Less is More: How the Canada Health Act Might be Modernized

A burden on the struggling Canadian healthcare system that affects me as a Molecular Imaging Technologist is the over-utilization of diagnostic imaging procedures. Flood and Thomas (2016) state that “30 to 40 percent of total health care utilization in Canada is unnecessary” (p.405), while the Canadian Agency for Drugs and Technologies in Health deems 10 to 20 percent of medical imaging procedures inappropriate (CADTH, 2013, p.1). CADTH (2013) lists a host of contributing factors to this wasteful practice: advanced technologies such as CT, MRI and PET scans have broad screening, diagnosing and monitoring applications, which make them appealing as ‘one-stop shops’ for overworked physicians lacking the time required to collect thorough patient histories that would allow them to select a more appropriate, specific test (p.4); surrendering to patient demands for the most thorough tests available can lead to more positive patient perception toward physicians even when these may not be the best option; excessive wait times for MRI or PET may drive increased CT referrals as a ‘good enough’ alternative that can be booked sooner -when this is not the most appropriate option, the desired test is often later performed anyway, resulting in wasted resources, increased patient radiation burden, and perhaps further delays in diagnoses (p.4); increased referral rates for physicians with a financial stake in the diagnostic modality, which includes self-referral practices (p.11); repeated tests due to lack of communication between physicians and imaging centres (p.5); a general lack of physician understanding of the imaging modalities and the inherent risks of each, (p.7).

As technology continues to advance in these fields, it is likely that the applications for these tests will only grow, thereby increasing the scope of appropriate utilization. Therefore, it is imperative that wasteful practices are reduced. CADTH (2013) cited $220 million wasted annually across the Canadian healthcare budget due to unnecessary diagnostic imaging procedures alone (p.6). CADTH (2013) also reported a statistic from 2011, claiming that: “half of all MRI patients [are] waiting between 31 and 77 days”, (p.5). The expense, along with the resulting excessive wait times makes this a two-pronged issue with a common solution: reduce the number of unnecessary exams being performed.

The CAMRT has taken steps to uphold this philosophy among its MRT members by asking us to screen for appropriateness of orders (CAMRT, 2015), but this can be difficult with the limited access we often have to the patient’s history and may not be done until the patient has already arrived for their test. This means it may be too late to refill their slot regardless and results in further delays to more appropriate testing. CADTH, (2013) calls family physicians “gatekeepers to Canada’s entire health care system” (p.7), and feels that the major responsibility for this issue should be shared between GP's, as a leading source of referrals, and radiologists, as the undisputed authority in the field of medical imaging (CADTH, 2013).

Proponents of privatized options in the Canadian system look to solve waitlist issues by availing MRI services for a fee. However, the Canadian Institute for Health Information (2005, p.81) and The Council of Canadians (n.d.) seem to agree that the backlog of publicly funded MRI scans is due primarily to Technologist shortages, and dividing the workforce between public and private sectors only exacerbates this issue.

“Currently, there is no specific Canadian federal legislation that addresses appropriateness in medical imaging”, (CADTH, 2013). Solving this void would, in theory, go a long way to reducing inappropriate exams. Medicine entails, however, an intricate interplay of variables that cannot easily be laid out in a recipe book. Therefore, I believe one step in modernizing the Canada Health Act could be to legislate more stringent regulations, training and audit systems for diagnostic imaging ordering privileges. A second, would be to mandate the type of steps that Ontario has legislated, which reduces physician income for self-referral treatments or procedures (by 50 percent!) to reduce the incentive for such practices (CADTH, 2013, p.11). My third suggestion is not so much a modernization, as an enforcement: with the rising instances of private imaging clinics allowing the wealthy to jump the queue and leave the less well off to patiently wait for services to which they are supposedly entitled (Minister of Justice, 2017), enforcement of the ‘accessibility’ maxim of the healthcare plan should be a priority (Council of Canadians, n.d.).

References

Canadian Agency for Drugs and Technologies in Health. (2013). Appropriate Utilization of Advanced Diagnostic Imaging Procedures: CT, MRI, and PET/CT. Environmental Scan, (39). Retrieved from https://www.cadth.ca/sites/default/files/pdf/DiagnosticImagingLitScan_e.pdf

CAMRT. (2015). Canadian Association of Medical Radiation Technologists | Description of Practice. Retrieved May 27, 2019, from https://www.camrt.ca/mrt-profession/description-of-practice-2/

Canadian Institute for Health Information. (2005). Medical Imaging in Canada 2005. Retrieved from www.cihi.ca

Flood, C. M., & Thomas, B. (2016). Modernizing the Canada Health Act. Dalhousie Law Journal, 39(2), 398–411. Retrieved from https://ssrn.com/abstract=2907029

Minister of Justice. (2017). Canada Health Act. Retrieved from https://laws-lois.justice.gc.ca/PDF/C-6.pdf

Council of Canadians. (n.d.). Understanding the Canada Health Act. Retrieved from www.canadians.org