Week 7 - Medical Wait Times

Policy Issues:
Medical Wait Times
HLTH 405 / Canadian Health Policy
Winter 2012
School of Kinesiology and Health Studies

Course Instructor:
Alex Mayer, MPA

Announcement
• Don Drummond speaking at the Queen’s
School of Policy Studies this Thursday
o Rm. 102 at 12pm (noon).
o Presentation on his recommendations to reform
Ontario’s public services.
o Good opportunity to ask tough questions!

Topics for today’s lecture:

Policy Issue #3: Medical Wait Times
• Wait times as a policy problem
• Canadian Wait Times in a Global Context
• 2004 Health Accord: Wait Times Strategy
• 2005: The Chaoulli case
• Ontario’s progress: 2005-2011
• Remaining Challenges

Wait Times
• A mainstay of universal health care systems
rationed based on medical need rather than
ability to pay.
o Ensures that public health care resources are
being used to their full capacity (i.e.
‚efficiently‛) at all times.
o Imposes a time cost that discourages people
from accessing care for trivial reasons.

Wait Times
• Wait times can be measured for all health
care access points, including…
o Access to primary care
o Access to hospital emergency room (ER)
treatment
o Access to surgical and imaging procedures
o Alternative level of care (ALC) placement
o Receipt of home care services

Wait Times
• Not problematic so long as…
o Patients are appropriately triaged (i.e. patients
with the most urgent care needs are seen
immediately).
o All patients are seen within time periods
specified by clinical care guidelines, in order to
prevent unnecessary suffering, complications
and mortality.
o Wait times meet the public’s (taxpayers’)
reasonable expectations and do not undermine
public confidence in the health care system.

If medical wait times are a
normal part of our system,
why have they been the
subject of so much attention?

Wait Times
• Not problematic so long as…
o Patients are appropriately triaged (i.e. patients with the
most urgent care needs are seen immediately).
o All patients are seen within time periods specified by
clinical care guidelines, in order to prevent unnecessary
suffering, complications and mortality.
o Wait times meet the public’s (taxpayers’) reasonable
expectations and do not undermine public confidence in
the health care system.

Do Wait Times Worsen
Health Outcomes?
o Coronary artery bypass:
• Between ‘91-’93, 0.4% (n=34) of Ontario patients died while in
the queue. (Naylor et al, 1995)
o Hip replacement:
• Canadian patients experience higher wait times, hospital length
of stay and mortality rates than U.S. patients. However, a
competing risks hazards model shows that wait time is not
significantly associated with mortality. (Carrier et al, 1993;
Ho, Hamilton and Roos, 2000)
o Cancer Surgery:
• Only 2 of 6 studies registered a higher hazards ratios for PSA
recurrence among prostate cancer patients experiencing delays
≥3 months in waiting for surgical treatment. (Saad et al, 2006)

Wait Times Problem: Access
• In past decade, Canadians have consistently
identified ‘wait times’ as the #1 barrier in accessing
health services.
o For laypeople, wait times are a tangible indicator of
health care quality.
o Canada’s global rankings in this regard easily becomes a
flashpoint for public concern.

• Excessive wait times offer an effective line of
attack for private interests that would benefit
from the evolution of a parallel private-payer
health care system in Canada.
"Socialized Medicine" vs "Free Market Medicine" Video

• Whether it’s the ‘grass is always greener’ appeal of
two-tiered care, or the fear of losing what we have to
government mismanagement (overspending,
underinvestment, etc)
 Wait times undermine public confidence in the system!

Are Canadians Waiting Too Long?
• For a patient, the answer is always yes.
• Medically, however, a patient’s place in line is
determined by the severity and urgency of his/her
case.
o Severity refers to suffering, functional limitations, and risk of
premature death.
o Urgency refers to the extent to which clinical treatment is required
immediately to avoid complications or death, based on the natural
history of the pathology.

What the Media Sees

US Anti-Medicare Ad
http://www.youtube.com/watch?v=XwLp2KJCLOQ

Fact-Checking the Shona Holmes Case

“Time for a Reality Check on CNN’s ‘Reality Check’
by Julia Mason, The Ottawa Citizen

… I found Holmes’ story both compelling and troubling. So I
decided to check a little further. On the Mayo Clinic’s website,
Shona Holmes is a success story.

But it’s a somewhat different story than the headlines might have
implied. Holmes’ “brain tumor” was actually a Rathke’s Cleft Cyst
on her pituitary gland.”

According to the John Wayne Cancer Centre: “Rathke’s Cleft
Cysts are not true tumors or neoplasms; they are
benign cysts.”

Are Canadians Waiting Too Long?

Conclusion:
• Whether it’s the ‘grass is always greener’ appeal of
two-tiered care, or the fear of losing what we have
to government mismanagement (overspending,
underinvestment, etc.) and declining quality…
 Wait times undermine public confidence in the
system!

Solving the Wait Times
Problem

2004 Health Accord

Problem
• 2004 Health Accord:
In response to public concern, First Ministers put
wait times front and centre in the 2004 HA.
o Provinces/Territories to come up with medically acceptable wait
times (i.e. ‘benchmarks’) for certain key health services by 2005.
o ‘Five in Five’ plan – provinces to receive additional funding ($5.5B
Wait Time Reduction Fund) to target wait times for 5 key services in
the next 5 years, and to achieve meaningful reductions by 2007.
o Provinces commit to increase % of patients treated within
recommended benchmark period for cancer therapy, heart surgery,
diagnostic imaging, joint replacement and sight restoration.

And Then a Curveball…

The Chaoulli case

The Chaoulli Case
• 1996: Montreal businessman George Zeliotis waits
1 year for hip replacement surgery. While waiting,
he asks to purchase private insurance to skip the
queue.
• When he learns this isn’t possible, he takes his
case to court.
• He is accompanied by Dr. Chaoulli, who had
previously failed to establish a private hospital in
Quebec that would charge for publicly insured
services.

The Chaoulli Case
• The plaintiffs asked the Supreme Court of Canada
to strike down sections of the Quebec Hospital
Insurance Act barring citizens from purchasing
private insurance for publicly financed services.
• The Court agrees that wait times are
‚unreasonably long‛.
• By a 4-3 decision, the Court rules to strike down
the provincial policy (June 2005).

The Chaoulli Case
• Asked whether the policy violated the rights of
Canadians to ‚life, liberty and the security of the
person‛, the Court did not come to a majority
decision (3-3, with one abstention).
• Would have raised serious legal (and practical)
questions about the CHA.

Post-Chaoulli Discourse
Patient ‘right’ to reasonable wait times
Harper’s Wait Times Strategy Announcement
http://www.youtube.com/watch?v=JrePOsVHVgc

Problem
• August 2005
Wait Time Alliance release their final report ‚It’s
About Time‛ that outlines medically acceptable
wait times based on medical consensus and, where
available, research evidence, for the 5 clinical focus
areas (cancer therapy, heart surgery, diagnostic
imaging, joint replacement and cataract surgery).
.

Problem
• Provinces Commit to Set Targets for Wait Time
Benchmarks by 2007
o Early on, different provinces focused on different clinical areas.
o All would publicize benchmarks and wait times on provincial
websites.
o All would report on progress annually.

• In SK, people can visit Saskatchewan Surgical Care
Network website to determine the wait time for
their level of clinical priority.
o E.g. Level 3 surgical patient (out of 6 levels) will know that the
provincial target is to treat 90% of such patients within six weeks.

Problem
• In ON, cardiac patients are assessed according to clinical
guidelines and assigned a maximum recommended wait time of
6 months, depending on seriousness of their condition.
o Targets and Wait times to be found on the Cardiac Network Care of
Ontario website.
o In MB, median wait time for surgery was 2 weeks.

• For oncologist appointment, wait time benchmark in ON is 21
days.
o As of 2005, wait times ranged from 5 - 34 days, depending on the
type of cancer. For 10 out of 12 types of cancer, wait times were
within benchmarks. For lung cancer (24 d) and myeloma (34 d),
wait times exceeded benchmarks.

Problem

Prior to the agreed-upon
2005 Benchmarks, there was
a clear lack of nationwide
standards in reporting wait
times.
e.g. cardiac surgery

Problem
• Today, pan-Canadian standards for measuring waits and
collecting data exist for all focus areas, except for diagnostic
imaging where there are still informational gaps.

Problem
• Today, pan-Canadian standards for measuring waits and
collecting data exist for all focus areas, except for diagnostic
imaging where there are still informational gaps.
o Challenges
• Many imaging facilities are outside of hospital facilities
• Difficult to build consensus on medical urgency

Wait Times in Ontario
How has Ontario successfully managed to reduce
wait times in all clinical focus areas?
• Developing data measurement protocols in
accordance with Wait Time Alliance specifications
• Reporting data and sharing results online
Available at:
http://www.health.gov.on.ca/en/public/programs/waittimes/default.aspx

Promotes efficiency, transparency, accountability

How has Ontario successfully managed to reduce wait times
in all clinical focus areas?
• Pay For Performance program
 In Ontario, this involves tying compensation to hospitals’ senior
management to performance (‘Excellent Care for All Act’), which
include setting aggressive goals to meet all Ontario Wait Times
Strategy (OWTS) benchmarks.
 “Targets without incentives are not taken seriously”.
 UK research shows that pay-for-performance improve worst
areas of performance most quickly.

• Pay 4 Performance video
http://www.youtube.com/watch?v=Q8Wn22I32UQ

Why pay hospital management to show up to
work, and then pay them a little more to do a good
job? (Shouldn’t they do this anyway?)
 ‚Targets without incentives are not taken seriously.‛
- Alan Hudson, Lead on Ontario Wait Times Strategy
 UK research shows that pay-for-performance improve
worst areas of performance most quickly, especially for
low SES areas.

• To date, Ontario government has spent $1.5B on funding
additional procedures, system redesign, reducing
bottlenecks, tracking and publicly reporting on progress.
• The result:

In 2008, Ontario decided to roll ‘emergency room (ER) wait
times’ into the Ontario Wait Times Strategy.
• As of 2010, Ontario hospitals are using CIHI’s Level 1 NACRS database
to report on ER wait times.
• Covers about 90% of the population.
• Tracks time waiting in ER minus the time spent to register/triage a
patient.

Is pay-for-performance enough?
• Don Drummond’s Feb 2012 report suggests that the best
strategy for reducing ER wait times is to bring FHTs under
the LHINs
o To standardize best practices and offer better quality primary care
for complex cases (e.g. mental health, diabetes management, elder
care, addictions)
o To involve Family Health Teams in LHIN quality improvement plan
o To identify costly patients and fast-track cost-effective interventions
that connect them with community resources that meet their needs

Case Study
An 80-year-old woman lives alone, has diabetes,
arthritis, a colostomy from a previous bout with
bowel cancer and is a little forgetful. She has trouble
getting an appointment with her family physician as
the phone system is tiered and confusing (“press 1
for this, 3 for that”). Her daughter who lives far away
gets her an appointment when she visits. The mother
trips on a rug one evening and falls, breaking her
wrist. She cannot get up and is found the next day
by a neighbour and is taken to the ER.

Case Study
She gets a cast on her wrist, but feels unable to go
home alone. As a result, she is admitted after
spending 36 hours on a gurney in the ER. Due to a
mixture of pain medications, sleeplessness and
unfamiliarity, the patient gets confused and is
prescribed anti-psychotics. She then gets C. difficile
and is placed in isolation. The daughter is advised
that her mother needs a nursing home (LTC) bed.

Case Study
The daughter’s wish for her first choice of
an LTC home and the C. difficile, now complicated
by the patient calling out in the middle of the night,
result in the patient being on a waiting list for weeks.
Eventually the patient gets to the LTC home, where
the cancer returns. The patient is sent back to the
hospital, where she dies.

What should the next area of focus be…
• Next-day primary care appointments, perhaps?

• Wait for LTC bed? Home care?
• Bariatric surgery? (skyrocketing demand)

Week 7 - Medical Wait Times

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