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Dr. Barry Rubin, medical director at Peter Munk Cardiac Centre at Toronto General Hospital, poses for a photograph in a multi-purpose operating room on Monday, February 13, 2012. He is seen through a CT scan machine. (Matthew Sherwood)
Dr. Barry Rubin, medical director at Peter Munk Cardiac Centre at Toronto General Hospital, poses for a photograph in a multi-purpose operating room on Monday, February 13, 2012. He is seen through a CT scan machine. (Matthew Sherwood)

The Dragon's Den of health care: Who decides which innovations get funded? Add to ...

Who gives the go-ahead for a novel heart procedure? At University Health Network in Toronto, a judging panel includes a frozen-food magnate, a real-estate developer and a 28-year-old entrepreneur who vet medical innovations alongside surgeons.

The stakes are high: A refusal to bankroll a new procedure from a $1.5-million fund can spell fewer interventional options for those with failing hearts.

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“There will be some people where it will be a life and death decision,” acknowledged cardiologist Harry Rakowski, chair of the innovation committee at the Peter Munk Cardiac Centre. “As physicians, we are used to struggling with those decisions.”

But business executives aren’t. Their bad calls may spell financial loss, but not a poorer quality or shortened life for patients. What they lack in medical knowledge, however, they make up in business acumen: They have a knack for backing a winner.

“You really want to approve everything because everything is so important,” said panel member Jeff Rubenstein, chief executive officer of Export Packers Company Ltd., a fresh and frozen food company. “But on the other hand, you have a fiduciary responsibility. ... You really can’t approve everything because there isn’t an unlimited amount of funds.”

Barry Rubin, medical director of the cardiac centre, had the idea to create an innovation judging committee that would include business people who “have a good sniff test.”

Before this vetting process, doctors who wanted to test new procedures not funded by the public health system would ask administrators to find money from a hospital’s global operating budget, a fixed pot of cash. Others have preferred the more time-consuming route of building relationships with philanthropists in hopes of attracting funding.

With constraints on public-health spending and provinces seeking fee reductions from doctors, innovation has become the key watchword. Canadian hospitals have little left in their budgets for innovative projects, which are often the first to go in tight fiscal times. This novel model is a potential solution because it provides not only a structure but a process; it helps ensure donor money is wisely spent, while trying to encourage innovation among health-care providers.

In this case, written proposals must answer 10 questions, plus commit to a study on cost-effectiveness for up to three years. That proposal then goes before the 13-member committee that includes five lay people, doctors, surgeons and a hospital administrator. After the panel rates the proposal with a letter grade and renders its decision, it goes to the cardiac centre’s executive committee for final sign-off. After the cost-effectiveness study, it goes to a government-funded body that makes a recommendation to Ontario on whether the procedure should be funded.

At the first meeting to vet new proposals in late March, four ideas were on the table competing for a piece of the $1.5-million fund – a donor sum kick-started by Peter Munk and expected to climb to $2-million by next year.

One proposal was a treatment that controlled persistently high blood pressure. Another reduced the chances of amputation by inserting a balloon coated with drugs into leg vessels of patients with tissue-clogged stents. A third created a Web-based score that could help select which heart failure patients are at high risk of dying if not admitted to hospital.

A proposal that cost $30,000 per patient, however, was the one that caused the most discussion. It involved a clip to help reduce mitral regurgitation, a condition where the heart valve does not close properly when the heart pumps out blood. Dr. Rakowski described the device as looking like a “really good paper clip.”

It was, however, a treatment for heart patients who had run out of interventional options. Vlad Dzavik, deputy head of the division of cardiology at University Health Network, passionately argued on behalf of a colleague whose proposal it was, that it be funded.

“These are patients whose quality of life is incredibly poor,” said Dr. Dzavik. “They don’t have options. ... this provides a potential option.”

Dr. Rakowski, who chaired the meeting, graded it as a B, noting “if we commit to this now, we’re basically out of money.” He estimated it would cost almost $2-million over three years to perform the procedure on just two patients a month.

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