Persuading Canadians to “Hustle Off to Buffalo”

If you drive from Buffalo, New York to Ontario, Canada, you’re likely to see this message on highway billboards: “Fast-track Your Medical Procedure Here.” The red arrow on the sign points Canadians to Buffalo’s Kaleida Health, a five-hospital health care system located minutes from the U.S.-Canada border. (Thanks to HealthBeat reader Brad F. for spotting this story.)

Kaleida’s marketing blitz is designed to encourage Canadians to come south and avoid wait times for medical services that include bariatric surgeries, colonoscopies, joint replacements, fracture repairs and MRIs. The campaign began in November and includes local television print and radio ads as well as more than 30 billboards near major routes in Southern Ontario cities.

"We saw it as a way of … being responsive to the influx of phone calls (from Canadians). We saw it as being responsible," Kaleida's senior vice-president of business development, Don Boyd told a reporter from the Hamilton Spectator. "The intention behind this is not to be predatory … or imply any deficiency within the Ontario system."

The billboards emphasize that Kaleida provides health care in a "timely manner," and advise Canadians that "expedient treatment" is a “right.” (Here, I would suggest that, when it comes to elective procedures, immediate gratification does not always lead to optimal care. There is much to be said for giving a patient time to mull over the decision and make an informed choice.)

But Kaleida’s main website puts you on the fast-track to the OR. It features a shortcut button that links to the “Canadian page”, which lists directions to Western New York hospitals, a list of health-care services and prices of nearby hotels. Kaleida also offers special prices to Canadian patients, and a designated call centre for Canadian inquiries. (One wonders who pays for the “special prices” for Canadian patients?  American patients?)

While Boyd sees the outreach effort as a “way of being responsible”—and responsive to the needs of Canadians, Andrea Horwath, leader of Canada’s New Democratic Party (NDP), calls the advertising campaign "distasteful."

While hospitals have every right to advertise, I have to agree. There is something a tad tasteless about the sight of a hospital trawling for surgical patients, especially when the surgery might be dangerous.

Bariatric Surgery Anyone?

According to Canada’s Ministry of Health News Secretary Ivan Langris, most of the people who head south for medical care are going for bariatric or gastric bypass surgeries [a.k.a. “stomach stapling] ; only a small group leave the country for CT scans or MRIs.

This makes sense: when it comes to bariatric surgery, Canadians  may have to wait five years.

By contrast, wait times for diagnostic tests, hip replacements and many other elective procedures have dropped sharply in the last few years. For example, in most Canadian provinces (including Quebec) 75% of patients can expect to receive a hip replacement within 26 weeks.

In most of Ontario, the average wait time is under 200 days.

To an American, this might sound unacceptable. But the idea of putting off hip surgery for five or seven months is not as bad as it sounds. Normally, the need for a hip replacement does not develop suddenly. A patient and her doctor see it coming over the course of a year or two. Sometimes Canadian doctors put a patient on a wait list many months before he or she is ready to go ahead with the surgery. And, as one Canadian puts it, “at least there is a wait list and I know that I will get the surgery. In the U.S. my doctor might tell me I need it, but I might not be able to afford it.”

Moreover, medical researchers investigating “shared decision-making” in Canada have found that if patients have an opportunity to learn about the risks as well as benefits of elective surgery while waiting for the event, a fair number will decide that the procedure is not for them. Typically, they say “the pain isn’t that bad.”  The studies also reveal that when patients haven’t had the time to evaluate the pros and cons of a procedure, they are much more likely to regret having done it—and to blame the doctor.

Meanwhile, Kaleida is well aware of the bariatric market just over the border. Indeed in November, the hospital system announced that Kaldeida would take its show on the road and visit Ontario: “[T]he surgeons of the Kaleida Health Comprehensive Weight Loss and Bariatric Surgery Program will provide a FREE educational seminar on morbid obesity (100 pounds overweight or more) and surgical options available for weight reduction on Saturday, November 7 from 10 a.m. – Noon at the Holiday Inn, St. Catharines—Niagara.Is it appropriate to “sell” bariatric surgery?  Or is this, as advertised, merely an attempt to educate the Canadian public?

It is somewhat surprising that Kaleida’s advertisement seems to suggest that “morbid obesity” is defined by being “100 pounds overweight or more.”  One hopes that the seminar makes it clear that it’s not that simple. Normally doctors look at body mass index (BMI) as well as co-morbidities such as diabetes or heart disease which put the patient at risk. A patient is a good candidate for the procedure if “morbid obesity”–or obesity combined with another disease –is literally threatening the patient’s life.

Keep in mind, bariatric surgery is a drastic solution. A patient’s lifestyle will be forever changed. Then there are the risks of pulmonary embolism (a blood clot that goes to your lung) or a gastrointestinal leak which may require a second operation. In addition, the Mayo Clinic points out, there is “a lifetime risk of bowel obstruction, as well as “increased risk of breaking bones, particularly in hands and feet."

Unless a patient engages in a regular exercise program following the surgery, he may well put the weight back on. Finally, insofar a patient’s obesity is tied up with depression, the surgery is not a ticket to “feeling good.”

If patients expect that bariatric surgery can cure depression, they may be shattered when they find out that this just isn’t true. Research published  in the Archives of Surgery, shows that extremely obese Pennsylvania residents undergoing weight-loss surgery over a 10-year period had a higher-than-expected mortality rate from suicide.

I am not suggesting that suicide is a side effect of bariatric surgery. But a large number of deaths from suicides and drug overdoses is "a cause for concern," the authors, led by Bennet I. Omalu, MD, from the University of Pittsburgh, in Pennsylvania, write. “The fact that most of these deaths occurred at least 1 year after surgery suggests that  careful follow-up, especially the need to recognize and treat depression, should be provided for patients who have undergone bariatric surgery.”  Will Canadians who undergo surgery in the U.S. receive the follow up they need?

That said, this is a surgery that can save lives. I just would prefer to see Canadian doctors recommending the procedure to individual patients who they think need it—and then help them explore where and when they can get the surgery.( Last year, Ontario committed $75 million over three years to increase bariatric surgery capacities in four centers in the province.)The idea of American doctors heading over the border to hold seminars for patients that  they have never seen– in order to bang the drum for such a serious procedure– is troubling.

Why Is Kaleida Casting Such A Wide Net?

It could be that Kaleida’s administrators just want to help Canadians.

But as I researched the back-story, a news item caught my eye: “Kaleida Health of Buffalo, N.Y., closed
on a $100 million U.S. Department of Housing and Urban Development insured mortgage loan to fund construction of a new global heart and vascular institute.

“The $100,253,000 loan is Kaleida's fourth HUD mortgage loan.”

In September (three months before it unfolded the Canadian campaign), Kaleida broke ground for a $291 million heart and vascular institute designed to become the system’s flagship hospital. There, Kaleida Health physicians and University at Buffalo researchers will “deliver state-of-the-art clinical care, produce breakthroughs on the causes and treatment of vascular disease and spin off new biotechnology businesses and jobs,” according to Health Care Finance News.

“When complete, the Kaleida Health-UB facility  . . . will house nearly 600 patient beds, 30 operating rooms, 17 interventional labs for cardiac, vascular and neurosurgical procedures, four CT scanners and four MRIs.

“Kaleida anticipates that the new emergency department will accommodate more than 60,000 visits a year, while the hospital will discharge nearly 27,000 patients. Construction, which began Sept. 1, 2009, is expected to take approximately two years to complete, with doors opening in late 2011.”

Kaleida will need new patients to fill those 600 beds and 30 operating rooms. No wonder it is pulling out all of the stops to cultivate a new market.

Other news stories celebrate the fact that the expansion will turn Buffalo into a “world-class medical destination” and create “hundreds of jobs.”

Nowhere did I read that Buffalo suffers from a lack of hospital beds or that the region needs more heart and vascular centers.

Kaleida’s ambitions may well dovetail with the economic needs of the community. But what about its medical needs? Perhaps Buffalo, like so many American cities, could use more free smoking cessation clinics, so that fewer of its citizens will suffer from heart disease in the first place? Or maybe HUD”s “urban development’ dollars might be better spent on playgrounds and parks where both children and adults can exercise?

Can’t Afford the Stomach-Stapling? How About a Loan?

With a little more research I stumbled onto another disturbing piece of news: apparently Kaleida is in the vanguard of hospitals pushing their own credit cards as a way for the cash-strapped under-insured to pay their bills.

To be sure, this is not necessarily a bad idea. For someone who needs acute care this could, quite literally, be a life-saver. Have the cancer surgery today, and pay the bill off over time. But in Canada, Kaleida is peddling “elective” surgery. As the word implies, this is surgery that the patient may or may not “elect” to have. The patient has a choice: it is optional. Your doctor won’t say: “You must do this.” He will say “You may want to consider this.” A caring physician will then outline the pros and cons.

Writing for the American Prospect, Helaine Olen observes: the hospital system “advertises credit cards as a way for patients to commence receiving services,” much the way a department store might advertise its credit card as a way to buy a $1,000 coat that you can’t really afford. But you don’t have to wait. You don’t have to think it over. But it now; pay later.

“Kaleida helpfully notes that G.E.Money's CareCredit ‘lets you begin your treatment immediately,” Olen writes  “–then pay for it over time with low monthly payments that are easy to fit into your monthly budget.”

As “the use of credit to pay for medical expenses becomes more and more common, a new concern has begun to worry reform advocates and other players in the system,” she continues. “Have we unwittingly given the nation's financial sector a seat at the table when it comes time to once again discuss restructuring our health-care system?

"The consumer finance industry is becoming a stakeholder, and as they increase their profit from people who are struggling to pay their bills,” says Elizabeth Warren, the nationally known bankruptcy expert and co-author of a 2006 study on medical debt.

“'The financial services institutions are becoming much more active in the medical marketplace than ever before,' adds Richard L. Clarke, president and CEO of the Healthcare Financial Management Association, a trade organization for financial professionals ranging from controllers to accountants in the health industry. 'They see a huge volume of transactions, large dollar amounts flowing back and forth, and they see themselves as the middle person being able to process those transactions, manage that cash, and make some money.'"

Thus, the business of medicine generates yet more business– and the medical industrial complex adds another wing.

Build the beds and someone will fill them—even if they have to borrow to do so.


3 thoughts on “Persuading Canadians to “Hustle Off to Buffalo”

  1. All readers–
    Mysteriously, all of the comments on this psost disappeared.
    I have no idea how or why.
    (Nor does our technology expert at the Foundation He’s very good and usually can solve these things. . .
    If this were a particularly controversial thread I might worry that a troll had somehow gotten in and deleted comments.
    But it wasn’t. So I suspect this was just a fluke of technology.
    Anyway, let me reconstruct the thread:
    As I recall, much of the discussion focused on whether 5 or 6 months is too long to wait for hip replacement.
    Most of you thought it was–though one reader who had recently had a hip replacement indicated that it all happened too fast.
    She’s happy she had the surgery, but would have liked more time . .
    In retrospect, you’ve convinced me that 5 or 6 months is too long, but “we can schedule you for Friday” is too fast.
    As one physician/reader said in an e-mail–“Probably somewhere in between is about right.”
    I do think that here in the U.S. we tend to rush into things. But clearly waiting times in Canada can be frustrating. Though at least you know that eventually, you will get the elective surgery.
    Here, if the surgery is elective, and you don’t have the money or the insurance coverage, you may well not get it.
    If anyone would like to re-post their comment, please do. (I dont’ have copies of them, or I would re-post myself).
    People also commented on the risks of bariatric surgery.
    Of course it does save lives, but I still don’t think it’s something that hospitals should be advertising “direct-to-consumer” on highway billboards.
    Not everyone who is overweight is a suitable candidate for this surgery.
    It’s something that a doctor who knows the patient, and his medical history, should recommend to patients who he thinks would benefit, in cases where likely benefit outweighs risks.

  2. Maggie,
    It must have been my comment you’re referencing here:
    “In retrospect, you’ve convinced me that 5 or 6 months is too long, but “we can schedule you for Friday” is too fast.”
    Your phrasing indicates you’re still thinking like a central planner (maybe that’s what you mean when you say “we have to think collectively”). You seem to assume there is a right answer, for all patients, and with enough smart people or enough discussion “we” will find it, and build it into policy. No, no, no.
    I am not a physician. I work in the orthopedic surgery field and know many surgeons who do joint replacement. For 10 years my role was clinical and I spent hundreds of hours in the exam room listening to the discussions leading to the decision for a joint replacement.
    You simply don’t know enough to pronounce either that 5 or 6 months is too long for a specific patient or that “by this Friday” is too short. Either might be true or false. My fault with the Canadian centrally planned system is that it offers only the one, because it represents nothing more complicated than a government induced shortage of supply. Support rationing if you want, but don’t insult yourself by contriving arguments to dress every rationing decision up like sound, compassionate care. There are MANY patients for whom a 6 month wait is simply suffering.
    If you are a patient who has decided you are ready for a knee replacement, and your doctor agrees with you, and sound conservative measures have been tried, it is perfectly reasonable to have that discussion on a Monday and be scheduled for surgery on Friday. (This would not be your first conversation with the surgeon, you would have discussed the timing of surgery several times.) There are MANY patients for whom this is clinically appropriate. After you become a candidate for the surgery, there is no reason whatever for sitting around another 5 or 6 months.
    On the other hand, if you just made your way to the doctor for your knee pain, and your arthritis was just diagnosed, and you haven’t tried lifestyle adjustments and oral medicine, then it is also appropriate to put you off for a few months or even longer. (Often patients who make it to us have been through this stage with their primary care doctor.)
    There is a diagrammable algorithm, but the speed at which you as an individual move through that algorithm is highly variable, if for no other reason than that the key fork in the decision tree is subjective: pain.
    And, again, I personally know a number of places where you can get an elective joint replacement with no insurance and no money.

  3. Tim–
    You write: “You simply don’t know enough . . . ”
    When I wrote that probably “somewhere in between six months and “I can get you in Friday” is best,” I was quoting an experienced hospitalist who has seen many patients before and after surgery.
    More importantly, I am relying on years of experience and knowledge that the Shared Decision-Making Foundation has accumulated as it explores the importance of giving patients the time to really understand and the risks and potential benefits of any elective surgery.
    They find that if patients have an opportunity to make an informed choice (rather than passively offer informed consent) about 20% decide against the knee or hip replacement.
    Of course device-makers are not happy when patients decide against the surgery . . . but responsible surgeons want their patients to think it over. (See what Dr. Jim Weinstein says in the film of Money-Driven Medicine about how he felt that patients were too quick to agree to orthopedic surgery–he was a leading orthopedic surgeon at the time.)
    Finally, what you refer to as “central planning” others refer to as “evidence-based medicine” using guidelines which differentiate between different pools of patients based on age, co-morbidities etc.