Health Committee on Feb. 28th, 2013

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

My question is for Dr. Guirguis.

There are other treatments, other methods to combat obesity. The balloon is not the only one.

Could you tell me if the material you are presenting here is approved by Health Canada?

Could you then tell me if the balloon stays in the patient’s stomach permanently? Finally, what are the side effects and risks associated with the balloon?

[Dr. Emad Guirguis]

I attended French school in Egypt, but in Barrie, there is not a lot of French. If you don’t mind, I will answer in English.

[Djaouida Sellah, NDP, Saint-Bruno—Saint-Hubert, QC]

Go ahead.

[Dr. Emad Guirguis]

The answer to the first question is, yes, it is totally Health Canada and FDA-approved.

The answer to the second question about the balloon is it stays in for six months. There are balloons now being developed that could stay in for up to 12 months. But it comes out. So the chance of regaining the weight is higher than with the lap band because it's not a permanent device.

I should mention too in response to Patrick Brown's question, the balloon was approved by Health Canada first and still hasn't been approved by the FDA, although it's been proven to be quite safe and effective.

The third question was about the complications of the lap band; there are two complications. One is slippage of the band. It can slip out of position. This complication has gone down significantly since the new design of the band that came out in approximately 2009. The way it's designed, it stays in position. We have a technique whereby we sew it in position in the stomach. So number one is slippage, which is very rare.

Number two is erosion. The band can erode through the wall of the stomach. Usually it's not life-threatening bleeding, but it can cause bleeding much as an ulcer would. That's correctable. We go in and unbuckle the band. In the majority of cases, the erosion will heal on its own. We just have to remove the band. Then six months later, once it's healed, we go back in and put in another band. Slippage is also quite correctable. We go back in and reposition it and re-secure it with a new tunnel around the stomach.

[The Chair, Conservative, Joy Smith]

Thank you, Doctor.

I will now go to Ms. Block.

[Kelly Block, Conservative, Saskatoon—Rosetown—Biggar, SK]

Thank you very much, Madam Chair.

I want to welcome both of you here, and I've appreciated what you had to share with us.

Dr. Guirguis, last week I had the opportunity to be in India and tour a state-of-the art surgical facility, which sounds as if it had a funding model very similar to what you are operating under in terms of a privately built facility. But definitely fee-for-service is what you would have as a physician to do surgery and what have you.

I'm not sure that I completely understand the arrangement between a facility like yours and the provincial government. Would you be willing to explain that a little more?

[Dr. Emad Guirguis]

Currently in Ontario there are no specific arrangements with respect to out-of-hospital facilities and provincial government funding, except that we can perform publicly funded procedures and bill for the procedural fee alone. So that's currently the state of out-of-hospital facilities.

But I do acknowledge that there are several countries now performing publicly funded procedures such as hernia, thyroid surgery, and my specialty in an out-of-hospital facility while receiving public funding. I believe that this is a model for the future. The provincial government in Ontario has already expressed in several press releases that it would like to see more and more procedures performed in out-of-hospital facilities. Two examples are cataract surgery and endoscopy. However, with the current model, if we were to take on the large volume of publicly funded cases and only bill the procedural fee, we would go bankrupt. That's the stark reality. I'd love to do it, altruistically speaking, but the funding just isn't there for the majority of publicly funded procedures.

[Kelly Block, Conservative, Saskatoon—Rosetown—Biggar, SK]

In conversation with one of my colleagues about the lap band procedure, you mentioned that it wasn't hard to get approval from Health Canada for this. But I'm sure that with the innovative way you are operating your facility there must be some red tape you had to deal with. Could you give us any ideas on where red tape could be cut in federal legislation so that it would help individuals like you develop more facilities like this?

[Dr. Emad Guirguis]

That's an excellent question. As for red tape, the biggest challenges were in the initial building, the nine months it took to make sure the building codes, fire codes, elevator codes were in line with the City of Barrie and building standards. Then it was making sure, specifically for the surgery facility, that we meet the pages and pages of criteria for safety such as sterility, backup generators, and emergency evacuation. Those were the biggest challenges.

The inspection process is fairly intense. There is the CAAASF as well as the College of Physicians and Surgeons. It took months to prepare for the inspections. In Ontario you can't just open an out-of-hospital facility and start operating as we did two or three years ago. It has to go through a very intense process.

On the question of funding, I may be repeating myself a bit but an important message is that we hope the federal government would make recommendations saying that out-of-hospital facilities are safe and effective and should be viewed as a viable alternative for delivering publicly funded, medically necessary health care. We want to be respectful of the Canada Health Act, and we want to provide health care that is necessary for the communities, but we believe our model can administer that health care in a cost-effective way. For example, we could look at tendering contracts for hernias or thyroids or other publicly funded procedures. We believe that those patients don't need to be in a hospital setting. They don't require hospitalization; they don't have complicated illnesses that require critical care admissions. We believe we can perform this quite safely and effectively outside.

[The Chair, Conservative, Joy Smith]

Thank you very much.

Now we'll go on to Dr. Morin.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Thank you very much, Madam Chair.

My first question is for Dr. Sutherland.

That was a great presentation, but the information that you shared with us troubled me. You have made a sad observation. In fact, Canada ranks dead last in a number of areas, although we spend a great deal of money in Canada. You said that the provinces and the federal government are spending $60 billion on health care, $30 billion on drugs and on physician care, but that it takes about 12 months to see a specialist. That is a rather bleak picture.

You mentioned a number of possible solutions to improve the situation. However, I do not expect changes to take place overnight. You mentioned the possibility of using residential and long-term care centres more to free up hospitals, to serve the people better and perhaps to even get people to be more independent in their own homes.

Some health agreements were signed in 2004 and objectives were set. Some areas were more critical and the feds allocated budget envelopes specifically for those sectors. Do you feel that, in the next agreement, which should be signed in 2014-2015, we should make sure that there is funding set aside for long-term care?

It is annoying, because the provinces are spending the money as they see fit. Would it not be a good idea to establish criteria or performance objectives for more specific investments, such as long-term care?

[Dr. Jason Sutherland]

That's an excellent question. We could spend an hour talking about it, but I think long-term care is a critically important and growing sector where there are many opportunities to align funding with the objectives you want to achieve.

For example, there are initiatives occurring in Ontario and Alberta to line up the funding for long-term care homes based on the acuity, the clinical complexity, and the physical needs of the patients in the long-term care residential home sectors. I think these are important steps in sort of a case-mixed-based funding or activity-based funding for other sectors.

However, there are also opportunities for integrating quality measures because the standardized data collection is already occurring. So for example, if some of these long-term patients are cycling in and out of the hospital because they're not receiving adequate wound care or physiotherapy while in the long-term sector, those should be important indicators that there are problems of quality there and potentially provide opportunity to align the funding of these institutions or facilities with what you want to achieve, whether it's functional independence or quality of life as high as possible for some of these patients. So, absolutely, yes.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

I just want to make it clear. In your point of view, you're saying that the next health accord should tie specific issues such as long-term care with federal funding. Are you suggesting that some of the money be delivered to the provinces if certain objectives were achieved?

[Dr. Jason Sutherland]

I think that there are definitely opportunities. However, as I go back to my first recommendation, I think that the national health information agency needs to make and can make short-term strides on implementing standardized data collection in the provinces that are not doing so, because otherwise, you're just pouring more money after more money and you don't know if you're getting good value for that money.

Notwithstanding that fact, there are many provinces that are collecting the standardized information upon which you can make inferences about cost effectiveness, quality, and efficiency. I think in those provinces it certainly would be very easy to measure domains and measures in these different domains.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

How much time do I have?

[The Chair, Conservative, Joy Smith]

You have about 30 seconds.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Okay, good.

Are you also saying that the national health agencies should have a bigger role or just disseminate the best practices more?

[Dr. Jason Sutherland]

Specifically with regard to the Canadian Institute for Health Information, I think that they should be much more proactive in collecting data in the provinces because right now that collection is voluntary in a number of provinces. If those provinces don't have the infrastructure, electronic or physical, the data is not making its way into the system.

[The Chair, Conservative, Joy Smith]

Thank you so much, Dr. Morin, for your very good questions.

Now we'll go on to Mr. Lizon.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Thank you very much, Madam Chair.

Thank you, witnesses, for coming here this afternoon. I would like to go back to Dr. Guirguis.

I'm still not quite clear how it works in the Ontario set-up because you said you respect the Canada Health Act and procedures are paid by OHIP or the provincial government.

In the case of this procedure for obesity, what percentage of the total cost or total fee would that constitute?

[Dr. Emad Guirguis]

I'm not sure I understand the question.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

For that procedure, If I'm a patient how much would you charge me for it?

[Dr. Emad Guirguis]

It's the procedure plus basically lifelong care. The fee is $18,000 for the program.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

How much is covered by the province, by OHIP?

[Dr. Emad Guirguis]

Zero.