Five years ago, researchers in Ontario raised concerns about access and quality in privately owned clinics that performed colonoscopy, suggesting that the quality in these clinics was significantly below the standard of care in public hospitals. Privately owned clinics can be either for-profit or not-for-profit. Medical services provided at these private clinics are paid for publicly.
Since that time, the College of Physicians and Surgeons of Ontario has begun regulating and inspecting these clinics.
In the last five years, quality in private colonoscopy clinics appears to have improved, and for the first time, Cancer Care Ontario (CCO) is exploring expanding its provincial colon cancer screening program into these clinics.
Quality and access concerns
Concerns about quality in privately owned colonoscopy clinics began in 2007, with the release of several research papers. This research showed that roughly 13% of colonoscopies in Ontario between 1999 and 2003 were not completed (the scope did not make it all the way through the colon), and that a leading risk factor for an incomplete procedure was having the colonoscopy performed in a private clinic. In addition, the research suggested that there were more missed cancers in private clinics than in hospitals. The researchers concluded that “colonoscopy practice in office settings may be suboptimal.”
Other research raised concerns that private colonoscopy clinics were more likely to screen patients more frequently than recomended by guidelines.
Around the same time, concerns were growing that some private colonoscopy clinics were charging patients user fees, in violation of the Canada Health Act. Data collected in Toronto in 2009 suggested that about a third of patients receiving colonoscopy in private clinics were being charged to access the services. This led to criticism from groups such as Canadian Doctors for Medicare, who argued these fees were against the law in Ontario.
Low funding and no regulation
One of the main contributors to quality and access problems within private colonoscopy clinics was less generous per case funding than is provided to hospitals. When a colonoscopy is performed in a hospital, the doctor performing the procedure is paid by the Ontario Health Insurance Plan (OHIP) for providing the service and the hospital’s expenses are covered through its global budget. In some high volume hospitals there is additional program funding associated with Cancer Care Ontario’s provincial colon cancer screening program.
When a colonoscopy is performed in a private clinic, the doctor is paid by OHIP, but the clinic itself receives no money from the government and no funding from CCO. Therefore, the clinic must find other ways of covering operating expenses (including purchasing equipment, sterilization procedures, staff, etc.).
This lack of funding made it difficult for private clinics to maintain the same quality standards as hospitals. In order to remain profitable, some private clinics may have rushed procedures, leading to incomplete colonoscopies. Others did not maintain the highest standards of sterilization. Some private clinics turned to various forms of alternative financing, such as charging patients for anesthetic or mandatory counseling with a dietitian.
Sherif Hanna, head of surgical oncology at Sunnybrook Hospital and former director of the Kensington Clinic, a private clinic identified by several experts as having high quality standards, says “when a clinic is only billing OHIP, [high quality] is not feasible.” At Kensington, he explains “we were operating at a loss – the only reason we were able to stay afloat was the Kensington Foundation,” a charitable foundation that helps fund the clinic.
The other main contributor to quality and access concerns in private clinics was a lack of regulation. Prior to 2010, the College of Physicians and Surgeons of Ontario (CPSO), the organization responsible for regulating Ontario’s doctors, did not have jurisdiction over private colonoscopy clinics. As a result, there was no organization responsible for establishing and enforcing quality standards for these clinics.
Without an independent organization to establish and enforce quality standards, there was no mechanism in place to ensure quality of care in private clinics was at the same standard as the care provided in hospitals.
At the same time, without oversight from the College, regulations prohibiting user fees were not enforced consistently, creating potential barriers to access for patients.
In recognition that surgical services and other medical procedures were moving outside of hospitals, the CPSO and the Ontario government moved to create a regulatory framework for community-based clinics that would be providing these services.
“The goal,” explains CPSO registrar Rocco Gerace, “was to get a single standard of care for the entire province, regardless of where a procedure is performed.”
In 2010, the CPSO was granted jurisdiction over procedures performed at a range of Out-of-Hospital Premises (OHP), which included private colonoscopy clinics. The CPSO established quality standards for all OHPs, and initiated an inspection program for these clinics.
The CPSO also developed a specialized guide for colonoscopy clinics, which advised each clinic to form a quality assurance committee to establish standards, monitor activity and improve performance. These committees are mandated to ensure that clinic care is appropriate to the volume and scope of service provided.
The CPSO also inspects private clinics on a five year cycle. Clinics are evaluated on the basis of premises, staff requirements, patient admission requirements, procedure standards, infections control standards, and quality assurance activities.
In 2011, the CPSO completed 104 assessments of out-of-hospital premises, of which roughly 50 were private colonoscopy clinics. 54% of the facilities received a full pass, 43% passed with conditions and 3% failed. Doctors working at facilities that failed inspection were barred from performing any procedures at these facilities.
There appears to be wide agreement in the medical profession that the CPSO’s enforcement activities have had a dramatic effect on quality in these private clinics. According to Dr. Michael Gould, a gastroenterologist and Medical Director and President of the Vaughan Endoscopy Clinic, “the quality has elevated enormously.” He thinks that there remains room for improvement with the process, “but that’s always the case with a first process… The College started in the right place and it will continue to improve over time,” he says.
Integrating private clinics into the provincial screening program
Linda Rabeneck, Vice President of Prevention and Cancer Control at Cancer Care Ontario, explains that until now CCO has declined to inlcude private clinics within its provincial colon cancer screening program, because of concerns that they were unregulated and the evidence that their quality was inferior. As a result, CCO has contracted exclusively with hospitals, which are both more expensive and have longer wait time than private clinics. CCO believes, however, that the time is right to test whether private clinics are ready to become a part of the provincial screening program.
After the CPSO began to regulate private clinics, CCO invited these clinics to participate in a pilot where they would report on their activities (volumes, indications, quality measures, etc.) through the same electronic system used by hospitals to send data to CCO. While some clinics refused to participate, many others have begun reporting to CCO. This reporting infrastructure has provided CCO with the ability to monitor quality across the province, and compare the performance of participating clinics and hospitals.
This October, CCO invited facilities who have passed CPSO inspection and use their reporting infrastructure to contract with CCO to provide a set number of colonoscopies under its provincial screening program.
Doctors at private clinics will continue to bill OHIP for their services, but CCO will provide some additional funding for contracted procedures to the clinics to cover operating expenses.
According to Rabeneck, ongoing funding for private clinics will depend on clinics continuing to pass CPSO inspections and report their data to CCO. CCO will also require every private facility it contracts with to have back-up hospital arrangements with doctors who have hospital admitting privileges.
Rabeneck believes the funding from CCO should reduce the incentive for colonoscopy clinics to charge their patients for access to services. These funds also will cover the necessary costs of running a colonoscopy clinic in the community, which will make it considerably easier for private clinics to maintain the same high standards as hospitals.
Gould believes this pilot program will benefit everyone. “This is the right way forward,” he says. “It makes no sense to keep colonoscopies in hospitals when they can be done for half the cost in the community.” He predicts that the program will not only save the health care system money, but also free up hospital resources to focus on more acute care.
Hanna agrees, and believes the additional funding available from CCO will provide a powerful incentive for private clinics to ensure the highest quality in order to qualify for the program. “A rising tide raises all boats,” he says, “clinics will either raise their standards to compete, or they will close.”
A thoughtful focus on quality
Five years ago, the quality of care provided by Ontario’s private colonoscopy clinics was extremely uneven. Today, these problems appear to have been largely addressed through regulation, and these clinics are on the verge of being integrated into the provincial colon cancer screening system. For Rabeneck, “it’s a nice example of what can be accomplished with a thoughtful focus on quality.”