The Pain-Racked Patients Alberta’s Orthopedic Surgery Centre Won’t Take

Don MacKinnon has been a farmer his entire life. Up until last fall, the 82-year-old still helped with the harvest, driving a combine on his family’s grain farm near Sedgewick, Alberta, two hours southeast of Edmonton.

But for months now, his days have been spent in his darkened living room, lying on his couch with one leg propped up to take pressure off his hip in an often futile attempt to reclaim the sleep that intense pain denies him at night.

“He is depressed, and he is frustrated,” his daughter Sheila said. “When you look at my dad's decline over the last six months, it's unbelievable.

“He is no longer driving. He barely gets off the couch because he is in so much pain. He can't walk with a walker more than 20 steps before he has to sit down.

“If he had surgery when he was supposed to, that would not be the case today.”

MacKinnon is one of more than 1,400 complex surgical patients on a waiting list at the Orthopedic Surgery Centre, or OSC, a 56-bed stand-alone clinic operated by Alberta Health Services at the Royal Alexandra Hospital in Edmonton.

First referred to a surgeon in January 2022, the octogenarian still had not had surgery when he developed heart problems in October 2023. That knocked him off the waiting list until November 2024. Six months later, he is still waiting with no date in sight. Others have been on the waiting list for more than three years, with some forced to access hospital emergency rooms for pain management.

The OSC has been closed since July 2024 to patients like MacKinnon who require intensive overnight care after orthopedic surgery. It won’t operate on them because of an ongoing impasse between Edmonton’s orthopedic surgeons and Alberta Health Services, or AHS, over staffing costs that essentially represent a rounding error in Alberta Health’s massive budget.

The Tyee has obtained a copy of a proposal produced by the surgeons to reopen OSC. It calls for an additional $975,000 in annual funding, which is 0.003 per cent of Alberta Health’s $28.4-billion budget for 2024-25.

Still, senior health officials, backed by Health Minister Adriana LaGrange, have insisted the clinic will not resume serving complex surgical patients unless the surgeons’ proposal is cost neutral.

High private surgery fees for ‘cream’ patients

“Cost neutral? What do they think that means from a patient’s perspective?” said Sheila MacKinnon. She can’t fathom why LaGrange is holding the line over less than a million dollars after the United Conservative Party government wasted $70 million on children’s pain medication from Turkey.

Sheila is fully aware that while the OSC sits idle for patients like her father, Alberta Surgical Group, a private, for-profit chartered surgical facility in south Edmonton, is performing dozens of hip, knee and shoulder day surgeries each week, under contract to AHS.

Health policy experts refer to Alberta Surgical Group’s patients as the “cream” of the health-care system — otherwise healthy people without co-morbidities who don’t normally require overnight, intensive post-surgery care.

The Globe and Mail obtained internal AHS documents that showed existing and proposed Alberta Surgical Group facilities were negotiating surgical procedure fees nearly double those of other chartered surgical facilities, which were also higher than the cost to perform those surgeries in a public hospital. LaGrange and Alberta Surgical Group have disputed those figures.

Sheila noted that the stated mission of AHS is to provide access to quality health care to all Albertans. LaGrange, she said, “has eliminated the accessibility for all those patients on [the OSC] waiting list.”

The unwillingness of AHS and LaGrange to increase funding by a relatively small amount to a public facility meant to serve complex patients — while allegedly paying inflated procedure fees to chartered surgical facilities — appears to validate the warnings issued by critics before the UCP launched, in 2019, its Alberta Surgical Initiative, an ambitious plan to expand private surgical delivery.

Based on historical evidence from other jurisdictions such as the United Kingdom, the critics warned there would not be enough surgeons, anesthesiologists and surgical nurses for both public and private surgical delivery.

They warned that chartered surgical facilities would starve the public system, increasing wait times not just for complex orthopedic patients but also for other surgeries, including for cancer — which is exactly what a recently released report from the University of Alberta’s Parkland Institute concluded.

In August, AHS rejected a previous proposal from the surgeons that would have cost $240,000 a year. The surgeons conducted more research and in March submitted a higher-cost proposal they contended would result in cost savings in the long run and better outcomes for patients.

The proposal recommends 24-hour patient-care coverage, employing three shifts at a cost of $325,000 per shift annually for a total of $975,000. The surgeons contend this amount could be covered by cutting another program.

Switch from ‘clinical assistants’?

In Edmonton, orthopedic surgeons are often peripatetic, operating in several hospitals and private facilities, sometimes on the same day. It is impossible for the surgeons to care for their patients after surgery, and, in fact, it’s not best practice because surgeons have a narrow skill set.

Orthopedic surgery patients who require an overnight, or several-night, hospital stay in Edmonton are monitored by “clinical assistants” who are supervised by a physician. They are often international medical graduates, hoping to get accredited in Alberta.

The surgeons’ proposal said the clinical assistant program has become a revolving door with high turnover and inconsistent coverage. Six funded positions in orthopedics at the Royal Alexandra Hospital have never been fully staffed for most of the nine years the program has existed.

The report proposes ending that program and shifting the funding to fully licensed doctors who would work at the hospital, termed hospitalists.

“Those physicians can ensure timely discharges, daily followups on labs and imaging, and proactive management of any medical issues — tasks that simply aren’t possible at the often 75[-to-one] current staffing ratio.

“In essence, the funding would be used to fix the root problem — lack of hands-on providers — rather than patch it with temporary measures.”

The surgeons’ report cites several studies that show the return on investment in hospitalist-led care — better outcomes, shorter stays, cost savings per patient — far exceeds the status quo. The proposal claims that if the three-shift plan were implemented, it could support the completion of 15 to 20 procedures a day, Monday to Friday, with the possibility of expanding the surgeries to weekends and evenings.

Currently OSC performs four orthopedic surgeries a day and some urology surgeries, none of which require overnight stays.

In an emailed statement, LaGrange’s press secretary indicated the proposal has so far not been accepted.

“Alberta Health has committed to working collaboratively to resolve this issue and has provided options to find a solution through established processes under the Alberta Medical Association Agreement, as well as in accordance with the advice from the senior medical leadership team at AHS.”

‘Undermining’ a solution ‘for peanuts’

Steven Lewis has more than 45 years of health-care policy and consulting experience, including as an adjunct professor at the University of Calgary.

Lewis said the creation of the Orthopedic Surgery Centre in 2010 was an overdue, evidence-based step in the right direction: it is a stand-alone hospital built specifically to facilitate high-volume surgery to achieve economies of scale, adjacent to acute care at the Royal Alexandra Hospital if it is needed.

“So they did that, and now they are essentially undermining it — and for peanuts,” Lewis said, adding that leaving the OSC closed for months while hundreds of patients suffer is “literally incredible.”

Lewis said hospitalists in Canada are typically general practitioners, of which there is already an acute shortage in Alberta. He questions whether “siphoning off” more of them to work in hospitals would benefit the overall health-care system, and he said there are differing views on whether hospitalists offer good value for money.

The surgeons’ proposal mostly cites U.S. studies, which Lewis said may not be entirely applicable in Canada. “Another, more durable and systemic approach might be to train more clinical nurse specialists to provide the pre- and post-surgical care for inpatient cases,” Lewis said.

“Nurses provide the bulk of care on medical wards where patients are even more complex and may have a wider variety of risk factors. There is no self-evident reason why they cannot provide the required surveillance, monitoring and risk detection on a specialized surgical unit where the patients may be somewhat less complex.”

Dr. Braden Manns of Calgary, a former AHS vice-president, said Lewis’s assessment of the value of a specialized public surgery clinic like OSC is “completely right.”

“With not-for-profits, you get to own the entire surgery procedure from start to finish and you get to design operating rooms specifically for hips or just for knees,” he said.

It also avoids the possibility, Manns said, of the sort of scandal that has now resulted in several investigations related to Alberta Surgical Group. The investigations are based on unproven allegations contained in a wrongful dismissal lawsuit filed by former AHS CEO Athana Mentzelopoulos.

Manns left AHS more than 18 months ago, so he doesn’t know why LaGrange is not funding the OSC. But he suspects Alberta Health is attempting to create a uniform program for hospitalist care for every type of patient, including post-orthopedic surgery patients.

Sheila MacKinnon’s mother, Pat, a retired nurse, met with their UCP MLA on Friday. Sheila isn’t holding out much hope it will hasten the surgery her dad needs to live out his remaining days free of pain and suffering.

“They don't care and they won't care until somebody in their family ends up in the same position,” she said.

“I say to people: Health care isn’t free. You pay for it with your taxes. My dad paid his taxes all his life and look what he gets from it. And there is no accountability.”

If you have any information for this story, or information for another story, please contact Charles Rusnell in confidence via email.