Posted on January 22, 2017

OAC’s 2017 Pre-Budget Submission: Making Heart Disease a Priority in 2017 and Beyond



Making Heart Disease a Priority in the 2017 Ontario Budget and Beyond

2017 Pre-Budget Submission to the Standing Committee on Finance and Economic Affairs
January 20, 2017

 

Introduction

Heart disease is a leading cause of death and illness in Ontario.

Across the country, heart disease kills more women each year than all forms of cancer combined.

Congestive heart failure is the single commonest reason patients go to emergency rooms and are admitted to hospital in Ontario, where their care is very expensive and can be difficult to carry out in an efficient and timely manner due to recent funding cuts to hospital beds and health care resources.

It is estimated that up to 80% of heart disease is preventable by quitting smoking, eating a healthy diet, getting active and maintaining a healthy body weight.

Despite these statistics, the Ontario government has no co-ordinated, province-wide strategy to address heart disease and its ravaging effects on Ontario patients & their families, provincial health care expenditures, and economic productivity.

The Ontario Association of Cardiologists (OAC) believes this must change. We are calling on the Ontario government in the 2017 Budget to work with our organization to formulate the Ontario Heart Disease Prevention and Treatment Strategy. Key elements must include:

  • Restoring the cuts to hospitals that have recently (i.e. since 2012) decreased the number of cardiac care beds and cardiac resources in Ontario;
  • Strengthened investments in Ontario’s outpatient cardiac care infrastructure to support patient access to care close to home whether it be in the hospital or cardiologist office;
  • Support for the Auditor General of Ontario’s 2016 Annual Report, which recommended collaboration with Ontario’s cardiac care specialists (OAC) to ensure that the province’s limited health care resources are spent appropriately and maintain high standards of cardiac care;
  • Improved e-health integration initiatives to optimize the delivery of high quality cardiac care services in the community and hospital environments; and,
  • A co-ordinated multi-stakeholder plan that includes disease prevention, patient education, and cardiac care service delivery aimed at reducing overall incidence and expenses related to heart disease in Ontario.

As physicians who specialize in diagnosing and treating heart disease, Ontario’s cardiologists provide cost-effective care every day that is crucial to saving lives and improving the quality of life of thousands of patients with heart disease.  Recent cuts to health care funding and cardiac services are making this more difficult to deliver each day and if not reversed increased cardiac death and illness will occur.

The OAC would welcome the privilege to partner with the provincial government to develop and implement the Ontario Heart Disease Prevention and Treatment Strategy.

About the OAC

The OAC is a voluntary professional organization that represents the majority of academic (i.e. hospital-based) and community (i.e. clinic and/or office-based) cardiologists in Ontario. Founded in 1995, the OAC’s mission is to protect, maintain and improve the current high standard of cardiac care for Ontario patients across the province and ensure the cardiologists who deliver the care are fairly remunerated for these services.

The OAC is an advocacy leader for Ontario’s cardiologists and their patients. It exists independently of the Ontario Medical Association (OMA) to ensure the voice of cardiology is heard regarding issues that affect the care of cardiac patients in Ontario. While all cardiologists in Ontario are required to be members of the OMA, the OMA does not provide its Section on Cardiology with the support or infrastructure to allow it to act as an effective advocate for cardiac patients. The OAC fills this gap. Without its ongoing advocacy program, the continued high standard of cardiac care in Ontario is at risk.

Current Cardiac Care Landscape

Ontario’s once strong and co-ordinated system of hospital-based and outpatient cardiac care has come under significant strain in recent years due to arbitrary unilateral government cuts to cardiac care services. Table 1 outlines the drastic reductions that have been made since 2012 in the absence of consultation with Ontario’s cardiologists.

 Table 1: Ontario Government Budget Cuts Affecting Cardiac Care (2012-17)

Service Description Effective % Cut
 Various (incl. ECG; pre-op echo; cardiac catheterization & others)  Reduction in fees & harmonization of codes  FY 2012/13  10%
Congestive Heart Failure Patient Care Chronic Disease Assessment Code (E078) eliminated for cardiologists treating patients with congestive heart failure April 2015 100%
Echocardiography and Nuclear Cardiology Procedures Two professional fees combined and reduced for various types of echocardiography and nuclear cardiology procedures October 2015 20% of previous P1 fee
Service Description Effective % Cut
All cardiology procedures and services “Across the Board” discount applied to all OHIP physician billings (incl. professional and technical fees) April 2013 (0.5%)February 2015 (2.65%)

October 2015 (1.3%)

4.45%
Global Billing Cap The government will claw back any OHIP physician services budget spending that exceeds a 1.25% increase over previous year April 2016 Unknown amount

The cuts to cardiology services within the Ministry of Health and Long-Term Care’s physician services budget have forced cardiologists to make hard choices regarding when and where they can provide cardiac care services. Patient access to care is threatened because cardiologists increasingly cannot afford to provide the services that have been promised by the Ontario government and patients have come to expect. Some clinics and offices have closed and patient access to cardiac care is significantly delayed as a result. This is not good for cardiac care. Time is muscle when it comes to delivering cardiac care and this concept needs to be recognized by government.

The OAC recognizes the Ontario government’s desire to meet its balanced budget commitment by the year 2017-18. We agree that the Ontario government should live within its means. What we object to, however, is the elimination of the government’s deficit on the backs of Ontario’s cardiac care specialists and their very sick patients.

In December 2016, Ontario Premier Kathleen Wynne and Finance Minister Charles Sousa called on the federal government to provide annual health care funding growth at 5.2%, a figure that they said was “fair and evidence-based and has been validated by a number of third-parties, such as the Conference Board of Canada, the Parliamentary Budget Officer and the Fraser Institute.”

Yet, what did Minister of Health and Long-Term Care, Hon. Dr. Eric Hoskins, offer in the latest physician services agreement “proposal” to the Ontario Medical Association last month? Annual budget increases of less than half of this amount. Does the government expect physicians to cover budget overages related to immigration and demographic change, costs which are rising sharply and out of their control, themselves?

The government’s attitude and approach to cardiac care has been disappointing. It is leading young doctors to avoid setting up in this province, forcing others who are currently here to leave and inspiring older doctors to retire early. Cardiac care service delivery is at the brink of chaos. Cardiac care must be delivered by the experts, highly trained physicians, who have the knowledge necessary to correctly diagnose and manage the cardiac patient.

Auditor General of Ontario’s 2016 Annual Report

The OAC understands that health care resources are limited and that what is available must be spent appropriately. This is why we brought forward concerns to the Auditor General of Ontario in June 2016 after trying for many months to resolve with the government what we considered to be misspending of public resources in cardiac care.

In the 2016 Annual Report of the Auditor General of Ontario, Ms. Bonnie Lysyk stated: “Concerns of the Ontario Association of Cardiologists (Cardiologists Association) about cardiac-care spending in an open letter to the Auditor General were reasonable.” Specifically, she found that the government overpaid at least $3.2 million between April 2012 and May 2015 for two cardiac rhythm monitoring tests (Holters & loop recorders) that were inappropriately claimed and paid. Moreover, the Auditor General supported the OAC’s concerns over the vast expansion of commercial echocardiography (cardiac ultrasound) labs in Ontario that have been fuelled by an arbitrary change to the physician services budget in October 2015.

Her recommendations were clear. She stated, “To strengthen the oversight of the use of cardiac ultrasound services, the Ministry of Health and Long-Term Care should work with the Ontario Association of Cardiologists and the Cardiac Care Network of Ontario to:

  1. Assess the effectiveness of the Cardiac Care Network of Ontario’s Echocardiography Quality Improvement program intended to deter inappropriate use of cardiac ultrasound services;
  2. Monitor the use of cardiac ultrasound services claimed by facilities, such as those owned by non-physicians, and take corrective actions when anomalies are identified; and
  3. Recover the $3.2 million of over payments to physicians related to cardiac rhythm monitoring tests that were inappropriately claimed.

It is time to stop the arbitrary and unilateral funding cuts focused on achieving a political objective.

Instead, we urge you to think more broadly. It is time to recognize the serious economic and human consequences that heart disease is having in Ontario and develop a new comprehensive and integrated approach to dealing with one of Ontario leading causes of death and illness. It’s time to work with the OAC to develop the Ontario Heart Disease Prevention and Treatment Strategy.

Why Work With The OAC?

Ontario cardiologists are doctors who save lives and improve the quality of life for thousands of patients facing heart disease. In an emergency, they step into a patient’s life suddenly and are trusted implicitly to help. Throughout all patient encounters they listen; ask questions; perform tests; and interpret results. Patients count on their years of training and experience to help them in ways that no one else can.

While cardiologists work in a multitude of settings including hospitals, the majority of cardiologists provide services as independent small businesses through clinics and/or community offices. They do not receive salaries, do not have a guaranteed pension or even a drug or dental plan provided for them. Instead, cardiologists make their income from government payments earned through billing for services they provide, minus the costs of running their clinic or office, which can easily represent 3%.

These costs include, but are not limited to:

  • Staff & Benefits (These costs have doubled in the past seven years)
  • Computers
  • Medical Supplies
  • Medical Equipment (e.g ECG, echocardiography machines, etc.)
  • Rent – Office
  • Insurance
  • Financial Management
  • Continuing Medical Education

In short, government payments to cardiologists are not exclusively income.

Furthermore, unlike other independent small businesses in a community, cardiologists cannot charge for services based on what they cost. Even though they face a growing population from immigration, an aging community and the costs of new equipment, community cardiologists are locked into an inflexible system that expects them to absorb the cost of change and poorly thought out government strategies to reduce the costs of delivering cardiac services. There are stringent rules about what a cardiologist can charge the health care system per patient regardless of the amount of time required to help a particular patient with heart health issues. If a patient requires additional visits to their cardiologist or more time per visit due to complications than the system’s rules prescribe, then the cardiologist is expected to absorb the additional costs. The cardiologist has reached the stage that there is no further room to absorb any additional costs; some services are being cut resulting in restricted patient access to cardiac care in the province of Ontario because of the lack of government funding.

Ultimately, cardiologists provide tremendous value to the health care system by saving lives and improving the quality of life of thousands of patients through their cost-effective services. The time demands can be enormous (late nights, on-call, weekends, emergencies) and the emotional costs of dealing with individual lives and their loved ones is unique.

As the Ontario government develops the 2017 Budget, we ask it to re-examine its treatment of the cardiology profession in the past four years and recognize the crucial role and tremendous value it is delivering to patients and the health care system.

OAC’s 2017 Budget Priorities

Heart disease is a leading cause of death and illness in Ontario. It has an enormous impact on the lives of Ontarians of all ages, living in all areas of the province and comprises a major component of province-wide health care expenditures. Yet, there is no recognition of this from the Ontario government. There is no comprehensive, co-ordinated approach to tackling this disease and the enormous human and economic impacts it is having in Ontario today.

We believe that this must change.

The Ontario government must show leadership on this issue. The future of patients currently living with heart disease and of our cardiac care services in Ontario depend on it. That is why we are calling on the Ontario government to heed our call by working with Ontario’s cardiologists to develop a province-wide Ontario Heart Disease Prevention and Treatment Strategy. Key elements of such a strategy would include:

  1. Restoration of funding to hospitals providing cardiac services to Ontario patients to increase the number of cardiac beds and resources and enable cardiologists to deliver care that meets current international standards.
  2. Strengthened investments in Ontario’s outpatient cardiac care infrastructure to support patient access to care close to home. For example, restoring the chronic care code for cardiologists and internal medicine specialists who treat congestive heart failure patients. This small annual investment of approx. $3 million/year will be revenue neutral if not improve your government’s bottom line as it will help keep many of these very sick patients from having to go to the hospital where the care is much more expensive.
  3. Consistent with Auditor General of Ontario’s 2016 Annual Report, collaboration with Ontario’s cardiac care specialists to ensure that the province’s limited health care resources are spent appropriately and maintain high standards of cardiac care. The Ministry should commit to recovering the $3.2 million misspent between April 2012 and May 2015 and reinvest this in areas of cardiac care that need it.
  4. Improved e-health integration initiatives to optimize the delivery of high quality cardiac care services in the community and hospital environments; and,
  5.  A co-ordinated multi-stakeholder plan that includes disease prevention, patient education, and cardiac care service delivery aimed at reducing overall incidence and expenses related to heart disease in Ontario.

Conclusion

The time has come for the Ontario government to make combatting heart disease in the province a top priority. To do so effectively, it needs to stop viewing cardiologists and cardiac care services as a cost centre within the provincial treasury. No more unilateral cuts. No more demonizing or bullying cardiac care specialists.   Instead, reach out, as per the Auditor General of Ontario’s advice, and work with us to ensure that high quality cardiac care services are provided to patients appropriately all across the province.

In the past, there has been a strong track record of collaboration between Ontario’s cardiologists and the provincial government, which led to the formation of Cardiac Care Network of Ontario and served as a model for Cancer Care Ontario. We believe that the conditions exist for this to collaboration to work again in an effort to ensure that patients with heart disease get the kind of care we all believe they are entitled to and that doctors who deliver the care are appropriately remunerated.

A comprehensive Ontario Heart Disease Prevention and Treatment Strategy is needed. Let’s work together to ensure finite health care resources are spent appropriately in cardiac care so that the best results for patients can be delivered wherever they may live in the province.

For more information, contact:

James Swan, M.D. F.R.C.P. (C) F.A.C.C.
President
Ontario Association of Cardiologists
34 Eglinton Ave. West, Suite 410
Toronto, ON M4R 2H6
Tel: 416-487-0054
Toll-Free: 1-877-504-1239
E-mail: president@ontac.ca

Web: www.ontarioheartdoctors.ca

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