Private MRI, public problem

Our reporter paid $1,500 for a scan. Why these procedures aren't always good for patients — or our healthcare system

A small knot began to form in my stomach as the technician strapped my arms and legs down to the bed.

My pulse began to quicken at the thought that I was about to be inserted on my back into a narrow, cylindrical tube about two feet in diameter.

I wondered if the technician, as friendly as he was, could see my eyes bulge slightly when he placed an airfilled ball in my hand and told me to squeeze it “in case of an emergency.”

A moment later, I was slowly conveyed horizontally into the open mouth of the gleamingwhite MRI machine.

The Star had paid $1,500 for me to get a “Liver Fat Quantification MRI” that was supposed to tell me how much fat was inside my liver cells, a potential sign of nonalcoholic fatty liver disease.

The goal was not to monitor the health of one of its reporters (though that was a potential benefit), but to get a better understanding of whether the growing number of private, forprofit healthcare services in Ontario is good for patients, good for doctors and good for the overall health and welfare of Ontarians.

On the one hand, proponents of private health care argue that allowing patients to pay for treatment out of their own pockets helps to reduce wait times and crowding in the publicly funded system.

But a growing chorus of healthcare professionals say they are concerned that forprofit services, such as those offered by private imaging clinics, will do the opposite.

Many doctors are particularly concerned about fullbody MRI screening, which they say is problematic because it can raise false alarms that send patients back into the overburdened public health system for a litany of followup tests that studies have shown mostly come back clean.

There are also concerns that the rules and ethical guidelines governing how forprofit health companies operate are incomplete and out of date, leading to situations such as the one I encountered, where a clinic paid a practising doctor to provide a referral, and he did so — without ever meeting or talking to me.

If I'd paid out of my own pocket, I would emerge from the procedure $1,500 poorer — but would it be worth it? Would I gain critical insight into the state of my health that the public system, strapped as it is, just couldn't provide? And if enough Ontarians did the same, would we all be healthier?

I was on my way to finding out. Once fully inside the MRI machine, the air was filled with a loud, highpitched electronic buzzing, like the sound of those old dialup modems, only an octave lower. I was grateful for the earplugs the technician had advised I wear.

A man's prerecorded voice told me to perform repeated breathing

The Star covered the cost of a private MRI scan to get a better understanding of whether the growing number of forprofit healthcare services in Ontario is good for patients. Here's what we found

exercises in which I had to hold my breath for about 15 seconds. This went on for about 25 minutes, followed by some loud clicking noises.

And then it was over.

`Miraculous' new test

The idea of fullbody scans entered the public consciousness about 25 years ago when Oprah Winfrey devoted an entire show to what she called a “miraculous” new test that could allow doctors to see inside patients' bodies and find illness “long before you can feel any kind of sickness.”

The problem with these early fullbody procedures was that they were done using computed tomography (CT) scans, which subject the body to hundreds of times more radiation than regular chest Xrays.

But as technology improved in the ensuing years, some doctors and entrepreneurs realized that a newer procedure, called magnetic resonance imaging, or MRI, could be an untapped gold mine. After all, what could be more alluring than the promise to catch harmful disease, like cancer, early?

MRI machines don't use radiation, but rather much less harmful magnetic fields and radio waves, to produce highresolution images of the inside of the body.

One company capitalizing on the popularity of MRI scans is Prenuvo. It has clinics in more than a dozen cities in North America, including one in Vancouver. Prenuvo also has its sights set on Toronto, where the company says more than 10,000 people have signed a waitlist on its website.

Andrew Lacy, founder and CEO, says that of the “tens of thousands” of scans Prenuvo has done, “approximately five per cent” of patients have been alerted to potentially lifesaving diagnoses.

“Healthcare systems are reactive and as a result of being reactive, we catch disease late and it's expensive and leads to worse outcomes for patients,” he says over Zoom from Los Angeles, adding that now more than ever, patients want to “take control of their own health care.”

“They're willing to pay for it if it means they can better manage their own health.”

The company's Instagram account is a master course in online marketing, featuring health tips, feelgood mantras and glowing testimonials from celebrities like Kris Jenner, actor Tori Spelling and TV show host Maria Menounos. In Menounos's case, her Prenuvo scan detected a 3.9cm tumour on her pancreas that turned out to be stage 2 pancreatic cancer.

Last year, Kim Kardashian sung the praises of the Prenuvo procedure in an Instagram post to her 360 million followers, saying it “really saved some of my friends (sic) lives.”

But Prenuvo will be late to the party when it arrives in Ontario, where there are already a host of companies offering private MRI scans.

Some of these companies appear to be referral services for people seeking MRI or CT scans not only for diagnostics, but also legal and insurance reasons. You don't need to have anything wrong with you at all to book an appointment — but you do need a referral from a practising doctor.

There's Simply MRI, which offers “simple, fast and reliable private MRI scans for disease and cancer screening.”

There's Axxess Imaging, which says it can provide access to MRI and CT diagnostic imaging services within one to three business days with a doctor's referral.

A company called Ilumina says results can come “within 24 hours.”

MedCentra claims it is Ontario's “largest and fastest provider of nonOHIP, thirdparty MRI exams.”

Greater Niagara Medical Imaging owns a chain of clinics across the province and offers fullbody MRIs that it says can check the brain and neck for signs of cancer, aneurysms and “ischemic injury.”

It offers the procedure under the name “Whole Body MRI.”

That's the clinic I contacted for my procedure.

`A number of health risks'

There is no medical association in Canada or the United States that recommends privatepay fullbody MRI scans to screen for disease.

Health Canada warns that fullbody MRI screening “poses a number of health risks and offers no proven health benefits.”

The American College of Radiology, whose members are responsible for interpreting the results of fullbody MRI, says there is “no documented evidence that totalbody screening is costefficient or

While some Ontario patients with real medical issues are waiting as long as 99 days on average for an MRI under OHIP, I got an appointment for my medically unnecessary scan in a matter of days after entering my credit card number on a website

effective in prolonging life,” and warns that such scans could lead to the identification of nonspecific findings that will “not ultimately improve patients' health.”

The American College of Preventive Medicine bluntly advises “don't use wholebody scans for early tumour detection in asymptomatic patients.”

Timothy Caulfield, a health law professor at the University of Alberta who has researched the spread of misinformation for decades, says fullbody MRI screening is not supported by scientific evidence, nor ethical guidelines.

“I just think it's an inappropriate way to make money and it's built off of fear and a misleading concept of what screening can do for individuals,” he says.

Because MRI scans provide such highresolution images of our soft tissues, such as organs, blood vessels and lymph nodes, they can be a blessing if a doctor is trying to identify a specific suspected ailment in a symptomatic patient. But they also pick up every bump, scar or spot — normal or not — which doctors call “incidentalomas,” asymptomatic masses or lesions that are usually harmless.

“It's such a sensitive technology that you're bound to find something,” says Samir Gupta, a respirologist and associate professor at the University of Toronto. He's also a contributor to Choosing Wisely Canada, a group of medical practitioners aiming to reduce unnecessary tests and treatments. “Even though you know the chance of these incidentalomas being something significant is very low, once you know about it, you have to follow it up.”

A recent systematic literature review by a pair of radiologists in the Netherlands, where fullbody MRI screening is banned, analyzed 12 studies comprising the results of the procedure on more than 5,000 healthy patients. They found that the procedure found “abnormalities” in 32 per cent of the patients, but for most of these findings, “it remains unclear if they would lead to disease or death when left untreated,” said Thomas Kwee, coauthor of the study and a radiologist and associate professor at the University Medical Centre Groningen.

“Often you know already before you do the biopsy that this is nothing,” Kwee told the Star. “But you still have to do the biopsy.”

And that means the patient gets sent back into the public health system for tests, including CT scans, more MRI scans, or maybe even surgeries, in an effort to find out whether the finding is serious or not, says Ania Kielar, president of the Canadian Association of Radiologists. This can lead to overdiagnosis, overtreatment and the illusion of benefit.

“There are risks associated with all of these things, and somebody who was previously healthy may end up with complications from all of these interventions that then occur,” she says. “You were a healthy person who went in for this test and now suddenly you're a patient.”

Kielar adds that when these patients come back into the public system, which is already overburdened, they join the queue just like everyone else, which can lead to worry and anxiety.

“In Canada, the major problem is that everybody's waiting way too long for what we actually need,” Kielar says, “and then you add these extra people who probably didn't need it in the first place — and now we have a bigger problem.”

Remarkably easy

For a procedure that isn't backed by any hefty scientific research, getting a fullbody MRI scan in Ontario is remarkably easy.

The website for Whole Body MRI says all patients have to do is book a scan and get a referral, which it offers through one of its “physician partners” if you don't have your own doctor.

(I had already tried to get a referral from a doctor through a virtual clinic, but she declined to give me one, noting that I was a healthy 43yearold patient with no risk factors.)

When I phoned Whole Body MRI, the woman who answered said the company could provide me with a referral from a doctor, but only once I paid for the MRI. I would have to fill out a short medical history form that asked if I had any metal in my body, such as aneurysm clips, cochlear implants or shrapnel.

Whole Body MRI offers fullbody screening for $3,250, as well as scans targeting specific body parts, such as the prostate and breast, for $1,950. I opted for a “Liver Fat Quantification MRI,” which cost $1,500 and was the cheapest MRI on offer.

A couple of days later, without having met or spoken to a doctor, I received a referral and was booked for my scan at Whole Body MRI's Mississauga location.

As I sat in the waiting room of the clinic, which is licensed by the province to provide procedures paid for by OHIP, I wondered if I was about to take up time in an MRI machine that might otherwise be used by patients who really needed a scan. While some Ontario patients with real medical issues are waiting as long as 99 days on average for an MRI under OHIP, I got an appointment for my medically unnecessary scan in a matter of days after entering my credit card number on a website.

Whole Body MRI told the Star

that “97 per cent of our clinic's business is based on OHIPcovered services” and that it uses excess capacity on its MRI machines to provide both OHIPcovered services and privatepay scans.

“We do not prioritize privatepay scans over OHIPcovered procedures,” it said.

After my MRI, I learned from a secretary at the clinic that the doctor who had referred me was named Vaneet Rai. According to Rai's profile with the College of Physicians and Surgeons of Ontario, which regulates doctors in the province, he is a family physician whose primary practice is in a nearby medical centre. I wanted to know why he referred me for a medically unnecessary procedure without having met or spoken to me.

Whole Body MRI said in an email that a referring physician requisition “is required to obtain a test that is not medically necessary” and that the consulting physician “reviews the intake forms and ensures the scan is being done for screening purposes.”

If, on the other hand, the doctor had determined that the scan was medically necessary, Whole Body MRI would have directed me to contact my family doctor and would have cancelled the procedure I had paid for. The company said it has cancelled 12 such online bookings in the last few months based on information provided by the patient.

I asked the College of Physicians and Surgeons what its rules say about whether doctors should refer patients to unnecessary procedures. It said it does not tell physicians what imaging they should refer a patient for, but that referrals must be made “based on informed clinical judgment following a prop

My experience getting a private MRI scan left me confused. I couldn't figure out who was responsible for what, or what regulations govern this whole new private healthcare sector

er evaluation of the patient's needs.”

The college would not say whether that evaluation had to be conducted in person, or whether the doctor even had to speak to the patient, but rather that such evaluations “can be conducted in various ways, depending on the physician's clinical discretion.”

College policy does say that referring physicians must “clearly communicate to patients” what the physician's anticipated role will be in managing care during the referral process, including how patient care and followup may be managed. That did not happen in my case.

“In my view, a doctor referring an individual they have never met, whose medical records they have never seen, for a medically unnecessary or medically necessary test, is substandard and unethical,” says Toronto medical malpractice lawyer Paul Harte. “The college should be promoting a standard of practice, not coming up with excuses to facilitate one of their members increasing their revenue.”

In response to Harte's comments, the college said its oversight “ensures that physicians adhere to the standard of care for treatments provided.”

Whole Body MRI said that physicians it works with receive a “small consulting fee” to review patient information, but would not disclose how much.

Rai declined to comment for this article.

Report in three weeks

Three weeks after my MRI, I received an email with the report on my scan. I couldn't tell from the report whether phrases like “hepatic SI inphase: 339” or “no upper abdominal lymphadenopathy” were good or bad, so I asked Whole Body MRI if I could speak to Rai about what the report meant.

They told me that the doctor's role in signing my referral form was simply to enable my MRI appointment. “This does not include a consultation to discuss your MRI results,” Whole Body MRI said, adding that I should go to my family doctor for any followup.

As for what responsibility physicians have, if any, to discuss test results with their patients, the College of Physicians and Surgeons said doctors should communicate “clinically significant” results promptly, but can use their judgment on whether to inform patients of “nonsignificant results.”

Perhaps if I had gone for the $6,250 full “male package,” which includes a fullbody MRI, prostate MRI screening, and a coronary angiography, my experience would have been different. Whole Body MRI said that a Liver Fat Quantification MRI is “an entirely different test” from a fullbody MRI scan.

Either way, my experience getting a private MRI scan left me confused. I couldn't figure out who was responsible for what, or what regulations govern this whole new private healthcare sector. When I asked the college and the province who is ensuring private healthcare clinics like Whole Body MRI are following the rules, they each pointed a finger at the other.

The college told me that licensing considerations for MRI services are overseen by the Ministry of Health. The Ministry of Health told me that it does not regulate uninsured procedures, like privatepay fullbody MRI scans, and that it is the college's role to set out expectations for the conduct of physicians, including the provision of these types of services.

Kerry Bowman, a bioethicist at the University of Toronto, says there needs to be clearer rules about what services forprofit clinics can offer and how OHIPcovered procedures and privatepay procedures are prioritized.

“It really goes to the very core of the whole Canada health system,” he says. “I think what we need is transparency. If there is a structure, it has to be just and it has to reflect the values of Canadian health care.”

Harte says regulators should go even further and not allow MRI machine licences to be used for any unnecessary radiology on a private basis.

In my case, after spending $1,500 on an MRI, I was left with more questions than answers.

And I never did get an explanation from Whole Body MRI about whether my liver is healthy.