Blindly increasing access to medical tests will lead to wasted resources, higher anxiety among patients, and, in some instances, the creation of a two-tiered system, in which many in critical need of examination will be left out, warns a medical professor at the University of Calgary.
The warning is predicated on research by Dr. Braden Manns at the U of C and a team of researchers who studied the consequences of allowing private players to provide cardiac imaging in Alberta in the late 1990s.
The researchers evaluated hundreds of thousands of patient files between April 1, 2011, and Dec. 30, 2019, in the province and found that more than a quarter of nearly 400,000 individuals with a low cardiovascular risk received at least one cardiac imaging test.
People with high blood pressure, high cholesterol and diabetes are often considered to be at a greater risk of cardiovascular diseases.
With some doctors, the frequency of tests was even higher. Low-risk individuals referred to some doctors, who are also paid to interpret these cardiac tests and often are the owners of such private for-profit cardiac testing clinics, were five to 30 times more likely to be tested than those referred to specialists who weren’t paid to interpret these cardiac tests, the study found.
While having more people tested may seem like a positive outcome, Manns said, the reality is more complex. For starters, the number of cardiac surgeries did not increase much in the time period. Although the facilities were run by private companies, the services were paid for by the government. That meant more tests of those who weren’t considered a risk consumed hundreds of millions of taxpayer dollars.
“We paid about $700 million more than we would have if we hadn’t offered these tests in the for-profit system,” Manns said.
These tests would sometimes also show false positives, meaning aberrations that didn’t need treatment, potentially causing concern among patients who had little reason to worry. More importantly, some of these examinations are invasive and result in side effects.
“So with screening, we’re always trying to find people who have aggressive problems that need to be treated, and we don’t just want to identify people with low-grade issues that were never going to cause a problem for them,” Manns said.
The study is made relevant by the announcement of legislation that will allow Albertans to pay for diagnostic screening without a referral from a doctor. However, if the test reveals any significant or critical condition, its fee would be reimbursed to the patient, although the criteria for those standards have not been specified.
“We want to see a flood of investment and health professionals into Alberta to strengthen our preventative health-care system for Albertans right across the province,” Minister of Primary and Preventive Health Services Adriana LaGrange said in a government video, marking the announcement. “This will help us to do it.”
Alberta Minister of Health Adriana LaGrange speaks to media in October.
Premier Danielle Smith said the current wait times for certain tests, which extend beyond 400 days, have less to do with staff shortage and mainly concern the number of procedures Alberta pays for.
Renaud Brossard, vice-president of communications at the Montreal Economic Institute, favoured the idea in a recent media interview.
“Every single time someone goes to a private testing facility, well, that’s one less person who’s waiting in line in one of those public facilities. It helps reduce the waiting lists in both sectors,” he said.
However, Manns said he’s concerned that private players will attract existing staff at hospitals, which are already suffering a hemorrhage of healthcare workers. Data gathered by the Canadian Institute for Health Information showed Alberta’s staff levels for certain healthcare workers, including nurse practitioners, were well below the national average.
“Well, we only have a limited number of nurse practitioners in Alberta, so if the nurse practitioners are working with the radiology clinic, explaining the results to patients, they’re not working in primary care,” Mans said. “And I would argue that we have a much greater need for those nurse practitioners to work in primary care than we do to have them working in these radiology facilities.”
Manns also found that to be the case in other departments while studying the impact of privately-run cardiac imaging facilities.
“It’s hard to get (specialists) to staff the coronary care units when you have a heart attack,” Manns said. “Why? Because (many of them) are working in these testing facilities, where they work Monday to Friday. It’s an easy job, and they get paid a lot more.
In a recent op-ed penned by Manns and two doctors who hold important positions in the medical field, the authors cite two examples. In the first, a 35-year-old woman with heavy, irregular bleeding and no family doctor pays for tests that reveal a uterine mass.
Meanwhile, another woman with the same symptoms but without the money waits months for her public ultrasound and MRI. Unfortunately, she had cancer. “By the time she’s finally scanned, it’s spread,” they write. “She dies waiting for a system that promised fairness.”
Such instances, they say, will create a two-tiered system, in which those without means are deprived of dignified care.
“It’s a quiet but rapid march toward U.S.-style health care,” they write, highlighting the province’s move to contract out labs to a for-profit provider, which led to a $97-million debacle, contract out surgeries to for-profit providers, which would cost double the public price, and enact Bill 55 earlier this year, which will let the government contract out hospitals to corporations.
Even those who can afford testing may not necessarily benefit from quicker access to testing without a doctor’s referral, Manns said.
“We all have worries about our health at times, right?” he added. “Say, you have this little niggling heartburn at night. Then you see an ad that pops up on your social media feed saying you can get a cardiac CT scan for only $600.
“People think, ‘Well, that’s going to reduce my anxiety. Now I’ll know exactly what’s going on.’ So you go and you pay for that test. Inevitably, though, it doesn’t reduce your anxiety, because oftentimes, the problem doesn’t go away, or the test actually shows you something that doesn’t change what we do. Maybe there’s some calcium in your blood vessels of your heart, but it actually increases your anxiety.
“So we’re going to prey on people’s anxieties.”
Editor’s Note: This story has been updated to include primary data from CIHI instead of a report by an injury law firm analyzing the information. The story also clarifies specific healthcare workers whose staffing levels are below the national average.
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