Dr. Rod Davey is photographed Feb. 04 2011, in an operating room used primarily for orthopedic surgery at Toronto Western Hospital in Toronto. The provincial government has reduced funding for orthopedic ( hip and knees) surgery to Toronto hospitals and is sending it to hospitals in other areas.Fred Lum/The Globe and Mail
Declining health-care funding and quirks of government infusions are pushing surgeons to delay costly hip and knee-replacement operations in favour of less expensive procedures, such as removing bunions.
As part of a $5.5-billion federal fund designed to reduce waiting times in the country's hospitals, the provinces that divvy up the money set targets for the number of operations to be done within the fiscal year. Once that money runs out, additional operations must be paid for out of a hospital's own budget until the next round of funding begins.
That's why physicians such as Dana Fleming select cases that suit a hospital's bottom line, while patients requiring more costly hip and knee operations stay stuck in the queue. "What's less expensive [to the hospital]is bunions and shoulder surgeries," said Dr. Fleming, who practices in Windsor, Ont., and is past president of the Ontario Orthopaedic Association.
Initiated in 2004, the fund aims to cut waiting times in five designated procedures: hip and knee replacements, cataract surgery, heart operations, diagnostic imaging and cancer radiotherapy. It has had some notable successes, reducing queues in many locations - but it has shown little benefit in others. And with federal waiting-time funding slated to evaporate in 2013-2014, a tension is developing among provinces and hospital chief executives who face a problem as old as medicare itself: what to do when no amount of money seems enough.
"When you look at the overall success of the 2004 accord, hips and knees never was a stellar success across the country," said Lorne Bellan, co-chairman of the Wait Time Alliance, a national watchdog association comprised of 14 medical organizations. "I do think Ontario really did take this to heart and did reduce wait times in a number of areas. Manitoba and B.C. showed initiative to tackle these issues as well."
But despite the huge infusion, some hospitals in Toronto are performing fewer joint replacements, after they were given less incentive money this year; the province sent a bigger piece of the pie to outlying areas.
Toronto orthopedic surgeon Rod Davey works in a Local Health Integrated Network that saw a reduction of 232 joint replacements this fiscal year compared with the last. For some patients, that means postponed surgery.
"If we do it [the operations] we do it at a loss," said Dr. Davey, co-chairman of the Toronto Central LHIN Joint Health and Disease Management Committee. "… No one likes to operate for nine months and do nothing for three months."
Dr. Fleming received an official letter at Hôtel-Dieu Grace Hospital in Windsor last week, stating that expensive procedures such as hips and knees will be curtailed until the next fiscal year, starting April 1.
Overall, though, some areas of Ontario have made dramatic strides in reducing waiting times.
The hospital where Dr. Davey operates - Toronto Western, part of the University Health Network - has some of the shortest waiting times in the province, with 90 per cent of hip-replacement patients being operated on 78 days after a consultation with a surgeon, according to figures from December, 2010, the latest available.
In Ontario, about 90 per cent of hip-replacement patients were operated on 120 days after having a consultation with a surgeon, the December figures show, compared with five years earlier when the average waiting time was 345 days, Dr. Davey said.
The success can be attributed to the province's financial incentives. Community hospitals are paid a $6,882 incentive for each hip or knee patient, while teaching hospitals get $8,930. As a result, hospitals suddenly saw these patients as sources of revenue.
But once hospitals hit their target number of operations, the incentive money dried up, and joint replacements, costing between $10,000 and $12,000, became a financial drain. Emergency and urgent joint patients, however, always receive quick care.
Allan Gross, orthopedic surgeon at Mount Sinai Hospital in Toronto, said his institution has already hits its target, adding that "for our last two months, we have to limit the number of joints that we're doing."
Dr. Davey and other orthopedic surgeons, such as James Waddell, chairman of Ontario's orthopedic surgery expert panel, are hopeful the province will find the money to make up for this year's shortfall in Toronto.
"We've already appealed to the Ministry of Health to increase the funding envelope, but you know the provincial government doesn't have any money," said Dr. Waddell, an orthopedic surgeon at St. Michael's Hospital, which saw 90 per cent of hip replacement patients operated on 212 days after a consultation with a surgeon - one month longer than the provincial target of 182 days.
Ontario Health Ministry spokesman Andrew Morrison said the government does not keep a reserve on hand for more joint replacements, adding a fixed amount of money is provided in the beginning of the fiscal year.
Some hospitals have long waits for reasons over which they have little control. In Lindsay, Ont., the 388-day wait for hip replacement has more to do with two orthopedic surgeons who departed. If Ross Memorial doesn't hit its target, it has to pay that incentive money back to the province.
"We're putting on a push, last quarter of the year, hoping by the time of the end of the year, we will end up close to our targets," said chief executive officer Brian Payne, noting that it has since hired two new surgeons.
Nova Scotia has attracted attention for having some of the most persistently high waiting times in the country for joint replacements, despite the huge infusion of federal funding. Half of patients requiring knee replacement surgery had the operation within 239 days, according to figures from July 1 to Sept. 30 of last year - a slightly longer wait than four years earlier.
Liberal health critic Ujjal Dosanjh said the federal government should have been riding those provinces that did not whittle down their waiting times, yet took the money anyway.
"On big issues, they [the federal government]have flunked the test," Mr. Dosanjh said in a telephone interview from Vancouver. "There's not the level of accountability in that accord that we would have liked."
The federal government, he said, should be negotiating now with the provinces over the transfer funds, plus any additional money for waiting times.
Jenny Van Alstyne, a spokesman for Health Minister Leona Aglukkaq, acknowledged some challenges remain, but "the tremendous work that has been done to reduce waits for Canadians across the country is heartening."
Dr. Bellan, co-chair of the Wait Time Alliance, isn't so sure. He finds it frustrating that some provinces have managed to reduce their queues for care while others have not.
"If some provinces could do it," said Dr. Bellan, "then why couldn't all of them do it?"