Saturday, February 20, 2016

Brother, Can You Spare A Dime ($0.10 CAD) For A PET?

The Canadian healthcare system has been touted as the most wonderful thing since sliced bread, the epitome of the Single-Payer model, the Way It Should Be Done, the ultimate, logical manifestation of where we are headed. The Affordable Obama Care Act is, of course, just a brief bus-stop on the highway to Canada.

But wait just a moment, eh? All is not perfect in the land of the frozen. How many Americans (or Saudis or potentates of various small nations) go to Canada for esoteric, life-saving surgery? Conversely, how many Canadians cross the border (no wall as yet) for their care? (Answer: Depending on the source and the year, upwards of 50,000.) Yes, drugs are cheaper Up North, because the Canadian government artificially caps the prices, forcing us hosers in the U.S. to pay the difference.

It seems that some procedures might require a wait. A long wait. In fact, wait times are so much a part of the Canadian healthcare culture that there are official websites devoted to telling our Canuck friends just how long they'll have to wait. Here's the link from the Ontario Ministry of Health and Long Term Care, for example.

If you should happen to check Diagnostic Scans, you'll be able to chose CT or MRI. Let's pick MRI, and then select a nice town in Ontario called Sudbury, which yields:

Diagnostic Scans
Magnetic Resonance Imaging (MRI)Target:28 days
Hospital Name
Wait time (days)
Provincial Wait Time
(9 out of 10 patients complete their procedures in this time)
Hôpital régional de Sudbury Regional HospitalSudbury83
Northeast Mental Health CentreSudburyNR/NS

Can you imagine the b*tching and moaning you would hear if you told an American he/she would have to wait over three months for an MRI? Yanks get upset if they can't get their scan the day it's ordered.

The site above doesn't mention PET/CT scans, and there's a reason for that. There are 12 (give or take) PET/CT scanners in all of Ontario, and utilization is, well, a bit different than we see here in the States:
The volume and percentage of PET/CT scanning across the province in 2013 remained steady in relation to the previous year (Figures 2 and 3). The number of completed oncology-related PET/CT scans per million population increased from 510 in 2011 to 671 in 2013, which may be a result of an increase in the population of the province and of rising cancer incidence rates (Figure 2). The increase also might be attributed to some head and neck cancers becoming part of the insured indications for PET/CT scans in April 2012.

That would be just under 700 PET/CT scans per million, yes? In the US, that figure is 5,000 per million population. In fact, here is a breakdown of scanner distribution and utilization in some of my favorite countries, although some of the numbers are a little older:

Which brings us to the PET/CT status of Sudbury, Ontario, which is either heartbreaking or heartwarming, depending on your point of view. It seems that the citizens of Sudbury themselves have been asked to pay for the regional scanner themselves. The following quotes are all from the Canadian Broadcast Company (CBC):
Sudburians have spent years trying to raise millions of dollars to buy its hospital a PET scanner. A Positron Emission Tomography (PET) machine uses a type of sugar to detect cancer, cardiac issues and even dementia.

The Ministry of Health and Long-Term Care has told the city it's up to residents to raise the money needed to buy the region's first machine, which is estimated to cost as much as $5 million dollars.
The machines are cheaper than that, but you have to have a shielded room in which to put them, and a great deal of additional infrastructure, so the price is probably not far off the mark. Or the CAD. But this sure sounds unusual. Making the patients pay for the scanner? I knew this sounded familiar, and in fact, another Ontario hospital, Seaforth Community in East Huron, had to hold a radiothon to pay for its PACS in 2007. Again, the money just isn't there for a critical service. Well, we assume the money just isn't there, eh?
A Sudbury doctor says his community's struggle to get an important piece of cancer detection equipment is another example of the provincial government's attempt to block the technology...

The Ministry of Health and Long-Term Care has told the city it's up to residents to raise the money needed to buy the region's first machine, which is estimated to cost as much as $5 million dollars.

Dr. Dave Webster says asking the community to foot 100 per cent of the bill is a way for the ministry to purposefully slow down the introduction of PET technology across Ontario.

"It's quite simple. They don't want to pay for it," he said.

Webster, a nuclear medicine doctor who has fought for decades to bring more PET scans to the province, said the machine can accurately detect cancers that MRI and CT scans cannot.

"You have patients that would have survived their cancer had they had a PET scan at an appropriate time," he said. "And similarly, there are people that are told therapy is not possible and the PET scan shows they are."

"People in Ontario are more likely to die simply because they will not have access to what has simply been the standard of care on following up with cancer patients for more than a decade," he said.

Windsor doctor Kevin Tracey was a founding member of a ministry-backed committee set up more than 15 years ago to bring PET technology to Ontario.

He said he resigned in protest because the government was purposefully slowing down access to the scan.

"Basically, we're holding the number of patients down that need scans done. I'm sure there's monetary reasons why that's done," he said.

Tracey said Ontario is doing fewer PET scans than just about anywhere in the western world.

Ontario performs 11,000 PET scans per year, according to Cancer Care Ontario, while Quebec performs nearly four times that number, more than 40,000 scans annually, with a much smaller population.
There is a very personal facet to this particular PET tale:
(The decision to fund PET operations) was an early Christmas present for the family of Sam Bruno, a man who spent the final years of his life trying to bring a PET scanner to Sudbury...

Since his death five years ago, Bruno's family has spent years raising money for a PET scanner in Sudbury — and on Tuesday were one big step closer to realizing their dream.

The province has agreed to spend $1.6 million each year to operate the machine.

The community needs to raise $2 million more to make it a reality. A total of $1 million has been raised so far.

Hoskins said he hopes his ministry's funding commitment will be a shot in the arm to fundraising efforts.

Having a PET scanner in Sudbury to service northeastern Ontario patients means people like Bruno will no longer have to travel to Toronto for tests.
You might think Sudbury is too small for a PET/CT. You would be wrong. Sudbury has over 160,000 citizens, not much smaller than my little town in the Deep South. And we have three PET/CT's here. Sudbury has an-otherwise state-of-the-art oncology facility, lacking only PET/CT.
"We should have had it a long time ago," said Wayne Tonelli, co-founder and president of the Miners for Cancer charity. "We have a world-class facility here in Sudbury with our cancer centre. Let's get some world-class equipment here."
I'm assuming the "Miners for Cancer" actually favor a cure for cancer.

Editorial time. Forgive the somewhat jingoistic language to follow.

The healthcare here in the United States is good. Really, really good. People who can afford to do so come HERE to be diagnosed and treated. Those who can afford to come HERE do NOT go to Canada. Or Germany. Or Switzerland. Or Sweden. Or India. Or Anywhere Else. I'm not saying I contribute much, if anything, to it, but the best medicine in the world is practiced in the United States.   Now I don't think our system is perfect, and I have called for massive reforms, dumping Obamacare, Medicare, Medicaid, and revamping the whole thing including a huge revision of the laws governing the Third-Party Payers, our beloved insurance companies. Ours is a dysfunctional system and it has to be revised. But even with its blemishes, ours produces some of the best medicine in the world.

And yet, in our inexorable march toward Socialism, led by demagogues who would have us trade everything that makes America America for "free stuff", American health care stands to be crippled in the process of making it "free". And by the way, nothing is "free". Someone has to pay for the "free stuff".

We need to look at the case of Sudbury's PET/CT and understand the implications. There isn't enough money in Ontario to provide "free" PET/CT for Sudbury, and in fact, funds for this life-saving technology are limited province-wide. Thus, the fine people of Sudbury will have to fund the purchase themselves. That they are willing to do so to help their fellow citizens is the heartwarming part of this story. The heartbreaking aspect is that they have to do so. I see this as a huge crack in the perfect facade of Canada's single payer system. It FAILED the people of Sudbury. And it fails the people of Ontario, and indeed all of Canada by limiting resources and thus rationing their care.

In response to my East Huron Radiothon post of 2007, a (probably former) reader commented:
As a personal friend, and former patient of Dr. (mentioned in article), I need to comment!

Our healthcare is NOT free, but our taxes allow us wonderful healthcare, and an above-average level of access to all kinds of medical tests etc. What we need, we get. It's easy to stand in the U.S. and throw stones, but around here (Southern Ontario) we decide how many kids to have by deciding how many kids we WANT to have, rather than by how many our insurance (or lack thereof) will pay for! We take our kids to the doctor when they NEED to go, not when we have enough money to pay a co-pay!

My son was special-needs...yes, born at Seaforth Hospital. He received first-rate care, with swift and appropriate transport to Children's Hospital. On day 3, I heard a PCCU nurse say of my son "Well, there's a million dollar boy!", meaning his cost of care had already topped the million dollar mark. Had my husband and I NOT lived in Canada, our grandchildren would still be paying off the cost of that hospital stay...let alone the other numerous hospital stays our son had through his life.

We don't have a problem donating for good causes...we're neighbours. That's what good neighbours, and good citizens do.
It's hard to argue with this statement, but read it again. Maybe twice more. "What we need, we get." Sounds a little bit too close to "From Each According to Their Abilities, to Each According to Their Needs". But then maybe I'm biased.

The profit motive has brought an overabundance of expensive CT, MRI, and PET/CT scanners to the United States, with the inherent likelihood of over utilization. Contrast this to the neighbourly situation in Ontario which requires the citizens themselves to raise money for life-saving technology that the government, even using the generously given tax-dollars (CAD) cannot provide. Better to over-utilize, or better that ". . .(p)eople in Ontario are more likely to die simply because they will not have access to what has simply been the standard of care on following up with cancer patients for more than a decade..."? You tell me.

"Free stuff" can have a very high price-tag.

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