Health Care Without Borders
Hospital executives from Detroit and Windsor are looking to create a free trade zone to streamline patient care, clinical trials, medical device development, and training. But not everyone is on board.
Two hospital CEOs, from opposite sides of the Detroit River, want to foster regional economic development by collaborating more closely on a variety of medical ventures — and get others from around the country and Canada to join them.
Dr. John Popovich Jr., president and CEO of Henry Ford Hospital, and David Musyj, CEO of Windsor Regional Hospital, are working to partner on cross-border training for students interested in various aspects of health care, medical device development, clinical trials, and physician training. They also want to promote medical tourism.
“The (initiatives) all center around medicine and education as an industry,” says Popovich, leader of Ford’s 877-bed tertiary care, education, and research complex in Detroit’s New Center area. “It’s an industry that offers definite opportunities for development.”
The CEOs have been promoting their ideas to create a sort of “medical free trade zone” between the two cities in high-level private meetings. Their timing may be perfect; both home cities are looking to diversify their respective economies and fill gaps left by job losses within the automotive and manufacturing industries over the last decade. The climate may also be spot-on for regional cooperation as problems become too big or too expensive to solve alone.
“It’s no secret that the economy in places like Detroit and Windsor has taken quite a hit with the loss of manufacturing jobs,” says Gerry Cooper, associate dean of the Schulich School of Medicine and Dentistry-Windsor program at the University of Windsor.
The hospital leaders say they want to capitalize on the strengths of their respective areas as well as their close geographic proximity, despite flying different national flags.
“From my point of view, our (greater) region is unique in the sense that it has an international border that’s easy to reach, and (there are) health care and training institutions on either side of that border,” says Musyj, who has a dual U.S.-Canada law degree and holds citizenship in both countries.
Windsor Regional is one of the largest community-based, nonacademic hospitals in Ontario, offering around 650 beds in two locations — the Metropolitan and Ouelette campuses — that are about 10 minutes apart. The hospital had a $6.2 million deficit on revenue of $409 million in its 2014 fiscal year, which ended March 31, due to a one-time transfer of programs and services from Hotel-Dieu Grace Healthcare.
Collaboration between the hospitals is not unprecedented. For years they’ve co-hosted an annual patient safety symposium and they have shared patients with heart attacks.
For those in both Detroit and Windsor, cross-border familiarity goes well beyond education and health care. It includes international industries — particularly automotive — and, more informally, the cities’ cultures. Popovich and Musyj hope to build on the existing cross-border relationships to create a regional medical hub for economic development. “If there wasn’t a border, we’d be doing this today,” Popovich says. “(But) I have to say that we haven’t gotten as much traction (in the U.S.) as (they have in Canada). We’ve not had a ton of interest on this side.”
Economic Development 2.0
Although it may seem unusual for a hospital to be engaged in economic development, Henry Ford — whose parent, Henry Ford Health System, had net income of $500,000 on revenue of $4.5 billion in 2013 — has been doing exactly that for a while.
The hospital hired 75 Detroiters through a partnership with Detroit Employment Solutions Corp., and helped prepare and is starting to implement a master plan to redevelop the neighborhood — including an expansion of Henry Ford’s facilities — immediately south of the hospital. The neighborhood redevelopment includes a new distribution center for Dublin, Ohio-based Cardinal Health, which next summer will relocate from Romulus to Detroit, bringing with it 140 jobs.
Henry Ford Health System also is quite methodical in its approach. It partnered with Wayne State University and the Detroit Medical Center to employ a coordinated anchor strategy focused on stabilizing and fostering economic development in nearby neighborhoods, according to a case study on the U.S. Department of Housing and Urban Development’s website. Cross-border economic development is occurring elsewhere in Detroit.
The University of Windsor’s Odette School of Business is a “very deep and respected partner” of TechTown Detroit, says Leslie Smith, president and CEO of the business and innovation hub at the north end of Wayne State’s campus. Each semester, up to 40 students finishing their master’s degrees in business administration at the Canadian university work on their capstone projects by helping TechTown clients solve problems.
As part of a capstone project two years ago, MBA students designed an entrepreneurship curriculum for high school students.
Some Detroit public schools have implemented the resulting program, known as YouThrive.
“They’re just an extraordinary partner and have always known that a cross-border collaboration was crucial to their success,” says Smith of the university’s business school. “It is a true gift to us.”
Smith goes on to say that cross-border collaboration in medical device development is of particular interest to her because of its potentially huge economic impact on the region and for her startup clients.
Doctors Without Borders
Part of the hospital CEOs’ vision is that students pursuing degrees in health care — doctors, nurses, respiratory therapists, and others — will cross the Detroit-Windsor international border for their clinicals, or the in-hospital training period when they work with patients.
Some of the first students to participate may be those from the Schulich School of Medicine and Dentistry. The program is a “distributed campus” arrangement, with students enrolled at Western University in London, Ont. but attending classes at the University of Windsor.
Cooper, the associate dean, says talks are “pretty intensive” to partner with Henry Ford. He’s also talking with other potential partners in metro Detroit that he declined to identify. “For us, the first step is to look at formalizing some kind of agreement with a Detroit-based organization,” Cooper says.
The associate dean ticked off some of the benefits a collaboration with Detroit would offer his students, including an opportunity to experience a different health care system and working with a broader range of patients. The collaboration would also enhance his school’s status and its ability to attract the best students.
“It helps to differentiate medical education in Windsor-Detroit from anyplace else in America,” he says.
One program that is mentioned repeatedly is a dual-degree law program at the University of Detroit Mercy School of Law. Its graduates — Musyj is one — are qualified to practice in both the United States and Canada.
Dave Campbell, a Canadian who is also a partner at the Bowman and Brooke law firm in Bloomfield Hills, started work on a UDM dual degree in 2001 and carpooled with a handful of fellow students to attend classes in Detroit.
“Because the law schools are literally five minutes away, the students could be in Windsor in the morning and Detroit in the afternoon,” Campbell says.
To make crossing the border easier, Campbell and his fellow students got NEXUS cards, a U.S. Customs and Border Protection program that enables low-risk travelers to enter the United States in an expedited fashion. The card confers broad border-crossing privileges and acts as a substitute for a passport for U.S. and Canadian residents.
Other issues for streamlining cross-border student visits include determining how the federal government would classify the hands-on training, who would process the paperwork, and how to get a visa for a clinical rotation that lasts just a few months.
“The government isn’t used to that short of a period of time,” says Alison P. Shurtleff, an immigration lawyer with the Washington, D.C., office of Detroit-based Clark Hill. “I don’t know if they would consider that studying.”
The most likely visa would be the J-1, Shurt-leff says; it’s the type that’s obtained by all foreign doctors-in-training who come to the United States for postgraduate medical training, which lasts a year or more.
Hospitals are familiar with the visa process because of the postgraduate fellows and residents who come to them from other countries. They work with an independent agency — the private, nonprofit Educational Commission for Foreign Medical Graduates, which is authorized by the State Department to issue visas for advanced education.
“But there’s no organization approved by the Department of State for a medical exchange between the U.S. and Canada (like the CEOs describe),” Shurtleff says.
Popovich’s idea for cross-border clinical trials helped him recruit one of the hospital’s leading heart specialists to Henry Ford’s staff two years ago.
Dr. William O’Neill says doing clinical trials in Windsor was a big reason for him to come back to Michigan from the University of Miami (Fla.) School of Medicine, where he was dean of research. O’Neill was previously at the University of Michigan and Beaumont Health System in Royal Oak.
The interventional cardiologist is a leader in the advancing technique of catheter-based heart valve replacements. He says the United States is about three years behind Canada in the development of such devices, and he wants to give his patients access to the more advanced technology. He’s obtained a license to practice medicine in Ontario, is credentialed at Windsor Regional, and wants to test a mitral valve replacement from Neovasc, which is headquartered in British Columbia.
O’Neill may want to compare notes with two executives at Cook Medical in Canada, who also know about the difference between the United States and Canada when it comes to getting new medical devices to market.
“Generally, things are quicker here,” says Bill Bobbie, president of the Stouffville, Ont. Cook facility that’s part of the Bloomington, Ind.-based Cook Group, maker of diagnostic and therapeutic medical devices. Bobbie’s colleague, Greg LeBlanc, agrees, but also says, “Based on my experience, the ease of dealing with the two agencies when it comes to submittals is pretty much the same.
“But philosophically, I think Health Canada operates significantly differently,” says LeBlanc, who is Cook Canada’s manager of regulatory affairs and quality systems. “They’re more collaborative, more streamlined.”
In some ways, Health Canada and the U.S. Food and Drug Administration, the national agencies that oversee medical devices, are very much alike, especially regarding clinical trial data. And both agencies look for competent investigators and good infrastructure at facilities where human trials take place, LeBlanc says.
But there are substantial differences in the amount of time and difficulty between gaining approval in Canada and in the United States, LeBlanc says. It may take 90 days for the approval of a device in Canada; in the United States, it may take the FDA six months or more to approve an equivalent device.
To illustrate the difference, LeBlanc cites Cook’s Zenith endovascular graft. The graft is an artificial blood vessel that’s deployed via a catheter inside an aorta that has an aneurysm, where the vessel wall has thinned and bulged outward, threatening to break.
Because of the lengthier clearance process and the FDA’s “onerous” requirements for clinical trial data, American patients are receiving an earlier generation of the graft than their Canadian neighbors. The difference is important because technological and engineering
improvements that are applied to later generations make them safer for patients — which means U.S. patients aren’t benefiting from
Cook executives won’t go so far as to agree; they prefer to say the improved version allows doctors to treat a wider variety of patients.
Different approval regimens aside, researchers like the idea of having 20 years’ worth of uniform, centralized medical records on hand, thanks to Ontario’s universal health care program. Popovich envisions cross-border, population-based studies using huge data sets that include information on Ontarians and Detroiters.
“We breathe essentially the same air, we drink the same water,” he says.
Need New Hip, Will Travel
The area where the visionary CEOs may get the most backlash is in medical tourism — specifically, the kind that brings economically-minded U.S. residents to Ontario looking for cheaper MRIs and CT scans.
Ontario’s Deputy Premier Deb Matthews, who was health minister prior to elections earlier this year, told The Globe and Mail newspaper in April that she wanted an informal review of medical tourism to ensure that no public money goes into the care of patients coming from outside the province, that no Ontario residents wait longer for care as a result, and that any revenue generated from foreign patients goes back into the government-run system.
“We have to make sure that we can be very, very clear and demonstrate that this is a benefit to Ontarians,” she told the newspaper. “If we can’t demonstrate that, we won’t be doing it.”
Also in April, five Canadian health organizations representing health centers, doctors, nurses, midwives, and health reformers took an even stronger anti-tourism position. They wrote to Ontario Premier Kathleen Wynne calling for an outright ban on medical tourism in response to news reports of several hospitals in London and Toronto openly soliciting foreign patients.
“The public wants, and needs, a clear signal from (the provincial government) that it is not ‘open season’ on our operating rooms and clinical facilities,” according to the letter. “By taking a hands-off approach when public hospitals announce plans to offer fee-based medical services to foreign patients, Ontario risks stepping onto a slippery slope toward a two-tier system of health care, where a parallel for-profit system provides care to those who can afford to pay,” the letter read.
Doris Grinspun, CEO of the Registered Nurses’ Association of Ontario, one of the five groups who sent the Wynne letter, confirmed that the provincial government is still reviewing medical tourism and says the five organizations still oppose it.
“We absolutely do not oppose some of what (the CEOs) describe, such as joint research. We aren’t opposed to educational exchanges, but we do oppose the issue of providing care for a fee,” she says. “Medical tourism is a concept that will benefit only those who have the means, or those in such dire conditions that they will sell what they have to get to the front of the line.”
The situation is different for Canadians seeking medical care in Detroit, however. They do so either because they want to reduce long wait times or for emergencies.
When someone in Windsor has a heart attack and every minute counts, the Detroit-Windsor Tunnel allows ambulances to whisk patients to Henry Ford for balloon angioplasty, the current gold standard for care. Henry Ford treated about 100 such Canadian patients in 2013, but Windsor Regional hopes to have the necessary staff and facilities available 24/7 to treat local heart attack patients itself in little more than a year.
Other Canadian patients intent on receiving care more quickly cross the border for orthopedic surgeries on their knees, hips, and backs; pediatric procedures; women’s operations such as hysterectomies; and issues that require a multidisciplinary approach, says Kelly Meloche, owner of International Health Care Providers in Windsor.
Of the approximately 400 Canadians that her medical tourism firm helped find care abroad in 2013, Meloche estimates that about 60 percent saw doctors in Detroit.
Others also mentioned Canadians driving to Detroit for second opinions, cancer treatment, and participation in clinical trials, which are more plentiful in the United States.
A Deloitte 2008 survey of Canadian health care consumers showed that 17 percent would pay out-of-pocket for an elective procedure in another country, and 59 percent would do so if the government paid their expenses, although only 2 percent had done so.
However, for a necessary procedure, 23 percent said they would travel abroad and pay for it themselves, while 62 percent said they’d do it if the government paid. “There’s a shift in culture with Canadians looking for health care options, and it’s not just the wealthy,” Meloche says. “They’re saying, ‘I can’t wait.’ ” db