HEALTH

YOUR COMPLETE USER'S GUIDE TO BETER MEDICAL CARE

ALEXANDRA SHIMO June 11 2007
HEALTH

YOUR COMPLETE USER'S GUIDE TO BETER MEDICAL CARE

ALEXANDRA SHIMO June 11 2007

YOUR COMPLETE USER'S GUIDE TO BETER MEDICAL CARE

HEALTH

42 Taking control of your health 43 Emergencies 43 Vaccinations for exotic destinations 44 Medical travel agents 44 Genetic testing 45 Open MRIs 47 Wait-time insurance 47 Audiology 47 Prostate therapy 48 Fertility clinics 48 Preventive assessments 49 World Medical Card and air ambulance 49 Laser eye surgery 50 Niche GPs 50 Specialty surgeries 51 Fighting cancer 53 Finding a specialist 54 Our exclusive 2007 medical services directory

TAKING CONTROL OF YOUR HEALTH

ALEXANDRA SHIMO

In May 2006, Maclean’s launched the country’s first-ever national guide to medical care, focusing on services patients could buy. As we put the package together, we were astonished to discover just how many of these options were available. Private health care, once considered verboten, had gone from providing after-hours MRIs to offering complex and lengthy surgeries.

Since last year, we have broad-

ened the guide, adding new cat-

egories to reflect the developments on the Canadian health care landscape. In the course of this year’s research, we discovered a raft of new services that had passed below the media’s radar. OneWorld, a medical travel company, for instance, has started offering waittime insurance. Queue for more than 45 days for a procedure, and the insurer will pay for you to have private treatment either in Canada or the United States (see page 47). ChemoFit was another service we heard about as we interviewed medical experts across the country. Chemotherapy has different success rates depending on the patient. ChemoFit analyzes a patient’s own tumour cells in the laboratory to identify which

medication will work best (see page 52).

A relatively new field, one that is on the cutting edge of science, is pharmacogenetics. It turns out that people metabolize drugs at different rates, which can lead to a bad reaction to prescription drugs: Canadians can now have their DNA tested at a couple of executive wellness clinics.

Why so many new services? There are a

number of reasons, says Brian Day, presidentelect of the Canadian Medical Association. Baby boomers are just hitting their senior years. Many of them want different things from retirement than generations past. Rather than using retirement as one long holiday, many want to be as active as they were in their twenties and thirties, he says. They are much more proactive about their health than their parents. Medical technologies are rapidly

evolving, and baby boomers have the mindset and money to want to use these tools to improve their health and well-being.

YY9.IT.TJ999.T.9.9.9999.9. Percentage of patients seen in less than one hour 1 1 1

Some of the new services address gaps in public health care. Wait times in emergency rooms (based on patients’ estimates) are longer in Canada than in Britain, Australia, New Zealand, Germany and the United States, according to a 2005 international

Percentage of patients seen in four hours or more

study published in the journal Health Affairs. The Urgent Care facility at False Creek Surgical Centre treats the minor emergencies of people who don’t want to wait several hours to be seen, and who can afford the clinic’s fees (see page 43).

Another growth area is niche family doctors. Currently 3.9 million Canadians don’t have a GP. This makes it more difficult to tackle chronic illnesses and limits our progress in disease prevention, says Ian Bowmer, vicechair of the Health Council of Canada. According to OECD statistics, Canada has one of the lowest percentages of doctors per one million people in the developed world. We rank below Australia, Austria, Belgium, Denmark, France, Germany, Greece, Italy and so on: 17th out of 21. The crisis is so bad the Ontario Medical Association in a November 2005 report referred to family medicine as a “dying specialty” in need of “urgent resuscitation.”

While family doctors are in short supply, many of the executive health clinics are expanding, partly because they offer long, unhurried appointments with a GP once you have completed an exhaustive menu of preventive tests. At Toronto-based Medcan, a national executive health provider, members receive 24/7 access to a doctor and assistance accessing specialists in Canada and the United States.

Most of these private clinics

use electronic medical records.

In contrast, few physicians in the public system use e-health: Canada ranks among the two worst industrialized countries in the world for the computerization of health files, according to several recent studies.

The situation is so bad that Tony Fell, chairman of RBC Capital Markets, quit the board of Toronto’s health authority in frustration in April. In his letter of resignation, he wrote, “I was disappointed because the only way out of Canada’s health care morass was through a major upfront investment in e-health.” “Moving into the electronic age,” he told Maclean’s, “would save billions of dollars in the long run, cut wait times, avoid duplication,

and cut medical errors.”

By contrast, companies like Medicor, a cancer-care management group, place the computerization of a patient’s medical information at the core of its service. It collects all the relevant information from a patient’s various doctors and hospitals and stores it on a PDA so physicians working in the public system can deliver better care.

Another growing trend is catering to specific demographics. The executive wellness provider Scienta Health tailors its packages to baby boomers. The Mom and Baby Depot in Whitby, Ont., focuses its care on mothers and their kids. An annual membership fee means one-hour appointments with a pediatric team, lengthy family doctor appointments and 24-hour telephone access to a GP. Courses and counselling in everything from breastfeeding to baby behaviour management are covered. Currently, only women and children have access to the full range of services. Clients have asked the centre to expand, and it is currently trying to recruit a GP to look after fathers, too.

The growth of these clinics, at which patients pay for a portion or all of the service, are part of the evolving Canadian health care landscape. Your Complete Guide to Better Medical Care 2007 is the only national survey explaining what is happening, and how it could affect you. We thought our readers should know all the medical options on offer.

EMERGENCY CARE

No more eighthour waits

In September 2005, the Canadian Institute for Health Information released a report that sparked the imagination of Vancouver anesthesiologist Mark Godley. After surveying emergency rooms nationwide, the institute found that more than half of emergency room visits were for non-urgent or less-urgent cases. In other words, a lot of people didn’t really need to be there, Godley says.

TheB.C. doctor wondered whether there was some other way to treat these less-urgent cases. And in December 2006, that thinking resulted in a new medical service, the Urgent Care facility at the False Creek Surgical Centre.

With its six beds, surgical suite, lab, cancer infusion treatment (chemotherapy), and a bevy of diagnostic equipment, the sprawling private hospital made headlines in papers nationwide.

With the media attention came controversy. A month after its splashy opening, it had closed its doors to the Canadian public. For the past eight years, Godley had run the False Creek Surgical Centre, but adding an emergency room was a step too far for the B.C. government. It brought in investigators, and told the clinic to either shut down or stop charging patients.

Two months later, in March 2007, Godley reopened his controversial private clinic. By hiring emergency room doctors who have never worked in British Columbia, he has found a loophole through which he can charge patients for medical services, he says. “I opened this emergency room to take some load off the public system,” says Godley on a break from surgery. “That’s part of the reason. But I also really believe that the system would improve if we introduced an element of competition.”

WAIT TIME Less than an hour.

HOW MUCH?

(Patients are charged an initial diagnostic fee of $200 for each visit)

Fractures $190 to $225

Dislocations $330

Complex lacerations $250

Abscess drainage $225

Nasal packing/nosebleed $195

Mental health certification $175

Foreign body removal (a piece of wood in

your foot, for example) $200

Enemas $30

Ultrasound $499

Echocardiogram $520

Same-day specialist referral $1,250

—Alexandra Shimo

VACCINATIONS

All your shots in one quick spot

Planning a quick getaway to the Caribbean? The last thing you want is another item on your to-do list, let alone one that involves getting shots. Besides, you’re headed to a tourist destination, and you’re only going for a week. No need to see a doctor, right? You wouldn’t be the only vacationer to think this way: more than 50 per cent of travellers don’t seek any type of health advice prior to departure. Yet Dr. Jay Keystone of the Toronto General Hospital’s tropical medicine centre says travel illness is both a real and unnecessary risk, even at popular beach resorts. In countries like Haiti, Cuba and the Dominican Republic, up to 50 per cent of visitors contract enterotoxigenic E. coli, the bacteria that causes traveller’s diarrhea. In fact, “Montezuma’s revenge” is the most common vaccine-preventable infection among travellers. The second is influenza.

Keystone is also director of the Medisys Travel Clinic in Toronto, one of more than 20 private vaccination clinics in the city. Over the last decade, most provinces have delisted travel health, the logic being if you can afford to travel, you can afford to pay for the advice. In B.C., family doctors in the public health system are required to bill patients for any travel health consultation, and that’s on top of fees for vaccines. What’s more, many GPs don’t stock exotic vaccines such as Japanese encephalitis (for travel to some Asian countries) or yellow fever (for which there are strict refrigeration requirements). It’s all led to a gradual shift in travel-health expertise from the public domain to private centres like Medisys, several of which employ tropical medicine experts like Keystone. A typical consultation involves a thorough review of the travel itinerary, a medical history, and a discussion about vaccines and health precautions (anything from how to cope with jet lag to where in the world sexual activity is riskiest). Then a nurse comes in with a syringe.

On a recent business trip to China, David Jensen, CEO of a design consulting firm in Vancouver, followed the advice he got at the Travel Medicine and Vaccination Centre and tookDukoral, the anti-diarrhea vaccine, before leaving. (If needles conjure bad childhood memories, take heart—Duko ral is administered orally, in the form of a fizzy drink.)

“Every day was going to be full of meetings and travel, so I didn’t want anything like diarrhea to hold me up, because that would have been disastrous,” says Jensen, 6l. The money he spent, about $200 altogether, bought him quick service and peace of mind. “These places keep track of my shots, so I know what I need and what I have had,” he says.

In that vein, Keystone says Medisys plans to broaden its mandate beyond travel vaccines into standard immunization. “Adults tend to fall through the cracks,” he says. “They need tetanus, diptheria, polio. They need pneumococcal vaccine when they get older. There’s a new zoster [for shingles] vaccine coming out soon. They need HPV, they need hepatitis B.” Many travel clinics will throw in a tetanus shot with the other vaccines they administer to travellers. Keystone thinks the clinics can go even further and serve a formal role in keeping track of patients’ immunizations as a complement to family medicine. “The bottom line is that primary care doctors are so busy and overworked doing what they do,” he says. “They really aren’t geared to saying, ‘Have we updated this, have we updated that?’ ”

HOW MUCH?

Individual consultation $40 to $60 Group or family of four $100 to $125 Dukorol $75 to $80 Yellow Fever $75 to $98

—Dafna Izenberg

TRAVEL AGENTS

New hot spots for surgery

The World Health Tourism Congress, a threeday meeting of medical travel agents from around the world, was held in Cyprus this year. More than 60 countries were represented; six Canadian companies attended. Evenings featured champagne cocktails, a cornucopia of meze and international cuisines, and Cypriot music and dancing. During the day, the entrepreneurs listened to presentations to help them decide which hospitals in less developed countries were good enough to treat Canadian patients.

A worldwide industry that once evoked more bemused curiosity than credibility now has the financial backing of many international governments—Singapore, Philippines, Saudi Arabia, Kuwait, Oman and the United Arab Emirates, to name a few. It also has its own agency to set standards and mediate patient

complaints—the International Medical Travel Association. No one has documented the total number of patients travelling to get their various ailments fixed, but a recent survey suggested 1.3 million go to Asia yearly.

Canada is no exception to the growth in medical tourism. Companies such as MedSolution, Sun Medical Group and Surgical Tourism have added new surgical destinations, such as Mexico, Central America and the United Arab Emirates. Surgical Tourism has opened three new branches in Canada in the past two years, and four in Australia. New services are also available: patients can travel to India to receive a type of cancer care—intensity-modulated radiation therapy (IMRT)—that is not widely available in Canada. Currently, Surgical Tourism has a client from Walkerton, Ont., in Chennai, India, receiving IMRT for advanced lung cancer.

Some medical travel agencies focus on specific locations. Timely Medical Alternatives and OneWorld Medicare send patients only to private hospitals in Canada and the United States. Sun Medical deals almost entirely with Malaysia. Other companies specialize in specific types of operations: Montreal-based Gosculptura, for example, does cosmetic, dental and fertility trips.

To succeed in this business, a medical travel agent must gain the trust of the person travelling: patient testimonials, resumés of doctors, and conference calls with the designated surgeon are often part of the service. Prices usually include flights and a couple of weeks of convalescence. What is not included is any post-operative care once the patient returns home. Follow-up and physio are the responsibilty of the patient, although a good medical travel agent will help clients make the necessary arrangements.

HOW MUCH?

Sample price list for Indian hospitals. Prices include flights.

Total knee replacement $13,500 Hip resurfacing surgery $14,500 Cancer treatment $40,000 Teeth implants (eight teeth) $13,000 to $15,000

Facelift $7,500 to $8,000 Breast enlargement $7,500 to $8,000 Sample price list for Canadian and U.S. private hospitals. Prices do not include travel costs.

Total knee replacement $16,000 Hip resurfacing surgery (done in U.S. hospital) $20,870

Arthroscopic knee surgery $3,000 to

$8,000

Facelift $10,500

Breast enlargement $5,000 to $7,000

-A. S.

GENETIC TESTING

A diet designed for your genes

Late last year, the anti-flu medication Tamiflu and its creator, the drug company Roche, came under intense scrutiny. At least 84 Canadians had become ill after taking the medication; 10 had died, three within the past year. As drugs go, the coverage of such serious side effects is the exception, not the rule. Most of the time, adverse drug reactions go unreported to such an extent that the latest U.S. study concluded that 6.7 per cent of patients don’t react as they should to their medications. The Journal of the American Medical Association says that adverse drug reactions are the sixth-largest cause of death in the United States.

Which begs the question: why are most people perfectly fine with Tamiflu, while a few become psychotic and hallucinatory? It

depends on how your body breaks down the drug, which is determined by genetics. Pharmacogenetics determines how fast you metabolize medication by analyzing your genetic makeup. Currently there are pharmacogenetic tests for 60 to 70 per cent of all drugs: codeine can be tested; the cholesterol-lowering drug Lipitor cannot, says Jill Davies, a genetic counsellor at Medcan, a private clinic that offers pharmacogenetics.

Genetic counselling is another cutting-edge service available at a few private clinics. Patients work with a geneticist, poring over their family tree to determine which diseases they are most at risk of developing. Those at risk of getting, say, osteoporosis, are then offered information about how they can

change their lifestyle to help prevent the condition from developing.

Nutrigenetics is a new scientific field that analyzes a person’s genetic makeup to determine how they metabolize various vitamins and food groups. Doctors use the science to tailor a diet and vitamin-supplement plan to a patient’s DNA and specific disease risk. Some critics say this field is still in its infancy; currently only ScientaHealth offers this service in Canada.

HOW MUCH?

Genetic counselling $295 (genetic tests are extra, most are covered by medicare) Pharmacogenetic tests $300 and up (depending on the number of tests requested)

Nutrigenetics and genetic counselling starts at $750

—A. S.

OPEN MRI

No-fear scans for claustrophobies

Twenty-two years ago, when the first MRI was introduced in Canada, it was hailed as a medical miracle. Suddenly, physicians could literally see inside their patients’ bodies. Using a magnetic field and radio waves to send information from soft tissue to a computer, everything from cancer to tennis elbow became easier to diagnose. But for many patients, the test turned out to be almost as scary as the disease. Even though it may be aimed at a specific body part, conventional magnetic resonance imaging requires that a patient’s whole body be loaded either head first or feet first into a narrow noisy cylinder where, for as long as 45 minutes, he lies perfectly still while the machine does the scan. For claustrophobies—one in 20 Canadians according to the Canadian Association of Radiologists—the procedure is torture. And for anyone over 300 lb., or with very wide shoulders, it can be a physical impossibility. Conventional MRI machines have an opening that is just 56 cm wide, says CAR president Bob Miller, a radiologist in Halifax. “There’s not a lot of room in there.”

That’s why, over the past several years, MRI machine manufacturers have been building a better alternative. So-called open-bore MRIs, like the one offered at Réso-Concorde in Laval, Que., and at Canadian Magnetic Imaging in Vancouver, for example, are wider

and shorter and don’t enclose the patient. And because their openings are a much roomier 70 cm, they can accommodate those who weigh 450 lb. or more. But “open bore is still a tunnel,” says Calgary radiologist Deepak Kaura. “In MRI, the part ofyour body that is imaged has to be in the centre of the magnet, period.”

To that end, Kaura thinks the clinic he cofounded in the city’s Marlborough Mall offers the best solution for both claustrophobies and large individuals. Open MRI of Canada (purchased last month by CML Healthcare in Mississauga, Ont.) boasts what Kaura calls “the first and only new generation open MRI machine in the country.” It is a $1.3-million Hitachi, leased by Kaura in late 2005, partly because it is kid-friendly—he also works as a pediatric radiologist at the Alberta Children’s Hospital. His machine is so commodious, he says, that parents can lie down on the table with their children while they are being scanned. For adults, such as Olympic gold medal hockey player Hayley Wickenheiser, the open MRI is like the difference between day and night. “Hayley had been in a tunnel magnet, but she thought ours was so much better,” Kaura says. “She called it ‘great’ and swore, ‘there is no fear at all.’ ”

His patients come from all over Canada, he says, “both because they are not afraid and because they can get an appointment

fast.” The Canadian Institute for Health Information reports that Canada has 164 MRI machines in hospitals and 32 in free-standing clinics; or 5.9 MRIs for every one million Canadians. Patients can measure the cost at clinics like Kaura’s—$695 per area—against wait times that vary from 34 to 177 days, excluding emergencies.

In Melville, N.Y., meanwhile, a company called Fonar, founded by MRI pioneer Dr. Raymond Damadian, is marketing the ne plus ultra of MRI machines, the Upright. It lets people either stand or sit and watch TV while they are undergoing the test. “In 2004, it allowed a tiny baby to be scanned sitting on its mother’s knee,” says spokesman Art Brady. So far, not one of the machines, which cost US$2 million installed, has made its way to Canada.

In Halifax, CAR’s Miller thinks such open MRIs, especially of the heart, don’t produce the clearest images, but he is quick to add that in his 30-year career, he has never worked with one. Says Miller, “Some of the things you can get on a modern magnet in the past five years in terms of the speed and the ease are just out of this world.” Luckily, with open MRIs, the experience is even enjoyable.

HOW MUCH?

Open MRI scans $695 to $825

—Barbara Righton

WAIT-TIME INSURANCE

If you can’t see a specialist fast...

It takes about 125 days* to see a surgeon in Canada. That’s the median length of time from your doctor’s referral until you are actually lying on the gurney, waiting for the surgeon to start work. Of course, not everyone waits four months. For cancer patients, treatment takes a median of 35 days. On the other hand, those in need of orthopaedic surgery fare much worse. The median waits for this specialty are 282 days—more than nine months.

Wait-time insurance (called Medical Access Insurance) is a way of hedging your bets. Launched by OneWorld last year, it guarantees you won’t spend more than 45 days waiting to see a specialist. If you have to wait longer, you are given the option of having private treatment in Canada or the United States. Medical costs up to $1 million are covered. This insurance does not pay for the treatment of pre-existing conditions, at least within the first two years of buying it. Currently, the product is available only through employee insurance plans in Alberta, B.C. and Manitoba. OneWorld says it will expand to other provinces by the end of the year.

*These wait times are from this year’s edition of “Waiting Your Turn: Hospital Waiting Lists in Canada,”published by the Fraser Institute. They are longer than provincial wait lists, because they measure wait time from first referralfrom a GP to the time of surgery. Provincial wait times measure from the first consultation with a specialist to surgery.

HOW MUCH?

Starts at $75 a month for a family

—A. S.

AUDIOLOGY

Tiny hidden hearing aids

In Canada, it seems the act of having one’s hearing tested and enhanced is fast becoming a strictly private affair. According to the u Canadian Association of Speech-Language

Pathologists and Audiologists, the vast majority of roughly 1,200 practising audiologists do so in a private setting.

As with eye care and dentistry, the reasons are simple enough: expensive technology and the opportunities available in the private sector for those graduating from the country’s five university programs. “There aren’t actually a lot of good public sector jobs available,” says Dr. Lorienne Jenstad of UBC’s School of Audiology and Speech Sciences. “If audiologists really want to get into dispensing hearing aids, it’s easiest to do that in a private practice.”

Medicare coverage varies widely from province to province, but typically programs only partially cover hearing aids—if at all. In Ontario, for example, patients are eligible for up to $500 per hearing aid, which typically cost upwards of $2,000 apiece. Some private health insurance may cover the expense as well, though as with dentistry there is a wide range as to what and who is eligible. In most provinces, there are programs for veterans and members of First Nations.

New technology, also used in cellular phones and computers, has allowed hearing aids to shrink in size considerably. What are called “open fitting” hearing aids are among the newest and most popular advancements in the field. A thin, clear tube hooks onto the back of the ear and is connected to the ear bud, making it smaller and less prone to feedback and background noise. “They are more cosmetically appealing to people who wouldn’t otherwise wear hearing aids,” says Jenstad.

Several clinics across the country have also begun using electrophysiological testing, which measures how the brain responds to sound without depending on a person’s reac-

tions. It is particularly useful in a pediatric setting or where verbal commands may not be understood.

HOW MUCH?

1. Auditory tests $30 to $70 (some clinics offer the tests for free as an incentive to new customers)

2. Tinnitus tests $40 to $70

3. The Sound Hearing Clinic in Vancouver offers Auditory Processing Assessments— a two-hour diagnostic of a patient's hearing as it relates to learning and perceptive skills. It is a $400 procedure.

—Martin Patriquin

PROSTATE

A special sort of microwave

The prostate is one of those organs you’ll probably never think about, or need to think about, until it misbehaves. For older males, this is quite common—one in four men over 50 have symptoms such as slower flow or frequent urination, problems associated with an enlarged prostate.

When these symptoms become too irritating to ignore, the prostate can be surgically reduced or shrunk down to size using a special sort of microwave. A small antenna is inserted into the urethra that emits microwave energy, heating the prostate and destroying excess tissue. After half an hour of warming, the treatment is finished, and the patient can go home, or back to work.

Compared to surgery, transurethral microwave thermo therapy (TUMT) has a number of pros and cons. On the downside, it costs a lot of money and the patient must wear a catheter for five to seven days after the procedure, rather than a day or two, as with an operation. On the other hand, TUMT removes the risk of impotence, which happens to about one in 10 patients who undergo the surgical procedure.

HOW MUCH?

Transurethral microwave therapy $4,000

FERTILITY CLINICS

Turning back the biological clock

From the time she was 34, New Yorker Mamta Shah began to feel her biological clock ticking. On dates, she would worry she might be wasting her time with the wrong man. When she wasn’t dating, she felt she should be out socializing and making time to meet the right man. And so, starting in September 2005, Shah started flying to Montreal every six months to gain a few years of fertility. Freezing her eggs at the McGill Reproductive

Centre removed the enormous pressure she felt about being a late-thirtysomething single woman. “Since I had it done, I don’t feel so worried that I haven’t found the right guy and started a family already,” she explained from her Manhattan apartment.

Shah chose the Montreal clinic because it is one of the few places in North America that does rapid egg freezing. Normally, when eggs are cooled, the water forms ice crystals that

can cause damage to the cell. At the McGill centre, the cells are frozen at 20,000° C per minute. At this speed, there isn’t enough time for the ice crystals to form, and a far higher proportion of the eggs survive, says Dr. Seang Lin Tan, who helped pioneer the technique. It was those statistics that persuaded Shah to choose McGill, as well as the prices. The drugs and treatment are a lot cheaper this side of the border, says Beverly Hanck, executive director of the Infertility Awareness Association of Canada.

One in six Canadian couples are infertile: the cause is divided fairly equally between the sexes. Some technologies focus on the male: intracytoplasmic sperm injection (ICSI) injects a single sperm right into an egg, a treatment used for men with low sperm counts. Other advances, such as sonographically guided needles to collect eggs without the use of surgery, have made the procedure less

invasive for women. In vitro maturation (IVM) is a new technology that matures the eggs outside of the womb, and can help cancer patients who have become infertile because of radiation and chemotherapy. None of these treatments come cheap, and none are covered by the public purse. Only Ontario pays for IVF, and only when both a woman’s fallopian tubes are blocked.

The success rate for IVF varies according

to the mother’s age: the average pregnancy rate for women aged 35 to 39 is 31 per cent, and for women 40 and over, 19 per cent. For this reason, there is high demand and long wait-lists for the donated eggs of younger women. Since 2004, it has been illegal to pay donors for their eggs or sperm, and consequently there is a shortage of both at the fertility clinics. Patients who can’t use their own sperm or eggs are asked to bring their own donors.

In Canada, it is also illegal to pay a surrogate mother to have a baby for you. Clinics that offer surrogacy services usually ask couples to supply their own “gestational carrier.” At the Regional Fertility Clinic in Calgary, couples can receive donated embryos if they have been unsuccessful with other fertility treatments. The McGill Reproductive Centre has a different solution. It provides a contact list of clinics in South America where egg purchasing is legal and will monitor the pregnancy once the couple has returned home.

HOW MUCH?

In vitro fertilization: one cycle, including drugs $6,500 to $9,000 In vitro fertilization: three cycles, including drugs $15,000 to $25,000

In vitro maturation: one cycle $3,975 Pre-implatation genetic testing for disease $1,500 to $3,000 depending on the test

—A. S.

PREVENTIVE

The best cure, at executive prices

The comprehensive physical offered by executive wellness clinics is designed to detect developing problems. The examinations are usually long and involved; for example, the Medcan assessment, which includes an abdominal ultrasound and fitness appraisal, takes four hours. After the physical exam, clients have access to a range of services designed for people who don’t want to wait in line. Many of the clinics offer 24/7 access to doctors. Most promise to expedite your access to any type of specialist doctor you need. A second opinion from a U.S. doctor is another popular option.

These services are usually bundled together as a package, and are available to people who have completed the extensive physical exam. Medisys, for instance, a national executive health provider, offers a 24-hour travel line

in its “concierge” package. It will arrange medical care for members who fall ill while travelling abroad, ensuring the treating hospital has the correct medical information and does not over-bill the patient. Executive wellness clinics are a rapidly growing sector, but only a few, such as Medcan, have services that are open to people who have not completed the extensive physical. Specialist referrals (see page 53) and genetic counselling (see page 44) are both available to anyone at the Toronto-based centre.

HOW MUCH?

Initial assessment (depending on the provider) $900 to $2,500 Additional services (such as the travel line or 24-hour phone consultation with doctors) $400 to $600

—A. S.

WORLD MEDICAL CARD

Your records travel anywhere

The genesis for this medical innovation was born out of a series of needless deaths. A Norwegian businessman, Arne Veidung, heard about a number of people who died in hospital when they were given medication that reacted with the blood thinner they were taking.

Such small details—the absence of a few snippets of information—can have disastrous consequences. To help others avoid similar tragedies, Veidung created the World Medical Card in 1998. Sold in 20 countries around the world, the service was launched in Canada last summer. It stores a person’s prescription drug records, allergies, vaccinations and innoculations, next-of-kin contacts and donor

requests. These details, sealed inside a wallet-sized plastic card, are readable in the international medical language set out by the World Health Organization. To access this sensitive information, the card is cut open. For a nominal additional cost of $5, the information can also be sent to and stored on a cellular phone.

The World Medical Card is partnered with another service for Canadians working abroad. When they are hospitalized in a foreign country, or more than 240 km from their residence, the company provides air ambulances to fly them home. Part of this service includes making sure the destination hospital admits the returning patient.

HOW MUCH?

World Medical Card $45 a year Air ambulance service (includes World Medical Card) $275 a year for an individual; $430 a year for a family

The World Medical Card is sometimes bundled with travel, health and life insurance. Check with your provider.

-AS.

LASER

Eye surgery without a blade

Ophthalmologist David Rootman watches through a microscope as tiny laser beams pulse over each of Rico Ho’s eyes, forming a microscopic layer of bubbles within the cornea. A monitor in the surgery suite shows the same magnified image Rootman sees: a circle filling with bubbles from top to bottom creating a “flap” (a sliver of the cornea about 100 microns thick) that is then folded back to apply a custom-designed corrective laser treatment. “It’s going beautifully,” says Rootman, still looking through the microscope as he passes a cellulose sponge over Ho’s eyeball, smoothing the flap back into place where it immediately begins reattaching to the cornea. As he steps through the waiting area to the recovery room, Ho is clearly excited. “It’s already better,” he says.

A year after his condition (a mix of myopia, or nearsightedness, and astigmatism, a corneal irregularity that distorts images) worsened to the point that he had to ditch his contact lenses for uncomfortably thick glasses, Ho, 27, decided to try laser eye surgery. In researching his options, he quickly decided he wanted it done with IntraLase. Commercially avail-

able for about four years, the computer-operated IntraLase is often described as the “bladeless” option in LASIK (the form of laser eye surgery that involves creating a corneal flap). IntraLase carves the flap with bubbles instead of a hand-held oscillating metal blade, known as the microkeratome, that has been used since LASIK first became available in Canada in the mid ’90s.

Rootman introduced the IntraLase technology to the Yonge Eglinton Laser Eye Centre, in July 2005. After using it only one day, he never wanted to go back to the microkeratome. IntraLase is superior, says Rootman, for two reasons: precision and safety. He believes it allows better control over the thickness, shape and smoothness of the corneal flap, and is much less likely to result in any kind of surgical complication, such as a “buttonhole” (in which a piece of tissue from the flap remains on the cornea). “With the microkeratome, the staff hold their breath for the 10 seconds it takes for the blade to go across the cornea and come back,” he says. “So does the surgeon.”

While many eye centres across Canada are adopting the technology, there is some debate in the ophthalmology community about its benefits. LASIK MD, which has 17 Canadian locations and performs about 40 per cent of laser eye surgeries in the country annually, does not offer IntraLase. “To date there is no scientific evidence that proves it is a better way to create a flap,” says spokesman Michel Lanctot. “Yet people are paying between $300 and $500 more an eye just for that special technology.” Naysayers also point out that the procedure takes slightly longer with IntraLase, which has to do with the suction pressure required to harden the cornea prior to making an incision.

It isn’t that Rootman thinks the microkeratome is unsafe; he used it for almost seven years and had good results “99.99 per cent of the time.” But Rootman thinks IntraLase can do much more than get people out of glasses; he sees it as the future of ophthalmology: “I think in five years, all corneal surgery will be done with the laser, we won’t be using knives at all.” Already, he has performed 10 corneal transplants using IntraLase, operating on patients from his practice at the Toronto Western Hospital in his private clinic, as part of a study. “Those patients are only a couple of months out now,” says Rootman, “but I’m convinced that it’s going to be way better for patients compared to the standard.”

And that’s not the only way in which laser eye surgery, traditionally thought of as “cosmetic” because it eliminates the need for glasses, is increasingly becoming an adjunct to medically necessary procedures. For example, in order to work properly, the new

multi-focal lens many cataract patients are now having implanted requires the removal of any residual refractive error. “The combination of intraocular and laser refractive surgery has become the state-of-the-art care for many cataract patients,” says Avi Wallerstein, director of Lasik MD.

HOW MUCH?

LASIK procedure

With IntraLase $2,400 to $2,500 per eye (at Yonge Eglinton Laser Eye Centre)

With microkeratome $490 to $1,750 per eye (at LASIK MD)

—D. I.

FAMILY PHYSICIANS

Membership has its privileges

Currently, 3.9 million Canadians are without a family doctor. The situation has steadily worsened in recent years, and is more acute in rural Canada.

There have been a number of developments in the private sector helping patients who need a GP. Some clinics have expanded their services beyond the traditional doctor’s office. At the Mom and Baby Depot in Whitby, Ont., a membership fee allows the clinic to provide services that are not covered in the public system. There are free parenting classes, nutritional counselling, 24-hour access to a physician, and the promise of a next-day appointment with a doctor when your child is sick.

A pediatric team guarantees nine one-hour appointments for the first year of a baby’s life. For parents who have questions in between, there are open phone lines each morning with a nurse or doctor. Colicky child?Workshops offer tips to soothe a crying baby. Insomnia? There are sessions on infant massage to calm a child before bedtime (and parents receive discounts when their own muscles need a kneading). Clients who don’t want to pay the membership fee can access the walk-in clinic or the sessions on a pay-as-yougo basis.

In Toronto, Scienta Health gears its preventive doctor’s service to baby boomers. For an annual fee of $2,500 upwards, patients receive a personalized health and wellness program, with a naturopathic doctor and fitness trainer providing a tailored diet and fitness plan. There is high-quality, responsive primary care on demand, with a 24-hour phone line to reach a doctor. Don’t want to wait in line for specialist care in Canada? Want a second opinion on the latest cancer drugs? Scienta also has a concierge service that will fix you up with leading hospitals and experts around the world and walk you through the health care maze.

In Quebec, where a record 125 doctors have opted out of medicare, there are a growing number of clinics providing tailored GP services. Medisys, the executive health provider to former prime minister Paul Martin, offers a health care concierge service similar to Scienta Health’s. Clinique Medi Club du Sanctuaire, which reportedly treated current Quebec Premier Jean Charest, provides mobile blood tests and an on-site surgical clinic. Remember Dr. Jacques Chaoulli, the plaintiff who challenged the Quebec health laws at the Supreme Court? He’s in the process of setting up a medical group, where members will be able to access appointments with doctors for a $40 yearly membership fee. Patients will also be able to access specialists for about $200 per consultation. Chaoulli plans to roll out this new service in Quebec City and Montreal this summer.

HOW MUCH?

Mom and Baby Depot

$1,200 membership for moms and babies

up to a year

Scienta Health

$2,500 to $10,000 a year

Chaoulli Group

$40 annual membership

$100 to $150 for an appointment with a GP

$200 to $300 for a specialist appointment

-AS.

SURGICAL

It’s worth the drive to Montreal

RocklandMD is a large private hospital, with five operating rooms, that opened at the beginning of this year. Located in Montreal, it has a number of specialties, including orthopaedics; general surgery; ear, nose and throat; colonoscopies and gastroscopies. Since it openly bills both patients and the Quebec government, it has come to represent a new form of “hybrid” health care proliferating on the Canadian medical landscape.

Most of these “hybrid” clinics operate in Quebec, a province that has encouraged the development of private medicine with recent changes in legislation. (Bill 33, for example, enacted in December 2006, allows patients and the province to split the cost of surgery.) With these changes, Montreal has become a destination city for Canadians seeking quicker surgery in the private sector. Many travel to the Duval Orthopaedic Clinic in Laval for full hip replacements, the only place in Canada where patients can pay for these complex surgeries. Others go to the André Perreault Clinique de chirurgerie du pied de Montréal, which specializes in lower and upper extremities, including hands and ankles. In total, Quebec has six surgical clinics, second only to B.C. with 12. As a result, westerners tend to fly to Vancouver for speedier treatment, and Canadians in other parts of the country often go to Montreal. It’s medical tourism, homegrown.

HOW MUCH?

Patients are charged according to the complexity of the operation. Below is a selection of procedures; prices may vary depending on the clinic.

Ankle replacement $17,000 to $20,000

Spinal surgery $8,000 to $16,000

Partial knee replacement $11,500

Hip arthroscopy $7,000

Shoulder dislocation repair $5,000 to $8,000

Gallbladder removal $3,800

Hernia repair $3,000

Hysterectomy $3,000

Cataract $950 to $1,200 (per eye)

-AS.

CANCER

More tools to fight cancer

To put it bluntly, Canada’s policy on cancer drugs is a mess, says Dr. Kong Khoo, a medical oncologist in Kelowna, B.C., who co-wrote this year’s Cancer Advocacy Coalition of Canada report on access to drugs and funding. Canada has no national drug policy for cancer care but instead relies on a motley mishmash of arcane rules and inconsistencies. For example, Erbitux, which is an expensive but occasionally effective new drug for fighting advanced colon cancer, is covered on a caseby-case basis under the provincial health insurance plan in New Brunswick, but not at all in Ontario or other provinces. Some cancer treatments are covered strictly for seniors, although research shows these drugs would be just as effective in a younger demographic. Other drugs are available only at certain hospitals. “It’s ridiculous sometimes how new

cancer drugs are vetted or provided,” Khoo continues. “It has nothing to do with the disease or the potential benefit to the patient.”

Another problem is the lack of access to the most up-to-date equipment. Positron emission tomography (PET scans) is widely recognized as the best way to pinpoint where the cancer has spread. However, while the rest of the world has used these machines for the past decade, their usage is restricted in most provinces. Some justify their decision because of the cost. The Ontario government takes a different tack. It says the technology has not yet been proven, although this stance is at odds with decades of international research and clinical validation, says Dr. Jean Luc Urbain, president of the Canadian Association of Nuclear Medicine. In Ontario, medical trials are ongoing. When they will end has yet to be decided.

Patients who are not satisfied with these explanations and want to better their chances of surviving cancer have a number of options.

SCREENING TOOLS PET scans

There are four private PET scanners in Canada-two in Montreal, one in Vancouver, and one in Mississauga, Ont. The Mississauga

location fuses the images from PET scans, CTs and MRIs, which is the most advanced form of this technology.

HOW MUCH?

PET $2,350 to $2,850

Virtual colonoscopy

Colorectal cancer is the second leading cause of cancer deaths in Canada. It is also highly curable, if caught early. Tumours begin as polyps, or growths, that usually remain precancerous until they reach about a centimetre in size. Generally, it takes polyps about 10 years to reach this mass, so there is plenty of time to remove them before they spread.

Currently, there are two ways of screening for colon cancer. In a colonoscopy, patients receive some form of sedation, such as Valium, and then an optical scope is inserted into the colon to search for growths. This test is highly accurate, if a little uncomfortable. There is a very small chance of bowel perforation. The other test, the fecal occult blood screen, checks whether there is any blood in a patient’s stool. Polyps are more likely to bleed once they reach the cancerous stage. On the upside, this cancer screen is convenient, and extremely easy to use. However, since not all growths bleed, it doesn’t always

catch the early warning signs.

The virtual colonoscopy is a new screening tool just being introduced to Canada. It creates an image of the whole of the large intestine using a high-definition CT scanner. The most recent data suggests it is about as accurate as the standard colonoscopy, and it doesn’t require the insertion of a lengthy anal scope.

HOW MUCH?

Virtual colonoscopy $1,400

DRUG ACCESS

Patient assistance programs

Most drug companies have some form of patient assistance program, which supplies medications that aren’t covered by medicare. Each company sells only those drugs it produces. For example, Arimidex for breast cancer is sold by Delaware-based AstraZeneca. The Roche Patient Assistance Program is the exception, because it administers non-Roche products. These drugs can be expensive, but patients who can’t afford them may be meanstested, or the drugs may even be provided free of charge on compassionate grounds.

Drug companies will only supply medications that have been prescribed by the patient’s oncologist. Some drugs need to be administered through an intravenous drip; a few firms have their own infusion clinics for chemotherapy injection. These programs won’t deal with patients directly—a family doctor or oncologist must make the call.

Infusion clinics

Drugs that aren’t available publicly can be bought through private infusion clinics. There are a number of these centres in Canada, including the Toronto-based Provis Infusion Clinic and the False Creek Surgical Centre in Vancouver. At both locations, on-site oncology nurses or doctors oversee the treatment.

HOW MUCH?

Provis Infusion Clinic Avastin for colorectal cancer $3,500 to $6,000 a month Zevalin for lymphoma (includes two infusions of Rituxan) $35,000 total cost Abraxane for breast cancer $2,800 every three weeks

Some insurance policies pay for cancer drugs that are not covered by medicare. Check with your provider.

OTHER TREATMENTS ChemoFit

Introduced to Canada last fall, this therapy removes a small sample of the cancerous tumour and sends it to an Amherst, N.Y., lab for analysis. The biopsy is tested against different chemotherapies to determine which

best destroys the patient’s cancer cells. At present, only Toronto-based Medicor offers ChemoFit. Lab results take about a week.

HOW MUCH?

ChemoFit $2,500

HIFU

High-intensity focused ultrasound (HIFU) is the most advanced treatment for prostate cancer. With the patient under anaesthetic, a rectal probe fires focused ultrasound waves at the prostate, burning off the cancerous tissue without damaging the surrounding organs. The operation takes less than three hours—compared to weeks of radiation—and doesn’t have the risk of incontinence and impotence as from a radical prostatectomy.

HOW MUCH?

HIFU therapy $21,930

Care management

Launched in May 2006, Medicor Cancer Centres aim to smooth the gaps in cancer care in the public system. Clients receive an electronic version of their medical file, and regular appointments with family doctors, naturopaths, dietitians and counsellors to manage treatment and provide supplementary care. GPs are available 24/7 to answer patient questions, and help them navigate through the maze of public and private options. Second opinions with U.S. oncologists can also be arranged through this Toronto-based firm.

HOW MUCH?

For $250, prostate cancer patients receive a consultation with a family doctor and urologist and an electronic version of their

health record.

For $1,200 a month,

patients receive regular appointments with a GP, naturopath, dietitian, physiotherapist, massage therapist, counsellor, and management of their electronic medical records. Patients have the choice of opting out of some of these services.

MedExtra

This care-management company arranges consultations with U.S. oncologists and helps the patient’s Canadian doctors put these plans in place. MedExtra uses facilities such as the DanaFarber Cancer Institute in Boston or the Sloan-Kettering in New York for specialist second opinions. “The problem with cancer care in Canada is that our oncologists have adapted their care according to the scarcity of resources,” says Jeffrey Brock, founder of MedExtra. “They are constrained by the scarcity of the most cutting-edge drugs.” The company also arranges importation of drugs that have been approved by Health Canada but are not yet funded by medicare.

U.S. treatments

A number of centres facilitate cancer care in the United States. M.D. Anderson has a Toronto office that arranges appointments at its Houston hospital; Medcan is partnered with Johns Hopkins for treatment in Baltimore. Several executive health providers, such as MedExtra, Medisys and OneWorld, arrange for second opinions in U.S. hospitals, and follow up stateside if necessary. These firms usually offer discounts on the cost of care in the United States.

HOW MUCH?

The cost of cancer care in the U.S. can vary widely—from US$30,000 to US$1 million.

Reimbursement lawyers

Patients who have cancer treatments in the U.S. sometimes receive medical reimbursement from their provincial authority. There are a number of rules to qualify, though these may vary from province to province. Generally, the treatment must be unavailable in Canada, medically required, not experimental, and prescribed by two physicians. Even if a patient meets the criteria, this route can still take months of battling with government boards. However, in recent

years this path has become more popular and there are a number of lawyers willing to take on such cases. (See medical directory, page 57.)

—A. S.

SPECIALIST

Need a referral? Not a problem.

Stories about waiting for surgery rarely make the news. It’s hard to write an article about an event where nothing happens. However, for the more than 770,000 Canadians who are on a wait list to see a doctor or for treatment, waiting is news: the pain they are suffering can dominate their entire life.

Canadians who don’t want to put their lives on hold for a fixable medical problem have a number of options. In Vancouver, there is the Specialist Referral Clinic. Patients can phone the centre and tell the receptionist what kind of doctor they would like to see. If patients don’t know what sort of specialist they need, they can consult with a GP. Appointments with any type of doctor, from otolaryngologists, ophthalmologists and urologists to cardiologists can be arranged. A referral from your GP is not necessary. All the doctors are based in British Columbia and most are in Vancouver.

In Toronto, the executive wellness provider Medcan offers a similar service. It cannot guarantee a doctor’s appointment within a set period of time, but it promises to expedite access to Ontario doctors. The medical travel company OneWorld guarantees an appointment within three weeks for most specialties in Alberta, British Columbia and Manitoba,

with plans to expand nationally by the end of the year. Currently, this option is available only through employee insurance plans.

MedExtra offers expedited access to specialists across Canada as part of their caremanagement program. Patients consult with a MedExtra doctor, the relevant medical information is gathered and summarized and diagnostic tests are arranged if necessary. Then MedExtra finds a specialist in Canada— or the United States if requested—who can slot the patient in. The total service costs $180 per hour of MedExtra’s time.

WAIT TIME

Private: Up to three weeks Public: Varies widely depending on the province and specialty. For example, neurosurgery has the longest national average wait times from GP referral to specialist (21 weeks for an appointment),

followed by orthopaedics (16 weeks for an appointment). British Columbia and Ontario have the shortest median wait times for specialist appointments (seven weeks).

New Brunswick has the longest wait lists (21 weeks for the first appointment).

HOW MUCH?

Specialist Referral Clinic $500 to $700 depending on the type of specialist M

-A. S.