Seeking an answer to that seemingly simple question careens us into a field of ethical landmines and bedeviling public policy challenges.

Medicare, while fundamentally a public insurance program designed to spread risk, has its roots in social justice – the notion that basic healthcare services should be available to all regardless of ability to pay. Implicit too in the medicare model is that there will be rationing, that the care offered will not be limitless, lest the system become unaffordable.

Medical tourism, on the other hand, epitomizes the commercialization of medicine, the notion that if you have enough money you can get care when or where you want – equity, cost-effectiveness, and sometimes even legal and ethical considerations be damned.

Medical tourism is big business, worth an estimated $80-billion (U.S.) annually and growing.

Because of the high cost of care in the United States, Americans travel in droves. An estimated six million will seek medical care abroad this year. Countries like India, Thailand and Costa Rica woo these patients aggressively.

Should Canada, a country that is a stone’s throw away, do the same?

Would selling services to wealthy Americans be a good way of generating money to pay for the soaring costs of medicare?

Our surgical suites and diagnostic imaging equipment often sit idle. But if we sell medical care to foreign citizens, will it drain vital human resources (doctors, nurses, etc.) from the beleaguered public system?

And if we sell medical services to foreigners, can we refuse to sell them to our own citizens, even if they are paying to jump the queue?

Despite our universal health system, a growing number of Canadians are travelling abroad for care.

One of the few studies on the phenomenon, a 2008 report by international consultants McKinsey & Co., found that 7 per cent of medical tourists are Canadians. If you do the math, Canadians are spending around $5-billion a year out-of-country for health care.

If they are willing to throw around that kind of cash, what does it say about perceptions of Canada’s healthcare system, and about our ability to pay more domestically?

The McKinsey study found that, globally, 11 per cent of medical tourists travel for plastic surgery, like tummy tucks and facelifts, while more than half travel for general surgery and orthopedic care, new hips, bypass surgery and the like.

The principal reason given for travelling is “enhanced care,” meaning that patients feel the technology and skills of surgeons are better than in their home country, and that the care is faster and cheaper.

While a significant number of Canadians travel to the United States for care because they feel the quality is superior (à la Danny Williams), a growing number are heading off the beaten path, where prices are lower and ethics more flexible.

For example, patients with multiple sclerosis have been flocking to clinics in Costa Rica and Poland to undergo “liberation therapy,” a controversial procedure to open up veins in the neck. They travel because the surgery is not offered in Canada; it is deemed unproven and hence unworthy of coverage at this time.

Patients are paying in the range of $10,000-$15,000 for this procedure and sometimes doing fundraising events to get the money. Medical tourism is no longer restricted to the ultra-rich but, increasingly, it preys on the desperate.

Canadian patients with spinal cord injuries are traveling to China and Mexico for stem cell transplants, another therapy that has generated glowing testimonials but for which there is little scientific evidence.

With waits stretching years, those in need of a kidney transplant can travel to India or China for instant relief. But where does this supply of organs come from? Are they purchased from the desperately poor for a pittance or harvested from prisoners?

Similarly, when Canadians travel abroad for fertility treatment, they can purchase eggs and sperm and “rent a womb” from surrogates, commercial acts that are not permitted in this country.

If Canada prosecutes those who commit sexual crimes against children abroad, should it also crack down on those who essentially buy body parts and exploit women reproductively (if not sexually)?

A more practical, but no less thorny issue, is who is on the hook for follow-up care?

With a kidney transplant, for example, the surgery is a relatively cheap part of the procedure. It’s subsequently, when a person requires a lifetime of anti-rejection drugs and follow-up care, that the costs add up. And what happens when the transplant doesn’t take – a not-uncommon problem? Does that patient, who jumped the queue by going to India, now get priority for another kidney in Canada? Or do we have the right – legal and ethical – to send them back to India?

Similarly, if an MS patient travels abroad for an experimental treatment, what happens when he or she suffers a blood clot that requires expensive follow-up care and even additional surgery? Is medicare responsible for those costs, or is the individual? And what are the obligations on a physician called upon to “fix” a dubious procedure that she knows little about in the first place?

If a Canadian breaks his neck while skiing in the Alps and is left quadriplegic, medicare will cover those costs, no questions asked. If that same person seeks an experimental treatment like stem cells in hopes of walking again but instead suffers expensive complications like a brain tumour, should medicare treat him any differently?

There are no easy answers to these ethical quandaries. But there is no benefit either from keeping our heads buried in the sand.

Medical tourism is here to stay, so we need to debate and understand the pros and cons, chief among them the impact on medicare.

While the use of PET/CT is not currently indicated for diagnosing breast cancer, it can make a difference in the following areas:

• PET/CT accurately stages axillary and mammary lymph node involvement. Axillary lymph node dissection is currently a routine part of breast surgery, since it is the only way doctors who don’t know about PET have of staging breast cancer.
• PET/CT may detect distant metastasis resulting in more accurate treatment.
• PET/CT is also used to evaluate the response to therapy. Treatment can be altered, if necessary, for better results. 

• PET/CT is also used when there is suspicion of recurrent disease. Finding recurrent cancer early prolongs lives and increases the chance of beating the disease.

(1)   Source: Clinical Positron Imaging Journal, the official Journal of the Academy of Molecular Imaging, Vol 3, Number 5, Sept-Oct 2000.

How does PET work?

PET (Positron Emission Tomography) is a non-invasive diagnostic imaging procedure that identifies abnormal glucose (sugar) metabolism. Since certain cancer cells metabolize glucose more than normal cells, which often occurs before changes in anatomy, PET may identify the presence of disease earlier than other anatomic imaging techniques. As a result, PET may offer important information to aid in more effective treatment.

Along with Breast Cancer, PET/CT is considered particularly effective include lung, head and neck, colorectal, esophageal, lymphoma, melanoma, cervical, brain as well as other less-frequently occurring cancers.

I just spent time with a client as he recounted his ordeal with prostate cancer over two years ago, and I was struck by the fact that there were treatment options of which he was completely unaware. I was also struck by the fact that the way that his treatment process was described to him was frequently inconsistent, leaving him confused by many different scenarios presented to him as he moved from step to step throughout the process. To this day he remembers feeling “…as if the ground was always moving beneath him…” and he continues to live in fear that “…they didn’t get it all…” or “…it will for sure come back…” I felt sad that he had been left so confused by his providers, and talked at length about the treatment options for prostate cancer. I vowed that no patient would leave my office without knowing all of the options available to him!

International Health Care Providers connects its patients with the most up to date therapies available today. Prominent among these is the three-dimensional technology found in the operating rooms of our hospital partners; employing robotic technology, these techniques take modern prostate surgery to new level.

Robotic technology figures prominently in the spectrum of therapeutic techniques at Henry Ford Hospital in Detroit, housing the Vattikuti Urology Institute. To date, the Institute has performed more than 2,000 cases in this manner, and continues to perform more robot-assisted prostatectomies than any other hospital in the world.

With this procedure, the patient’s pain and blood loss, together with the risk of incontinence and impotence are significantly reduced. Recovery times in the hospital and at home are much shorter with this technique. With traditional radical prostatectomies, patients are expected to be in the hospital for two or three days. With robotic prostatectomy, most patients can safely be discharged one day after surgery.

Speaking of Henry Ford’s new operating suite for robotic surgeries, Mani Menon, M.D., director of the Vattikuti Urology Institute, says,
“This operating room is going to change the way operations are done. It is light years ahead of anything else that exists in the world.”

If I should have cancer, I want my care to be the most modern available – and I want no less for our patients! Dealing with cancer is one of the most stressful life experiences that patients will ever have. They deserve a thorough understanding of their options and the knowledge that their care is a the forefront of medical therapy. With care of the caliber of the Vattikuti Institute, Canadian men can face the challenge of a diagnosis of prostate cancer with confidence. For Canadian men, the quality option is just across the border….without the wait!

Patients experience continuing pain and disability – and so do their families. One patient experiencing excruciating pain while waiting for a knee replacement expressed her frustration as “I couldn’t participate in my life. I did not want to turn my husband into a caretaker.” Patients tell stories of lives put on hold; in those months of waiting, a lot of life, and lot of memories, are left in the ‘what-could-have-been’ dust.

As they move from waiting room to consultation then back to waiting room, patient’s pain worsens and hope declines. Many needing a joint replacement have worked hard most of their lives to be able to live their passions in retirement. “Passions” means chasing your grandchildren, crisp mornings on the golf course, and sunset bike rides with your life partner. Rarely do “Passions” come equipped with crutches and pain killers.

With our partner hospitals, the wait is short, and life can begin again. Before and after treatment, many other modalities are available to aid recovery. We can connect our patients with physiotherapy, chiropractic treatment, massage therapy, and pain management. We are dedicated to ensuring that each of our patients has a care plan throughout the process, and ensure that every patient has complete aftercare arranged before they leave for the hospital.

Canadians have health care options. Our partnerships with U.S.health care providers are the product of long hours at board room tables, ironing out every detail of our client’s recovery. The IHP team has worked hard and passionately at creating these health care choices, allowing patients to safely and seamlessly evolve from ‘waiting patient’ to ‘willing medical traveler.’

To those Canadians on waiting lists for health care, there are superior resources and options for you to consider. Call our office today and allow us to help you in making health care choices that will bring you back to your passion.

The “Liberation Treatment” is based in the thesis that blockages in the cerebral veins (CCSVI, or chronic cerebrospinal venous insufficiency) are responsible for some, and possible many, cases of MS. This concept, and the possibility that clearing these blockages may represent an effective treatment for MS, offers hope for those who are dealing with the symptoms of MS. To date, medical centers in the U.S. and Canada have taken a very conservative approach to this treatment; most are not pursuing treatment until well-validated research studies can be completed and the relationship of these changes to MS can be better understood.

There is rarely a day that goes by that my email or phone doesn’t chime in with an interested party looking to obtain access to what MS patients so dearly hope is the magic bullet they’ve been praying for. IHP is very anxious to help these patients – but only when we can connect them to a treatment that is safe and of proven effectiveness.

You may have heard that other groups are pursuing this therapy more aggressively, and are now sending patients overseas for surgical treatment. Unfortunately, the relationship of CCSVI to symptomatic MS is not well characterized, and, although many patients appear to benefit from clearage of their venous blockages, it is not clear what proportion of MS is due to vascular problems. Therefore, we have elected to wait to refer patients until we are sure that the safety and efficacy of this approach has been fully and rigorously evaluated.

CCSVI occurs when blood from the brain has difficulty flowing properly from the brain back to the heart due to blockages or narrowing of the veins. This concept was pioneered by Dr. Paolo Zamboni, one of the best-known investigators in this area. At the moment, there are no research studies being carried out in Canada, nor is any diagnostic protocol available at any Canadian medical center. At present, active research on vascular treatments for MS in the United States is being carried out at the Buffalo Neuroimaging Analysis Center (BNAC) under the supervision of Dr. Robert Zivadinov.

In a recent conversation with Dr. Zivadinov, it was quickly apparent that he cares deeply about his patients, talking with cautious excitement about the preliminary successful results of the Institute’s studies. He is dedicated to waiting until the clinical trials are completed to offer this treatment to the public.

Although this understandably creates a ‘wait time’ stress for MS patients, please be advised that we are monitoring progress in this area closely, and will advise our clients as soon as a safe and effective treatment is available.

What is available now at BNAC is a complete diagnostic evaluation including the following elements:

MRI of the brain and neck
Doppler ultrasound
Clinical visit with a neurologist
Neuropsychological evaluation
Blood testing.

The availability of this evaluation is very important for MS patients for two reasons: First, because no multitest workup specifically designed to evaluate vascular changes in MS is available in Canada, and secondly, because these changes are subtle, and scans should be viewed by radiologists specifically familiar with MS-associated vascular changes. Even highly competent general radiologists may not be entirely familiar with all of the subtle venous changes occurring in multiple sclerosis.

If you are interested in being evaluated for MS-associated vascular changes, please contact us. We invite MS patients and their families to complete the contact form on our website so that we may continue to keep you informed of new developments..

International Health Care Providers is pleased to announce the appointment of Dr. Collins to the Board of Directors of the Cowichan Seniors Resource and Support Society.

Congratulations Dr. Collins.

The number of hospital beds per capita in Ontario has fallen 56 per cent since 1990. That trend has continued in the lead-up to Thursday’s provincial budget.

The Ontario Hospital Association has not yet tallied recent cuts, but they are known to include:

•The physiotherapy clinic at Toronto East General Hospital and the after-hours, pain, audiology and cardiac rehabilitation clinics at St. Joseph’s Health Centre;
•140 jobs and almost 50 beds at Hamilton Health Sciences, which is planning to perform 1,200 fewer surgeries next fiscal year; and
•190 nursing positions at the Ottawa Hospital, where elective surgeries have been postponed and a reduction in operating room hours is under consideration.
“The way we deliver our services has changed a lot. Therefore, it’s not really a decrease in service when we take beds out,” explained Ella Ferris, vice-president of Toronto’s St. Michael’s Hospital, adding laid-off nurses can often find employment in other hospital departments.

Cowichan News Leader

Published: March 04, 2010 6:00 AM

Dr. T. Rand Collins says he’s on a mission to help those stuck in long wait lines for MRI scans and other medical procedures.

It’ll cost for travel to the U.S. and for any procedures, but the work will be done and done quickly, promised the senior vice-president of the new western operations branch of International Health Care Providers Inc.

“Patients are willing to go someplace to get care or evaluations, but don’t know how to do it,” said Collins

“If you’re somebody with a back condition and are having trouble getting into the lineup here in B.C. and think about going to the United States, well you don’t know where to go, who the doctors are, you don’t know how to evaluate the system, how to pay for treatment, all of this kind of stuff.”

Collins, a retired U.S. pathologist, said IHP basically provides a road map for patients looking to get health care in the U.S.

“We will get your medical records and will also call one of the hospitals we deal with in the States to set up an appointment,” he said.

“You simply go to (an American city) with a prescription from your doctor in hand and you will get your scan there.”

The scan results will then be sent to the patient’s Canadian doctor, Collins said.

Initially and for good reason, it seems the new business will likely focus on MRI scans.

Shannon Marshall, a Vancouver Island Health Authority spokeswoman, said there are no delays for CT scans or emergency MRIs, but patients could wait up to 15 months from the date of the booking for non-emergency testing.

“Anyone who needs an emergency MRI does not have to wait for their test and there are no wait times for CT scans,” she stressed.

However, wait times for non-emergency MRIs are approximately 11 months in Victoria and approximately 14 months if people want it done in Nanaimo.

One of the challenges experienced by VIHA is the MRI is preferred over CT scans because MRIs give more detailed test results and do not use radiation.

VIHA currently has four MRI machines: three in Victoria — one at Royal Jubilee Hospital and two at Victoria General Hospital — and one in Nanaimo Regional General Hospital.

The machines operate seven days per week, at an average of 10 hours per day.

“Since 2003/2004 we’ve actually increased the number of MRI scans by about 30 per cent across the health authority,” said Marshall.

“Last year we did 22,500, but we had some one-time funding from the government to provide a lift.”

But this year is a different story, with the number of budgeted MRIs set at about 19,000.

That’s where Collins and his company come in. There’s no big secret why the Cowichan Valley was the first choice for the business.

“It’s actually a good place because we have lots of retirees on the island,” he said.

Carol Hunt, of Cowichan Seniors Community Foundation, said she welcomes the new business.

“There’s no shock and amazement that this sort of thing is happening, but more, ‘Hey, they’ve chosen the Cowichan Valley and isn’t that interesting?’” she said.

“I don’t know anything about the company … but it certainly reinforces what our seniors foundation has been preparing the valley for and that’s how we have to really pay attention to our growing, aging population and how our community is transitioning into a place where not only seniors are choosing to retire.”

“Obviously the company has done its due diligence in doing a market analysis and is of the opinion coming to set up shop here will be a viable business.”

Indeed, said Collins, but his company is not without its detractors.

“Some feel we’re deserting the (Canadian) medical system and in some ways could damage it,” he said.

“To me it’s akin to the American argument that legalizing gay marriage will damage the institution of heterosexual marriage.”

Collins hasn’t been hired by any local patients yet, but said he knows they’ll come.

“The idea of shopping for care is not really in the Canadian psyche, but the pros of using IHP include quick care, which is important when you’re hurting and on a waiting list,” he said.

“Also, in my opinion, the top end of technology in the States is higher than that in Canada.”

And, added IHP founder Kelly Meloche, it’s not as expensive as one might think.

“With regards to price, IHP clients benefit from a 55 per cent discount for MRIs and 45 per cent for CT scans,” she said from her Ontario headquarters.

“This means a person can wait in Canada for several months waiting for an MRI or they can pay $600, have an MRI the same or next day, leave with the (image) disk and have the interpretations within 24 hours as well,” she said.

Collins said instead of being in competition with the Canadian medical system, his company actually enhances it.

“What we may be able to do is take some stress off the system by taking away those people who can afford this option,” he said.

“The last thing we want to do is be seen as threatening or adversarial to the doctors here — we really want to be a service for the doctors who are trying to get care for their patients.”

For more information about the company, log onto www.ihcproviders.com.

The most unfortunate aspect of the health care debate in both countries is that the real issues, and the real strengths and weaknesses of each philosophy, get lost in the flag-waving.

There is a great deal of sniping back and forth across the border from those who would use both systems’ problems for their own political ends. Sadly, both systems are broken, but in different ways. The United States has excellent health care and world-class technology that is available quickly, but a significant part of the population cannot afford it. And another large segment of the population can just barely afford it, surrendering the equivalent of their mortgage each month just to be protected against a medical catastrophe. Canadians are privileged to receive complete care for a nominal cost – but to the patient who waits months with a painful and debilitating condition, this can be cold comfort.

In many cases involving cancer patients or acutely ill patients needing emergent care, the Canadian system performs well. My father had bypass surgery, and though there were no bedside phones and the surgery ward had last been repainted about ten years ago, he received excellent care, with home care provided for a nominal fee. That is the beauty, equality, and power of the Canadian system. However, for an extremely large number of patients with “non-emergent” conditions, wait times are long, services are limited, and patients experience significant pain and disability while they wait for treatment. “Non-emergent” does not mean that the condition can safely wait months for resolution.

The problem with the Canadian system is that it is totally government run, with no alternative available, and no competition to goad officialdom to improve services. Consequently, Canadians are stuck with what government provides – sometimes very good, and sometimes deadly slow.

The problem with the American system (and here I beat a personal drum) is that it depends entirely on the free market, and provision of good health care, I believe, does not fare well in an atmosphere oriented to profit. Sick people are not profitable, and in the end, they get the short end of the stick from an insurance industry that basically wants them to disappear. One of the elements of my belief system that I absorbed with my (Canadian) mother’s milk is that health care, like the ability to vote and express myself freely, is a right, not a privilege. Having lived for a quarter century in the U.S., I am still not convinced that many Americans have grasped this concept. I’m not sure that those who campaign fervently for the right to carry a Smith and Wesson really believe that their fellow citizens should be able to take their children to the emergency room without worrying about whether they can pay for it. Personally, I think that it is my responsibility to fork over a bit more in taxes to make sure that the immigrant kids down the road can get their eyes examined. i find it interesting that the health care systems in the U.S. that really provide equitable care (Medicare and the Veterans’ Administration) are both government run.

What is the answer? It’s complicated. Canadians need more flexibility and the ability to step out of the queue and buy care if they want to. Americans need to be freed from the crushing burden of paying for care that only the rich or the employed can afford.