Pathology in Canada Richard G Hegele MD FRCPC

Pathology in Canada Richard G. Hegele, MD, FRCPC, Ph. D Professor and Chair, Dept. of Laboratory Medicine & Pathobiology University of Toronto Chief, Dept. of Paediatric Laboratory Medicine The Hospital for Sick Children richard. hegele@utoronto. ca www. lmp. utoronto. ca/

Conflict of Interest • University and Hospital employee • No commercial interests to disclose

Outline • Introduction to Canadian healthcare • Accreditation • Education • Research • Service

Canadian Healthcare System • Population: 35. 3 M • ~90% live within 100 miles of US border • Healthcare: Provincial jurisdiction • Funding: ~70% government

Accreditation • Laboratory – • Structures and regulations vary by Province Education – – UME: PGME: – University (LCME; Ca. CMS) University (Royal College of Physicians and Surgeons of Canada) Fellowships: Hospital-based (+ University diploma) – Hospital-University affiliation agreements

Royal College of Physicians and Surgeons of Canada • “Primary” Lab Medicine Specialties – – – • Anatomical Pathology General Pathology Hematological Pathology Medical Microbiology Neuropathology Subspecialties – – Forensic Pathology (Medical Biochemistry)

Royal College: AFC • Area of Focused Competence – – – Transfusion Medicine Cytopathology Others in development

Trends in Education • UME: Increasing integration • PGME: – – – Time-based to competency-based Can. MEDS 2015 AFCs – American Board eligibility

A LE R DE www. royalcollege. ca

www. mainequalitycounts. org

Research • Operating – – – Canadian Institutes of Health Research Charitable foundations Other • Personnel • Research infrastructure/overhead

Lab Testing in Canada • Hospital laboratories • Commercial laboratories • Centralized laboratories (Public Health, etc. ) • Other (referred-out testing; point-of-care)

Hospital Laboratories • ~ 55% of total lab work • Inpatients • ~4 -5% of hospital global budget • “Cost center”

Commercial Laboratories • ~ 45% of total lab work • Outpatients • “Revenue center”

Service • Utilization: “cost center” vs. “revenue center” • Hospital labs – new revenue streams • Commercial labs – capped • Offloading • Public-private partnerships • Outsourcing

Ontario: Offloading • Moving GI endoscopy out of hospitals into community clinics • ? Impact on GI pathology, incl. residency training Hepatitis C outbreaks at three Toronto colonoscopy clinics kept secret Toronto Star September 27, 2014 Toronto Public Health, which revealed the outbreaks when pressed by the Star, said 11 patients were infected and tainted sedative injections were the “possible” cause in all cases. “It has gone beyond appalling that the same mistakes are being repeated and are not being reported” - France Gélinas (NDP Health Critic)

Ontario: Public-Private Partnerships Toronto Star, Oct. 9, 2014 Secret government reports released Thursday by the Progressive Conservatives reveal the province is finalizing a deal to spend $317 million to purchase the brand-new - but virtually empty building.

Alberta: Outsourcing Australian company wins $3 -billion contract to run lab services in Edmonton Journal October 17, 2014 EDMONTON - An Australian company has won a $3 -billion, 15 -year contract to provide laboratory services in Edmonton. Sonic Healthcare Limited was selected by Alberta Health Services after a request for a proposal process that began last year. Sonic expects the contract will initially generate annual revenue of more than $200 million. The anticipated contract term is 15 years, with an option to extend the agreement for another term.

Conclusions • “Publically-funded” healthcare – myth vs. reality • Education – – – • UME: PGME: Fellowships: Visibility Competency-based AFCs Research – • Non-traditional sources of support Service – Utilization, funding, offloading, public-private partnerships, outsourcing