Why is the province picking private care?

Hey there, time traveller!
This article was published 11/07/2023 (838 days ago), so information in it may no longer be current.

Recently, I was asked by the head of respirology, and with the consent of the department of medicine, to advise on the waitlist problem for sleep studies in Manitoba. Despite having initiated the sleep lab at Misericordia Hospital in the 2000s, I was reluctant to involve myself in the issue because my wife is a sleep physician.

However, having reviewed the current situation and recent events leading up to it, disclosure is clearly in the public interest.

The vast majority of diagnostic sleep studies in Manitoba are performed by the Sleep Disorders Centre in Winnipeg. The centre currently receives about 730 referrals per month. Given that it only has sufficient resources to perform about 480 studies per month, the waitlist continues to expand by an estimated 3,000 annually, thereby extending the wait time by as much as an additional six months each year. The current waitlist is approximately 5,900.

Approximately two-thirds of patients can be studied adequately with a home study where patients pick up the device, hook themselves up and return the device and the study recording the next day. One-third of patients need a more complex overnight, supervised in-hospital study.

In 2008, the centre was created to manage sleep disorders provincially. This approach included a group of formally trained specialists and technologists and created a patient-centred approach that would reduce costs to patients and taxpayers and ensure good quality care.

Many provinces allowed private sleep labs at that time (almost 100 in Ontario) and it was suspected that prescription rates for CPAP devices was excessive in these jurisdictions, in cases where evidence did not support CPAP treatment. Businesses that sell devices should not be medically prescribing them. The rate of CPAP prescriptions at the centre is about 55 per cent, versus as high as 80 per cent in other places.

As well, some patients who are referred for sleep studies do not have indications for a sleep study and require alternative assessments. The service was designed to include a centralized referral and scheduling system with a computerized database that could be interrogated to monitor service quality including the tracking of wait times and prescription rates. Automatic screening of referrals ensures patients will be assigned to the most appropriate form of testing.

Even before COVID, the referral rate at the centre began to climb, requests for additional resources were unsuccessful and the waitlist was further compounded during the epidemic. In the fall of 2022, the Diagnostic and Surgical Recovery Task Force invited sleep medicine doctors at the centre to discuss the waitlist.

The doctors submitted an initial proposal to the Winnipeg Regional Health Authority intended to gradually reduce and eliminate the waitlist in six years. In February 2023, a second proposal from the group was submitted to WRHA aimed at eliminating the waitlist in approximately half that time. Neither of these proposals has been funded. Although the task force recently stated publicly that some funding for the centre had been approved, no confirmation or details as to what will be funded has been shared with the sleep doctors.

The PC government, however, had already signed a request for supply arrangement with Cerebra, a private company, to perform 7,500 home sleep studies over 24 months at a cost in excess of $600 per study, and which would have only a minor effect on the wait list. Last week, a government spokesperson inferred that the deal had been expanded to include 10,000 studies. The cost for the first two years will exceed $4.5 million.

There are certainly services that private companies can provide both efficiently and cost effectively. In the case of sleep medicine, these might include dispensing prescribed devices and disposable supplies and instructing patients to use them as well as carrying out home sleep studies. However, if you are selling devices and carrying out diagnostic tests, only a fool would give you the privilege to interpret the test and prescribe a device that generates a profit to you.

If private companies test and sell therapies, then test interpretation and prescription should be done at arm’s length — in this case by the centre. Another proviso requires that in order to maintain expertise, a sufficient volume of home sleep testing must be retained by the centre.

Under a public-private arrangement where taxpayers are footing the bill, companies should not be allowed to solicit physician or self-referrals for studies. Their scheduled patients should be provided by the Sleep Disorders Centre from its waitlist.

In order to eliminate the waitlist, there should be a sufficient, temporary ramp up in the number of studies followed by a ramp down in capacity to at least match the input of new referrals. In this particular case, we are starting with a waitlist of 5,900, which is growing by 250 per month. If we want to eliminate the waitlist in three years, we have to perform an additional 14,900 cases over that period or 414 extra cases per month and then ramp down gradually toward the end of that period to 250 additional cases per month.

Unfortunately, no details of the Cerebra arrangement have been shared by the government.

It is clear however that Cerebra has been soliciting private patient referrals, including self-referrals, since last December and that this strategy is failing to provide the expected volumes.

The government has exerted considerable pressure on the centre to provide Cerebra with contact information for patients on its waitlist while refusing to share vital information about how these patients will be diagnosed, treated and followed up.

It is important to understand that the Cerebra deal will have only a moderate and temporary impact on the wait time and will generate a suboptimal level of care. Cerebra is contracted to do 312 studies per month for 24 months, while the waitlist continues to grow by 250 per month. At this rate, even if the contract were to be extended, it would take about eight years to address the waitlist — even if demand didn’t increase.

The cost per Cerebra study is an estimated $650. It is unlikely that this would include the physician test interpretation fee, but even if we subtract that, the cost would be about $500 per study. No clinic visit is provided and therefore that expense cannot be included.

In contrast, the centre proposal costing $2.52 million over the same two-year time span would provide an additional 285 studies per month at a cost of $209 per study despite the fact that 12 per cent of these would be the more labour-intensive overnight, in hospital studies required for complex cases. If we add the physician interpretation fee, the cost is $377.10, and therefore, still far less expensive than Cerebra. Despite the much higher cost per study awarded to Cerebra than that requested by centre, Cerebra must still depend on the centre for supplying it with pre-screened and scheduled patients off of its wait list as well as providing subsequent followup care.

This is a real cost and additional work for the centre that the government is not funding. The centre would still have to perform all the complicated in-hospital studies for which it is not resourced, and these patients’ wait times would continue to grow. Private companies are under no obligation to share information such as the rate of non-diagnostic studies and device prescription rates, unless stipulated in an agreement — and it is very likely Cerebra’s agreement contains no such provisions.

It should be made clear that neither of these proposals would eliminate the waitlist in any reasonable period. As previously stated, the waitlist is growing by 250 per month and the Cerebra deal would generate only 312 tests per month or 62 above than the excess accumulation rate. The SDC proposal would provide only 35 in excess of referrals per month.

These proposals taken separately would take between eight and 14 years to eliminate the waitlist, assuming demand remains constant.

A more sensible approach would have been to approve the centre proposal (providing 285 extra studies per month) and issue a competitive RFP to private vendors for an additional 130 studies per month at a reasonable profit for a three-year term. This would have eliminated the waitlist in three years, cost substantially less than the Cerebra deal and actually would have solved the problem permanently.

It seems obvious why the government doesn’t want to discuss this topic. It is difficult to know what role the task force has played in producing this fiasco or at what level of government these decisions were made. We are now left with a very expensive strategy (at least 70 per cent more per study than the centre proposed) that is logistically almost impossible to implement and that will not solve the waitlist. It’s clear the privatization agenda is paramount, regardless of the cost or the long-term health consequences. Hard-held ideologies can be self-deceiving and expensive.

Dr. Dan Roberts is acting head of neurology at Health Sciences Centre