorter in other areas of the province and if people have the ability to travel to those areas, then the option to refer to another area is always open, and it’s been there for a long time in terms of diagnostic testing.”

Furthermore, Jala reported that prior to beginning the transition to the new machine, the Cape Breton Regional Hospital had the shortest wait times in the province for MRIs — 65 days. That is still a long wait for someone in pain but it is markedly better than the longest wait times in the province — 269 days in the Valley Regional Hospital in Kentville.

 

Second tier

Unwilling to wait until July for his MRI, Sharpe opted to pay for a private MRI in Halifax. This opens a whole other line of inquiry about two-tier healthcare in Nova Scotia which Jala does not choose to pursue but which I will, because I think the degree to which we’ve simply come to accept the existence of private medical clinics is an important aspect in any story about our healthcare system.

Canada’s single-payer system is based on the principle that care is provided on the basis of need, not ability to pay. Under the 1984 Canada Health Act (CHA), which sets out the framework for the system, medically needed hospital and physician care are to be provided on equal terms for all, without user-charges or extra-billing.

MRIs, when ordered by a doctor, are covered by Medicare in Nova Scotia — so why can a patient go to Halifax and pay for one? Well, it all started in Québec…

Back in the early ’80s, in response to draconian cuts to federal health transfers, the Québec government issued a decree allowing it to determine not just which services would be covered by public health insurance and how often they could be delivered but also where they could be delivered. This allowed the province to “delist” diagnostic imaging services – mammography, ultrasonography and themrography — performed outside hospitals. Québec used the same legal provision to delist CAT scans in 1988 and MRIs in 1995. Subsequently, similar legislation was introduced in Alberta, Nova Scotia and British Columbia.

Source: HealthView Medical Imaging, Halifax, website http://healthviewimaging.ca/

Source: HealthView Medical Imaging, Halifax, website. (Click to enlarge)

According to McGill University professor — and health policy specialist — Amélie Quesnel-Vallée, the delisting in Québec was intended to contain public healthcare costs but it had the effect of creating a private market for diagnostic scans covered by private supplementary health insurance, out-of-pocket payments and third-parties (like the Québec workers’ compensation board).

Writing in 2013, Quesnel-Vallée said that although the initial Québec decree predated the Canada Health Act, its extensions and the similar legislation passed in other provinces led to “repeatedly voiced” concerns from the Federal Government from 2000 to 2005 that the private clinics contravened the CHA “at least in principle, if not in strict legal terms.” From 2006, however, Quesnel-Vallée said the federal government went silent on the matter, even as the number of private clinics increased – particularly in British Columbia.

By 2017, a survey by the Ontario Health Coalition (an umbrella group of organizations aiming to “protect and improve” public healthcare) found:

…private MRI clinics that charge patients directly for services in six provinces. Despite the fact that MRIs are Canada Health Act covered services, the user charges are overt, with clinic staff in Nova Scotia, Alberta, British Columbia, Saskatchewan and Quebec stating outright that they are private clinics and patients are required to pay. Generally, we were told that the patient requires a physician’s referral for an MRI, which means that the test is medically-necessary and should be covered under the province’s public health care plan. In a number of clinics, we were also told that the patient should bring their public health card, despite the fact that the clinic is charging patients privately for services. In Ontario, we were told by one clinic that the patient could bring a corporate cheque to pay. Fees for MRIs were generally $800 – $900. The lowest prices cited by clinic staff were in Quebec, where fees ranged from $600 – $750 for a basic scan. In Nova Scotia the fee was $895. In Alberta, fees ranged from a low of $725 to a high of $950+. In B.C. fees ranged from $650 – $995. In Saskatchewan fees ranged from $900 – $950. Additional fees for contrast range from $200 – $250 and scans for additional body parts added $500 or more to the price.

 

Double-dipping

Perhaps even more disturbing, a 2017 investigation by the Globe & Mail looked at 71 private clinics across Canada and found that almost all of them are owned by physicians.

Furthermore, the Globe’s investigation revealed that 63% of the 699 doctors listed as owning or working in the clinics also work in the public system. To the newspaper, this was “an indication the rules against extra-billing are widely ignored.”

Patient records, court filings and government audits suggest that conflicts of interest by doctors (directing patients to clinics where they themselves have a stake in the profits) and double-dipping (billing both their patient and the government for different aspects of the same treatment) are routine. The situation is particularly acute in B.C., where there are now dozens of private medical facilities.

The Globe recounts the story of one British Columbian, a taco vendor named Rosalia Guthrie, who waited 16 months to have a shoulder injury assessed by a B.C. doctor. She called his office to find out how much longer the wait would be and was given the number of another clinic — his private clinic.

Guthrie ended up paying $500 to see the doctor who subsequently operated on her shoulder in the public hospital at UBC, for no charge (he received $401.67 for the surgery from the provincial health plan).

But Guthrie, who was planning a lawsuit in relation to the injury, requested a doctor’s report for her lawyer — eight pages for which the private clinic charged her $3,850. This despite the fact that provincial rules “forbid doctors for billing for such reports.”

The Globe article goes into much more detail than I can share here about the general lack of response by regulators and government to even the most egregious of these billing abuses. It also does a great job explaining the link between Guthrie’s case and a court case about double-billing that has been before the B.C. courts for over 10 years. Shareholders in the clinic Guthrie visited admit to billing illegally but are challenging the laws banning double-billing as unconstitutional. (As the Globe explains, the case was launched shortly after the province announced plans to audit the clinics.)

 

As seen on TV

But let’s get back to the Cape Breton Post article.

Sharpe gets his MRI but:

…after reviewing the results, his family physician and a neurosurgeon at the regional hospital recommended physiotherapy rather than surgery.

Sharpe says he then consulted “a couple of physiotherapists” including “one of the most reputable around.” He was told that “physio only works about 30 per cent of the time and that 80 per cent of those result in reoccurrence.”

X-ray of cervical spine (neck) AP (front) viewBy Stillwaterising (own medical image, work for hire) [CC0], via Wikimedia Commons

X-ray of cervical spine (neck) AP (front) view. (By Stillwaterising (own medical image, work for hire) CC0, via Wikimedia Commons)

Because this is a one-off Cape Breton Post article and not a New Yorker piece, this is simply allowed to stand as fact, but wouldn’t it be helpful to speak to a physiotherapist about the treatment of back injuries? If it’s true that physio is useful in only 30% of cases like Sharpe’s, should doctors be considering other options?

According to Sharpe, the “most reputable” physiotherapist around told him flat out there was nothing he could do for him and then came “the final straw,” as Sharpe’s family doctor told him:

…that the neurosurgeon would not see him because he was on pain-control opioids.

Again, this is a statement that needs some probing — is this the same neurosurgeon who had already recommended against surgery? Do Canadian neurosurgeons have some sort of guidelines about treating patients on pain-control opioids? Are opioids a recommended form of treatment for the type of injury Sharpe suffered? (I contacted the Nova Scotia College of Physicians and Surgeons to ask these questions but have yet to hear back.)

Jala, to his credit, does ask Dr. Warren Wilkes, the Eastern Zone medical executive director of the Nova Scotia Health Authority about Sharpe’s situation and Wilkes, after the usual disclaimers about being unable to discuss the details of a particular case, tells him:

Physicians make their decisions on care and treatment based on things like diagnostic test results, clinical guidelines that help guide approaches to care and the urgency of a health issue including the patient’s current condition — there are various forms of treatment for some conditions and surgery is not always a first step.

But rather than explore any of this further, the article goes south (literally), recounting how Sharpe found the answer to his dilemma while watching television:

“I saw an ad for a place in Florida that offered surgery to help improve the quality of life — that’s what I want, so I connected with them and it all sounds really good,” said Sharpe.

“It’s not cheap, it will cost a lot of money, but fortunately I can cash in some RSPs and get it done, but I know lots of people couldn’t afford that — that’s why I wanted to go public with my story, so others don’t have to go through this.

I presume that Sharpe does not expect a story in the Post will mean that no one ever again falls and injures their back. Perhaps he hopes that no one will ever have to travel to Halifax and pay for an MRI again — that’s a good hope, I can get on board with that. That’s a hope for proper funding and organization of our public healthcare system. But what I think he hopes is that Canadian patients will be able to get the surgery they “want” on demand — which is, effectively, hoping that patients will one day be able to prescribe their own treatments.

That, I gotta say, doesn’t sound like a great idea to me.

 

Surgery on demand

I sound like I’m criticizing Sharpe but I’m not. He’s a man in pain for which he can find no relief, and that makes him very sympathetic. It does not, however, make him an authority on the diagnosis and treatment of back injuries — or the operation of a single-payer healthcare system. And yet, the Post treats him as if he were both. This may be in line with the paper’s clearly defined mission to “tell stories” (I sometimes think the Post was purchased not by Mark Lever and Sarah Dennis but by the Brothers Grimm) but it’s not responsible journalism.

Sharpe speaks as though the success of the surgery he plans to have in Florida is a given — he almost makes it sound as though the very fact it is so expensive guarantees it will work. That makes me feel even worse for him, because surgeries, no matter how much they cost, are not always successful. Just ask Terry Bollea (aka Hulk Hogan). In 2013, the former pro wrestler sued the Laser Spine Institute in Tampa, Florida (which advertises on television extensively) for allegedly performing “unnecessary and ineffective procedures costing hundreds of thousands of dollars” on him.

Moreover, in the world of for-profit medicine, you can probably always find a doctor willing to do what you want done — for a price. British doctor and writer Gavin Francis explored the phenomenon in a 2015 article for The Guardian:

Recently an angry father insisted I refer his son for consideration of a tonsillectomy after a couple of episodes of tonsillitis. If I want to refer someone to have their tonsils out on the NHS [National Health Service], my local surgeons won’t countenance seeing them unless they meet certain criteria: seven episodes of tonsillitis in the last year, or 10 over the last two years, or three a year for the last three consecutive years. There are good reasons for this: tonsillectomy risks haemorrhage, infection and leaving you more prone to throat problems in the future. Though we all pay for NHS care through taxation, no doctor in the NHS will now remove your tonsils just because you’ve asked them to – that would be considered a grave abandonment of professional standards, and a flouting of evidence-based practice. But the private healthcare market specialises in treatment on demand, and the rules are different over there. When the father repeated his demand at a private clinic the surgeon’s professional reservations melted away and the operation was scheduled within days. The surgeon’s later correspondence contained a tortured justification for tabling the surgery that was painful to read. It must have been painful too for the patient who went on to need NHS hospital admission to address subsequent complications (bleeding and infection). Several of my own clinic appointments were used to deal with the aftermath. There is as yet no reliable mechanism for the NHS to bill private health companies for the expenses incurred when private procedures go wrong.

 

Conclusion

MRI of lumbar spine (X-ray of cervical spine (neck) AP (front) viewBy Stillwaterising (own medical image, work for hire) [CC0], via Wikimedia Commons)

MRI of lumbar spine (X-ray of cervical spine (neck) AP (front) viewBy Stillwaterising, own medical image, work for hire, CC0, via Wikimedia Commons)

There are problems with our healthcare system, I will not deny that, but other than the long wait for an MRI, I’m not sure what particular problems Sharpe’s story illustrates.

In fact, it may illustrate a problem not with the system but with our attitudes toward healthcare; a problem journalist Julia Belluz, writing specifically about back pain in Vox, characterized this way:

…Americans and their doctors have come to expect cures for everything — and back pain is one of those nearly universal ailments with no cure.

PC leadership candidate Clarke, on the other hand, who is trying to make healthcare one of this signature campaign issues, sees this story as representing everything that is wrong with Nova Scotia’s healthcare system:

This is completely unacceptable. Greg Sharpe should not have to spend $50,000 in Florida to get relief for his pain. Something must change.

That’s why as leader of the PC Party, I am committed to going back to the drawing board and bringing local decision-making back to our healthcare system, so patients and their needs come first.

Clarke accepts without question that the surgery Sharpe saw advertised on television and recommended for himself will be successful. He also seems to be stating, unequivocally, that all pain can be treated and that a lack of local decision-making is all that is preventing Sharpe from receiving adequate treatment for his pain here in Cape Breton.

Again, I don’t know the details of Sharpe’s case, but let’s imagine he’s suffering from what doctors call “unspecified lower back pain.” That means it has no obvious cause, like a pinched nerve, and it’s the most commonly reported type of back pain in the US (reported by 85% of back-pain sufferers).

According to Belluz’s Vox magazine article:

Low back pain is the second most common cause of disability in the US, but the most popular treatments out there — spine surgery, opioid painkillers, steroid injections — are unhelpful for most people, or even downright harmful. The evidence increasingly supports a range of exercise programs and alternative therapies, such as massage and yoga, that can help people alleviate their sore backs.

Moreover, new research is suggesting that in looking for the cause of (and potential cure for) back pain, you need to look beyond the merely physical. Writes Belluz:

[W]hen you compare people with the same MRI results showing the same back injury — bulging discs, say, or facet joint arthritis — some may experience terrible chronic pain while others report no pain at all. And people who are under stress, or prone to depression, catastrophizing, and anxiety tend to suffer more, as do those who have histories of trauma in their early lives or poor job satisfaction.

Belluz quotes Roger Chou, a back pain expert and professor at Oregon Health and Science University:

Our best understanding of low back pain is that it is a complex, biopsychosocial condition — meaning that biological aspects like structural or anatomical causes play some role but psychological and social factors also play a big role.

Also worth noting is that while health insurance will cover things like surgery, opioids and physiotherapy (two of which, you’ll note, apparently were recommended to Sharpe) it often won’t cover exercise programs or alternative therapies that have shown some promise in treating back pain. That could be a problem worth addressing.

But the bottom line is that back pain is complex. Diagnosing it is complex. Treating it is complex. Writing a story like Belluz’s, for which she read 80 reports on back pain treatment and a whole book by investigative journalist Cathyrn Jakobson Ramin, is complex. Much easier to interview a layperson who has decided — against the advice of his doctors and on the basis of a television ad — that he needs back surgery and give him the final word not just on his own case but on our entire healthcare system, as Jala does Sharpe:

How can our health care be so bad that this is my only option?

Personally, I’d like a second opinion.

 

 

 

 

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