Bariatric surgery tourism hidden costs? How Canada is not doing its part in covering bariatric surgery under the Canada Health Act

Summary

Many Canadians seek medical treatment outside our borders. Waiting times, rather than lack of expertise, are the number one culprit, and with globalization of health care, the number of patients who travel to obtain medical care will continue to rise. Though the provinces have covered the costs of complications from surgeries performed abroad for many years, complications from bariatric surgery performed abroad have been receiving negative attention. This commentary discusses associated costs and questions how the Canada Health Act should be covering bariatric procedures.

I read with interest the article by Snyder and colleagues¹ entitled, “Unpacking the financial costs of bariatric tourism gone wrong: Who holds responsibility for costs to the Canadian health care system?”. According to the Fraser Institute, it is estimated that more than 45 000 Canadians in 2015 sought medical treatment outside our borders — half of them from Ontario alone, one-third from western provinces (British Columbia and Alberta), and much fewer from Quebec (only 3360 of 45 000). Of these, 5000 patients travelled to obtain urological procedures, followed by orthopedic/neurosurgical interventions (3700). Waiting times, rather than lack of expertise, are the number one culprit, and with globalization of health care, the number of patients who travel to obtain medical care will continue to rise.

For several years, the Ontario Health Insurance Plan (OHIP) had been covering bariatric surgery performed in the United States because of lack of local expertise. It is clear that many patients came back with complications that needed to be covered regionally. The province finally took its responsibility seriously, embarked on a badly needed program in 2008, spent $75 million, and established the Ontario Bariatric Network. The actual number of bariatric surgeries performed increased from 297 cases in 2006–2007 to 2846 cases in 2012–2013 (an 858% increase),² with a very acceptable mortality of 0.16%, overall morbidity of 11.7%, leak rate of 0.84% and a reoperation rate of 4.6%; these rates were quite similar before implementation of the program.³ In the meantime, the province of Quebec not only did more than its share for decades, performing 50% or more of all bariatric procedures in Canada until 2011,² but also approved and covered all bariatric procedures available (adjustable gastric banding, sleeve gastrectomy, gastric bypass, duodenal switch), several of which most other provinces still do not cover. With Ontario and Quebec performing 80% of all bariatric surgeries in this country (2012–2013),² there is no capacity for taking patients from other provinces. Ontario’s central referral process excludes patients from other provinces, and interprovincial agreements do not cover the true costs of these surgeries (per diem rates are too low). Out-of-province surgery remains a slow case-by-case bureaucratic approval process.

On average the cost of bariatric surgery can be $15 000–$20 000 Canadian dollars, depending on the procedure, and the disposable staplers/cartridges needed for either a laparoscopic Roux-en-Y gastric bypass or a laparoscopic sleeve gastrectomy cost $2500–$3000. Of the 1.2 million possible Canadian candidates for bariatric surgery (5% with obesity class II and III), in 2012–2013 only 6000 (0.5%) underwent a bariatric procedure, mostly concentrated in Ontario and Quebec.² Based on these costs, if an extra 2000–3000 Canadian patients obtained this surgery abroad, the Canadian system would have saved $30 million–$60 million in direct costs. Further, if we consider the effects of bariatric surgery on reducing medical comorbidities, provincial health systems also save on the cost and management of chronic diseases (e.g., diabetes, coronary artery disease) for years; these savings were estimated at almost $6 million dollars per 1000 patients 10 years ago.⁴ Taken together, these savings amount to hundreds of millions of dollars per year. In comparison, France performed nearly 50 000 bariatric interventions in 2014 (two-thirds were done privately, but reimbursed by the state), which is proportionally 4–5 times as many as in Canada for a less obese general population (obesity France is 24% v. 28% in Canada).

Bariatric surgery has a mortality similar to cholecystectomy, hysterectomy or knee arthroplasty as well as an acceptably low morbidity rate. Complications of surgery that occurred abroad are likely to have happened in Canada as well, and the costs of those complications would have been covered in Canada anyway. Kim and colleagues⁵ estimated this cost to be half a million dollars a year in Alberta, still a small fraction of the cost to the province had they performed the procedure. Though some consider the costs of treating complications from bariatric surgery performed abroad to be onerous for the Canadian health system, ¹ rather, the resulting savings from patients receiving surgery elsewhere seems very profitable, if unethical, for provincial health networks on the backs of those who bear the costs of private surgeries.

Consider all the other categories of surgery (e.g., urological and neurosurgical procedures) for which Canadians travel abroad. Plenty of Canadians undergo orthopedic procedures in India or Europe and plastic surgeries in Cuba, the Dominican Republic, Costa Rica or Brazil. Who covers the complications of plastic surgeries not covered by the Canada Health Act? What happens when a patient who experiences a pulmonary embolus, a systemic infection, or a cardiac arrhythmia after a breast augmentation performed elsewhere arrives in a Canadian emergency department? In the past 40 years since the quality of top American centres like the Mayo Clinic, Cleveland Clinic, and hospitals in Boston and New York was established, plenty of Canadians have obtained treatment (e.g., cardiac, vascular, cancer, infertility) in the United States. Many of those patients came back to Canada with complications, and the Canadian health system took care of those complications, mostly because the costs of those procedures were not covered here. Why is bariatric medical tourism suddenly a problem?

Provincial health ministries hold a strong responsibility to take care of complications of surgeries performed abroad, as they are not doing their fair share to cover the costs for enough patients to obtain bariatric surgery under the Canada Health Act. Why does bariatric surgery have inadequate coverage? Perhaps negative biases toward obesity surgery or obesity in general are the culprit.