Volume 1: Inquiry Report Health Services Preferential Access Inquiry – Alberta The Hon. John Z. Vertes, Commissioner Volume 1: Inquiry Report August 2013 Volume 1: Table of Contents Table of Contents EXECUTIVE SUMMARY ............................................................................................... 1 ACKNOWLEDGEMENTS ............................................................................................ 21 SECTION I: INTRODUCTION ...................................................................................... 23 CHAPTER ONE: REASONS FOR THE INQUIRY ................................................ 23 A. A QUESTION OF ACCESS ................................................................ 23 B. THE ALLEGATIONS PROMPTING THE INQUIRY ........................ 26 (I) THE DUCKETT ALLEGATIONS ......................................... 29 (II) THE DUCKETT MEMO ........................................................ 36 (III) THE SHERMAN ALLEGATIONS ........................................ 42 C. THE INQUIRY’S ROLE ..................................................................... 48 CHAPTER TWO: THE INQUIRY’S MANDATE .................................................. 53 A. THE TERMS OF REFERENCE .......................................................... 53 B. SCOPE IN TIME ................................................................................. 54 C. SCOPE IN SCALE ............................................................................... 57 D. WAIT LISTS ........................................................................................ 58 E. THE ISSUE OF INFERIOR ACCESS ................................................. 59 CHAPTER THREE: PRINCIPLES OF INQUIRIES ............................................... 65 CHAPTER FOUR: THE INQUIRY PROCESS ....................................................... 69 A. GENERAL ........................................................................................... 69 B. ORGANIZATION ............................................................................... 69 C. COMMISSION COUNSEL ................................................................. 70 D. WITNESSES AND EVIDENCE .......................................................... 71 E. LIMITS AND PROPORTIONALITY ................................................. 73 F. BUDGET ............................................................................................. 73 G. STANDING AND FUNDING ............................................................. 74 H. RULES OF PROCEDURE ................................................................... 77 I. PRIVACY AND CONFIDENTIALITY ISSUES ................................ 77 J. RESEARCH AND EXPERT WITNESSES ......................................... 78 K. PUBLIC HEARINGS........................................................................... 80 L. DELIVERY OF THE REPORT ........................................................... 81 SECTION II: CONCEPTS, DEFINITIONS, AND SYSTEMS....................................... 83 CHAPTER ONE: HEALTH CARE SERVICES IN ALBERTA: LAWS AND STRUCTURES.............................................................................................. 83 A. THE LEGISLATIVE FRAMEWORK ................................................. 84 B. STRUCTURE AND GOVERNANCE OF HEALTH CARE IN ALBERTA ........................................................................................... 87 CHAPTER TWO: DEFINING ACCESS: PREFERENTIAL, PROPER AND IMPROPER ................................................................................................... 91 A. GENERAL ........................................................................................... 91 B. MEDICAL NECESSITY AS THE FOUNDATION FOR A Table of Contents DEFINITION ................................................................................................ 95 C. THE ISSUE OF CORRUPTION .......................................................... 96 D. MANY WAYS INTO THE SYSTEM ................................................. 99 (I) WORKERS’ COMPENSATION ............................................ 99 (II) PRIVATE DIAGNOSTIC IMAGING ................................... 101 (III) MEDICAL TOURISM .......................................................... 106 E. SOCIALLY JUSTIFIABLE PREFERENCES ................................... 107 F. PHYSICIAN ADVOCACY AND ETHICS ....................................... 111 G. PROFESSIONAL COURTESY ......................................................... 116 H. INCREASED CLARITY ON ACCESS ISSUES ............................... 127 I. A PROPOSED DEFINITION ............................................................ 128 CHAPTER THREE: RESPONDING TO THE PROBLEM OF QUEUES ............ 131 A. WAIT LISTS ...................................................................................... 131 B. WAIT TIME MEASUREMENT ........................................................ 132 (I) POLICY INITIATIVES ........................................................ 132 (II) TRACKING WAIT TIMES .................................................. 133 (III) DEMANDS ON THE SYSTEM ........................................... 135 (IV) ALBERTA BENCHMARKS ................................................ 136 (V) FINANCING ......................................................................... 136 (VI) PLANS FOR ENHANCED ACCESS ................................... 137 C. WAIT LIST MANAGEMENT .......................................................... 139 D. REFERRALS ..................................................................................... 146 E. ACCOUNTABILITY ......................................................................... 149 CHAPTER FOUR: TRANSPARENCY AND PUBLIC ADVOCACY ................. 153 A. TRANSPARENCY ............................................................................ 153 B. HEALTH LITERACY ....................................................................... 154 C. HEALTH ADVOCACY .................................................................... 155 SECTION III: CASE STUDIES .................................................................................... 159 1. MLA ADVOCACY ........................................................................... 159 INQUIRY FINDINGS ....................................................................... 164 2. COURTESY CALLS ......................................................................... 165 INQUIRY FINDINGS ....................................................................... 173 3. THE PAULA FINDLAY CASE ........................................................ 177 INQUIRY FINDINGS ....................................................................... 187 4. THE CALGARY FLAMES AND THE H1N1 VACCINE ................ 188 INQUIRY FINDINGS ....................................................................... 197 5. NURSES AND THE H1N1 VACCINE ............................................. 198 A) NURSES VACCINATING FRIENDS AND FAMILY ........ 199 INQUIRY FINDINGS ........................................................... 206 B) RED DEER IMMUNIZATIONS .......................................... 208 INQUIRY FINDINGS ........................................................... 210 6. EMERGENCY CARE AND TRIAGE PROCEDURES .................... 211 INQUIRY FINDINGS ....................................................................... 215 Volume 1: Table of Contents 7. THE PRIVATE PATIENT PATH ...................................................... 215 INQUIRY FINDINGS ...................................................................... 217 8. THE COLON CANCER SCREENING CENTRE ............................. 219 A) ESTABLISHMENT OF THE CCSC ..................................... 220 B) THE PROCESS AT THE CCSC ........................................... 221 C) ALLEGATIONS OF QUEUE-JUMPING ............................. 224 D) EVIDENCE OF IMPROPER PREFERENTIAL ACCESS ... 229 9. EXECUTIVE MEDICAL CLINICS .................................................. 238 SECTION IV: COMPARISON OF POLICIES ON PREFERENTIAL ACCESS: ALBERTA HEALTH SERVICES, COVENANT HEALTH AND DUCKETT ....... 243 1. ORIGINS OF THE POLICIES ........................................................... 243 2. SCOPE AND PURPOSE OF THE POLICIES ................................... 244 3. DEFINITIONS ................................................................................... 245 4. HEALTH CARE WORKERS ............................................................ 247 5. SPECIAL TREATMENT OF BOARD MEMBERS AND OTHER VIPS ........................................................................... 247 6. WHO DECIDES IN PREFERENTIAL ACCESS CASES ................. 248 7. DISCRETION .................................................................................... 248 8. ACCEPTABLE ACTIVITIES ........................................................... 248 SECTION V: CONCLUSIONS AND RECOMMENDATIONS .................................. 251 APPENDIX 1: ADMINISTRATIVE LESSONS LEARNED FOR FUTURE INQUIRIES .............................................................................................. 259 A. ESTABLISHMENT OF THE INQUIRY ........................................... 259 B. CONSULTATION ............................................................................. 260 C. THE TRIPARTITE ARRANGEMENT ............................................. 261 D. SENIOR CONTACT PERSON FOR PUBLIC INQUIRIES ............. 263 E. A SUGGESTION FOR THE FUTURE ............................................. 263 APPENDIX 2: INQUIRY