Can't take the heat?
With news in ITIJ’s last issue that Canadian repatriations are being hindered by bed shortages in the country, Milan Korcok asks: is travel insurance a convenient safety valve for Canada’s overheated health system?
First published in ITIJ 90, July 2008
With news in ITIJ’s last issue that Canadian repatriations are being hindered by bed shortages in the country, Milan Korcok asks: is travel insurance a convenient safety valve for Canada’s overheated health system?
A Canadian vacationer in Hawaii suffers a stroke and after successful clinical stabilisation is booked for an air ambulance transfer home to Alberta for rehabilitation. A lot of time-consuming and complicated professional assistance work is expended in the process: to say nothing of intense stress on the patient and his family. Then comes the response from a government bureaucrat: if the patient is privately insured and being treated in Hawaii, the only way to get him into hospital at home is to bring him back to Emergency and let him line up with the others. No priority. No pre-arranged transfer. No assurance of a bed. The alternative is to wait, and wait.
And waiting is what Canadian patients, travel insurers and their emergency assistance representatives worldwide are doing as hospital admissions staffs and health ministry bureaucrats who run the provincially-administered health systems portion out hospital beds to those already waiting in emergency rooms, bumping patients with private insurance to the end of the queue.
Deferring priorities
Kieran Bridge, travel health insurance lawyer and past president of the Travel Health Insurance Association of Canada (THIA), says that such deferral ‘is simply another tool for rationing healthcare … with the overall goal of reducing the cost to the provincial government of providing healthcare’.
Bridge notes that one THIA member reported to him that during the last snowbird season (October 2007 to April 2008), at least eight repatriations required a wait of at least five days, and one of them took 16 days from the time of medical authorization to transfer.
The problem, say other emergency assistance professionals, is not limited to Alberta, or even British Columbia where it is said to be worst, but to Canada’s most populous province Ontario, and other areas as well. Dr Ferial Ladak, medical director of Global Excel Management Inc., a Quebec-based assistance company that manages cases and repatriations for residents of all provinces, says that delays in bed procurement occur almost ‘every time [they] have a patient who is not acute and needs rehab, especially in Ontario and Alberta’. She says that one patient – a truck driver who had an accident in the United States – had to wait one month for a hospital bed in his home province. “We nearly had the patient’s family go to the press. The family wanted him home, so that was not a case of trying to repat for our benefit.”
deferral 'is simply another tool for rationing healthcare'
As for intensive care beds, ‘we certainly get bumped’, she says. “I have been told outright that if there are patients in other hospitals in the province waiting to be transferred to that particular hospital they will get priority, (especially) for such services as catheterisations and bypasses.”
Without doubt, the problem of rationing hospital beds is exacerbated by overcrowded emergency rooms, limited ward space and budgetary restraints on healthcare imposed by provincial governments. Canada’s government-controlled universal healthcare system prohibits private health insurance for services covered by provincial plans, although it encourages private coverage for out-of-country emergency medical care. That coverage, however, is limited to emergency services, not to continuing or follow-up care, and is predicated and priced on getting the stabilised patient back to his home province as quickly as prudence permits. It is designed as a supplement to provincial coverage, and is in fact not allowed to duplicate it – despite the fact it is often required to do just that when beds are deferred.
Therein lies the problem
Mila Pejovic, associate director of travel assistance and medical case management for World Travel Protection Assist, tells ITIJ that many ‘hospital bed coordinators and receiving doctors do not consider patients coming from Florida (or other foreign locations) their priority as they are already getting proper medical care’. She says: “They sometimes even comment that insurance companies only worry about costs.” This is regardless of the actual need for that patient to be transferred. “The receiving hospitals sometimes just refuse up front to take the patient,” says Pejovic. “They say ‘we are full’, or just inform us that they cannot take patients from out of the country as they have other patients already waiting in the hallways to be admitted.”
Some family physicians are more empathetic than others and do get involved in trying to secure beds for their patients who are seeking to be transferred home, she admits. “But a lot of them, regrettably, are not.” General practitioners without admitting privileges, for example, ‘often do not see urgency (in facilitating transfer) as the patient is well taken care of in another country’. “They perceive this as assisting insurance companies not patients,” she says. In general, Pejovic concludes, ‘we are faced with huge obstacles in each and every step of the process’. And the biggest obstacles, from her perspective, are in Ontario and British Columbia.
To patients and their families, encountering these delays in getting back to hospitals in their communities, to the health system they thought they could count on and for which they have paid all their lives, is incomprehensible. “We end up,” says Dr Ladak, “with angry patients, families and doctors, as well as stressed out case workers. The clients cannot believe that we have as much trouble as we do in securing beds, and they and the doctors get more and more agitated as the days go by. Finally, the procedures get done in the US because everyone is unhappy.”
The result is not only personal agitation, but very substantial cost
The result is not only personal agitation, but very substantial cost. Provincial health insurance agencies pay only minimal amounts for emergency medical services encountered abroad by Canadian travellers. British Columbia, for example, pays only as little as $75 a day for hospital care out of Canada; Alberta $100. Ontario pays up to $400 per day, but often doles out less, depending upon acuity of care. This leaves the remainder to be paid by travel health insurance policies or by travellers themselves if they are not insured or are inadequately covered because of pre-existing conditions or other limitations.
Waiting game
“Last year’s numbers suggest we had to wait an average of five days for a bed,” says Global Excel’s Dr Ladak. “And if you consider that a day in a US hospital can cost from $4,000 to $10,000 that can be significant.”
WTP’s Pejovic says that though most hospitals agree to put patients awaiting repatriation on their waiting lists ‘it is not unusual during [the] busy season to wait a week or two for a bed, even longer’. “And all of this has a huge impact on our operation, as bed search is extremely labour sensitive, and arranging for a repatriation sometimes requires a whole day of focused effort for just one bed,” she explains, adding: “In the meantime, patients can deteriorate and become untransportable.”
What is especially galling to many leisure, business or student travellers and their advocacy groups, is that Canada’s universal, publicly-funded healthcare system ‘guarantees’ portability of health benefits between provinces, although that guarantee is more vaguely interpreted when it comes to out-of-country benefits. The Canadian Snowbird Association, which represents travelling seniors, has for years lobbied governments to at least pay for out-of-country services up to what it costs for those same services to be provided domestically. The federal government, because it cost shares provincial health insurance, has the power to impose fines on provinces that contravene portability rules, but has rarely used that power, and clearly, $75 a day doesn’t cut it.
The argument goes that if those needing repatriation can at least get back to Canada on their own travel insurance ticket – which does pay for medically necessary repatriation – they should not be discriminated against and bumped out of the queue because they had the good sense to buy private insurance. Health ministry officials have, on the other hand, argued that people who are already in a hospital – albeit a foreign one – and receiving good care, should not displace patients at home who can’t get beyond their crowded emergency rooms.
The problem with that reasoning, says Bridge, is that many of these officials are unaware of the huge amounts charged by foreign hospitals, especially those in the US, and are equally unaware of the pittances the provinces pay toward these charges: “When I explained to the medical director of B.C. Bedline (the provincial agency charged with allotting hospital beds in that province) that the B.C. Medical Services Plan typically pays only about five per cent of the cost of US hospital care, he told me I was being ‘ludicrous’.” He had obviously never seen a US medical bill, added Bridge.
Compounding the problem
What compounds the repatriation problem, say some experts, is that not only are many patients denied beds in their own communities close to family and friends, they are sometimes declined beds elsewhere in their province by regional health authorities keeping an iron grip on their own parochial resources. Dr Robert MacMillan, medical director for Medipac International, one of the largest providers of snowbird insurance for Canada’s seniors, recently told a travel insurance industry conference that ‘unfortunately, (if) you even try to get a hospital bed outside your own community, people say “they’re not in our catchment area”’. WTP’s Pejovic concurs that though dealing with hospitals in the patient’s normal catchment area is difficult enough, trying to secure an admission beyond that area ‘becomes virtually impossible’.
Some have argued, convincingly, that this rigidity in apportioning hospital beds is contrary to the spirit and intent of the portability provisions of the Canada Health Act that governs the criteria provinces must meet in order to get their share of federal funding to run their health insurance programmes. Bridge notes that in British Columbia, his home province, hospitals in one health region routinely refuse to accept repatriated patients whose homes are in another. (B.C. is divided into six health regions or authorities, one of which bisects Greater Vancouver). Thus, in practical terms, he says, if someone living in North Vancouver needs to be repatriated, B.C. Bedline will not even call St Paul’s Hospital in downtown Vancouver (a different region) for a bed for that patient.
“There is no legal basis for this discrimination,” says Bridge. “All British Columbians pay provincial taxes to cover the cost of medical care. They do not pay taxes to regional health authorities, which are simply administrative bureaucracies set up by the Ministry of Health.”
Bridge has argued, on behalf of THIA, that there is no legal requirement for hospitals to use B.C. Bedline, which he says has no legal standing and was set up simply as an administrative tool by the Ministry of Health: thus there is no legal basis for hospitals telling assistance companies they cannot accept repatriated patients unless they are directed to do so by B.C. Bedline.
though dealing with hospitals in the patient's normal catchment area is difficult enough, trying to secure an admission beyond that area 'becomes virtually impossible'
In response, the chief operating officer of Healthlines Services B.C. (an agency funded by the B.C. Health Ministry) challenged THIA, in March 2008, to substantiate the allegations of illegality. Does this mean the question of repatriating Canadian patients from foreign hospital beds can only be settled in the courts? Is it inevitable that transferring sick people from one clinical environment to another will ultimately be decided by clerks and not by treating and receiving doctors and assistance professionals?
If so, how might they deal with Dr Ladak’s recent dilemma in trying to repatriate a young Ottawa area motor cycle accident patient who was confined for weeks in a US hospital bed but not considered a priority by Ottawa hospital authorities: “The patient kept crying that he wanted to come home, which had his family very upset. His head injury had made him very emotional and he did not understand things as well. He just wanted to come home.”