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.