How did it all go so wrong?
Twenty years ago, in 2005, the Alberta Hip and Knee Replacement Project was hailed as a solution to the long-festering problem of interminable surgical wait times.
The much-heralded pilot project produced some eye-popping numbers: The wait time for an orthopedic consult after seeing a family doc fell to six weeks from 35 weeks; the wait time from a consult with a specialist to surgery dropped to 4.7 weeks from 47 weeks; hospital stays after surgery dipped from an average 6.2 days to 4.3 days. Meanwhile, surgery volumes increased 25 per cent, and all the improvements were essentially cost neutral.
Two decades later, the numbers for Alberta surgical wait times are as bad as they’ve ever been.
The wait for a consult with an orthopedic surgeon after seeing a family doctor is 59.9 weeks on average (with 10 per cent of patients waiting 88.7 weeks). The wait for hip surgery after the consult is 25.3 weeks on average, and for knee surgery, it’s 37.1 weeks on average. (And the average wait times are 50.1 weeks for hips and 77.8 weeks for knees for 10 per cent of patients.)
What happened?
Twenty years ago, a research team led by the late Dr. Cy Frank created a patient-friendly continuum of care by cutting the red tape in an unnecessarily bureaucratic process, and providing a care manager (nurse) to each patient to help them navigate the system.
They also made important structural changes, creating dedicated clinics for orthopedic surgery and, controversially at the time, these clinics were a mix of public and private-for-profit models – all were paid an identical rate for their services.
But, despite initial enthusiasm, the pilot project was never really scaled up. Practitioners went back to working in splendid isolation. The bureaucracy crept back in, sending wait times creeping back up, seemingly permanently.
Subsequent governments proposed their own solutions, inspired more by ideology than evidence.
In 2006, the Progressive Conservative government of Ralph Klein (who was also in power in 2005) decided to outsource a large number of orthopedic surgeries to a for-profit company, Health Resource Centre. Long story short: It went bankrupt in 2010. Waits shot up again.
When the Alberta NDP eventually came to power in 2015, it also didn’t really do much on the wait-time file, other than rejecting contracting out. That didn’t magically resolve the problem either. In 2019, Jason Kenney’s United Conservative Party government renewed its enthusiasm for contracting out surgeries to private clinics with the Alberta Surgical Initiative.
There are now 82 private surgical facilities in the province, and 38 of the operators have contracts with the government – some good, some bad.
Earlier this year, attention was suddenly focused on this murky world when Globe and Mail reporters Carrie Tait and Alanna Smith revealed allegations of contract irregularities, with some clinics charging rates double what surgery costs in public facilities. Worse yet, the then-CEO of Alberta Health Services, Athana Mentzelopoulos, alleged political interference and then sued after she was fired.
There are now half a dozen investigations under way into this scandal, from Alberta’s Auditor-General to the RCMP. You almost need to shower after wading into the details of the allegations.
It’s certainly not how procurement should be done. But, from a policy perspective, there are some really important lessons here.
First and foremost, we have solutions for seemingly never-ending problems like wait times. Good, evidence-based research points the way.
But let’s not pretend it’s simple. There are many factors contributing to wait times, including an aging population, new technologies, underused surgical suites, personnel shortages and more.
Worse than the technical impediments are the political ones. Our health systems, in Alberta and elsewhere, are administrative disasters, because they are devoid of accountability and micromanaged by politicians.
We suffocate potential solutions in a morass of partisan, dogmatic expediency. There is no vision.
Far too often, politicians are less interested in actually improving care and more drawn to fantastically simplistic and headline-generating ‘solutions,’ imposing their ideological views, or, in the most egregious cases, financially rewarding their buddies.
Having private, for-profit companies deliver care is not, in itself, bad policy. But contracts need to be well managed. Profits should come from efficiencies, not exorbitant rates that exceed the cost of public delivery.
Ultimately, the way to resolve the wait-time problem (and many other challenges) is to have health systems run by professional managers who are, as their title implies, allowed to manage procurement professionally, unencumbered by political whimsy.
That’s something we’ve waited for, for far too long.