Surgeons, with investors backing them, are ready and waiting on the Ford government to move forward on its plan for private surgical centres to do hip and knee procedures by the end of the year but need more from the government, proponents tell The Trillium.
The Tories passed the enabling legislation known as Bill 60 last spring against warnings from opposition parties and public health-care advocates that the plan will usher in two-tier health care and will drain scarce resources from the province's public hospital system.
Despite that, the government intends to see new private surgical centres performing hip and knee surgeries in 2024. It first has to finalize regulations and issue a call for licence applications but has done neither. Nor has it completed an expansion of diagnostic imaging, including CT scans, in private clinics, which is an earlier step in its plan.
Two proponents of the plan told The Trillium that surgeons are waiting in the wings for those details to determine whether or not they'll get on board, and time is of the essence.
"What will the funding structure look like to allow this kind of work to take place?" said Brian Rotenberg, an ear, nose and throat surgeon who works both inside and outside of Ontario's public hospital system and has established a consulting firm that helps physicians set up out-of-hospital surgical centres.
"All the groups we're working with — and there's quite a few, actually — are all moving their individual sites forward, getting ready for safe and efficient patient care, because those things don't depend on funding, but they're not pulling the trigger on either building something or renovating something until they know what the funding structure will look like."
In most cases, the new surgical centres will require a lot of money to be spent upfront, and most investors aren't willing to put up the funding without a clear pathway to financial sustainability, Rotenberg said.
Francesca Grosso, a health-care policy expert and lobbyist, has been urging the government to move faster on areas of surgery that can get online quicker than orthopedics because they can be done, in some cases, in existing out-of-hospital clinics.
Even when a new surgical centre would need to be built, the surgeons in these specialties generally already have experience running out-of-hospital clinics, Grosso said. Women's health procedures could be established far more quickly than the hip-and-knee surgeries the government is targeting, such as OHIP-funded post-cancer breast reconstructions, where there's a waiting time of more than 300 days in the public hospital system, she said, as an example.
Both Rotenberg and Grosso said there's interest in the medical community in doing far more procedures than just hips and knee procedures in private surgical centres.
"Orthopedic work — hip and knee replacements — and sports medicine, urology, ENT, some plastic surgery, some general surgery," said Rotenberg, listing areas of medicine where he knows there's interest in setting up clinics under Bill 60. "I would say in most surgical specialties that are able to do this kind of work outside of a hospital, there'll be groups within that who want to do it."
"Some things we can't do, for example, cranial neurosurgery, cardiac surgery — that's not going to happen," he added. "I say that, but actually, these things do happen outside the hospital in other countries, but that's like a Phase 10 thing down the road, and let's go through Phase 1 first."
According to Grosso, allowing surgeons to perform a wider variety of procedures would help make the centres more financially viable. For instance, the government has opened up cataract operations to private clinics, but not retinal or glaucoma procedures that require largely the same equipment and surgical expertise, she said.
Grosso said another concern about the government's request for proposals for licences to perform cataract surgeries that she hopes isn't repeated with other procedures is it wasn't geographically specific, steering proponents to pour work into proposals that were likely to be doomed to fail.
One of the overarching concerns that Grosso hears is that the government hasn't adequately consulted with the market — the surgeons and their investors — that it plans to tap into to build and operate the new surgical centres.
"There has to be a good consultation where their issues can be heard so that the government has an understanding of the market they're going to," she said.
Grosso said she believes the heightened politics over Bill 60 are contributing to the delay in finalizing the details but argued the government has already taken the political "hit" over the issue, so it shouldn't hesitate to move forward.
"Now they have an opportunity to deliver for the public," she said. "And I think that they should go big. I really do. And I think it's going to be really hard to get investors on board when they're trickling out procedures and adding these massive applications that may have requirements that are not informed by what the market can actually bear."
Aside from financial compensation, two key areas concerning the government's requirements have not been resolved.
One is to what extent hospitals will have to be involved in the surgical centres; the legislation outlines a minimum of having each centre have a surgeon with hospital privileges, but there's a concern among proponents that the government will require an additional layer of oversight that would bog down the new private surgical centres, according to Grosso.
Another unknown is what the government will accept from proponents of the centres to fulfil its requirement for a plan to staff them without draining health human resources from hospitals, which are struggling to recruit and retain staff, particularly nurses.
The province has repeatedly declined to spell out what will be required, and a spokesperson for Health Minister Sylvia Jones again declined to elaborate or provide any additional comment for this story before the additional regulations are ready.
But the concern over hospitals' health human resources is real and valid and should be mitigated, according to Rotenberg, who spoke with The Trillium between operations at the hospital where he works.
"We have a wonderful, wonderful nursing team here — but we're short," he said. "And just before the holidays, we had a number of operating rooms be closed because there was literally no allied health-care staff or nursing staff to run the room."
"But in saying that, I think it's also important that people have the right to work where they want to work, and if they want to work outside of a hospital because there's — and I'm just saying this randomly — better wages, or a better benefits, or better work environment, they should be allowed to do so. And people shouldn't be constrained in the manner in which they work."
Grosso, meanwhile, said she doesn't think pay will be better for health-care workers in a private surgical centre, and she noted they'd miss out on the Healthcare of Ontario Pension Plan. However, she said there are nurses who don't want to work in a hospital environment because of the difficult shift work that's usually demanded and argued that private centres could draw from a pool of generally older nurses who have already left the hospital system.
According to Grosso, while many are waiting, some players in the private health-care space have moved forward on private surgical plans without knowing what the government will ultimately greenlight.
That includes Clearpoint, the owner of the Don Mills Surgical Centre, which is one of only two facilities that legally performed OHIP-paid private surgeries pre-Bill 60 because it was grandfathered at the dawn of Medicare with a private hospital licence. While it has seen an increase in publicly funded surgeries under the Ford government, Grosso, who lobbies on its behalf, said it completed a major expansion and is still waiting to be allowed the volume of procedures it can handle.
She named another well-known health-care provider that straddles that public-private line, providing a privately paid executive health program alongside OHIP-funded services. Grosso said it has built operating rooms in downtown Toronto that are sitting empty, waiting for a licence under Bill 60. That provider declined to comment on this story.
A third major player is Walter Schroeder. The Canadian philanthropist set up a foundation that's pouring a fortune into renovating a massive medical building in Richmond Hill that is intended to be run on a charitable basis with a Bill 60 licence.
Schroeder has said the surgical centre will be able to accomplish 8,000 orthopedic surgeries a year. He and his team pitched the Ford government on the surgical centre back in 2021, initially requesting public funding to contribute toward the centre's capital costs with the backing of some of the province's major hospitals.
However, this year, construction on the project has been moving forward without public funding.
A spokesperson for the health minister previously told The Trillium that the government had received draft plans from Schroeder's team and that the centre’s application would be considered under Bill 60.
