insurance - don't leave home without it
only time Canadians are allowed to purchase medical and standard
ward hospital insurance is when they leave Canada. According to
Tim Lynch provincial governments are transferring their responsibility
for health coverage abroad to travel insurers.
regard their access to health services as being a right of privilege
of being Canadian. This places Canadian travel health insurers
in the unenviable position of meeting expectations in service
delivery that the publicly funded Canadian health system is not
always able to accommodate.
provision of health services in Canada is the constitutional responsibility
of the provincial level of government. The federal government's
Canada Health Act (CHA) governs the Canadian health system nationally.
Under CHA provincial health insurance plans cover all "medically
necessary" inpatient hospital and medical services. These
programs are managed in accordance with the CHA criteria of health
programs being: publicly administered, comprehensive, universal,
portable, and accessible – which generally means "free"
at time of need. The Canadian government ensures these national
criteria are adhered to through its fund transfer arrangements
that supplement provincial health ministry budgets. Under these
conditions, there are no markets for medical and standard ward
hospital insurance coverage for Canadians in Canada.
travel health insurance premiums cover the cost of providing a
local health services in the country being visited that stabilize
patients and repatriation of the patient back to Canada as efficiently
as possible. Standard case management criteria require travel
insurers to have a hospital bed available in Canada before starting
to transfer the patient home. Under Canada’s highly controlled
supply management health system, Canadians living in Canada often
have difficulty gaining access to hospital beds. Canadians in
need of a hospital bed when outside the country have to be accommodated
within these limitations.
is no legal obligation for insurance companies to actively engage
in trying to persuade hospitals to take patients," says Dr
Robert MacMillan, President, SelectCare Risk Management Corp.
Toronto. Dr MacMillan, who is also President of the Travel Health
Insurance Association of Canada, (THIA) goes on to say, "Insurance
companies are within their rights to just drop patients off at
hospital emergency departments; then The Canada Health Act kicks
in, and the hospital has to deal with the patient." Such
practice, he recognises, would be counter to any professional
standard of case management and would overload the system inappropriately.
talking with several Canadian travel health insurers in the researching
this article it is evident that the industry prides itself in
delivering a personal service at a time of need to patients in
their trust. The challenge is balancing these standard customer
obligations in a domestic publicly funded hospital system that
often fails to serve Canadians in Canada.
practised medicine for several years in Ontario and having served
as President of the Ontario Medical Association as well as Assistant
Deputy Minister for the Ontario Health Insurance Plan (OHIP) prior
to assuming a career in the travel health insurance business,
Dr MacMillan acknowledges that if he has trouble finding a hospital
bed for his patients, the industry in general has a problem.
he is unable to locate a hospital bed, Dr MacMillan’s strategy
is to recommends that the patient’s relatives complain to
their local hospital administrator. If that doesn't work he advises
that they complain to the office of the Minister of Health and
if that doesn't work he says there is always the media. In Canada's
publicly funded health system embarrassing their provincial minister
of health in public is often the last resort for patient care
Association of Canadian Academic Health Care Organizations (ACAOH),
which represents the interest of tertiary care teaching hospitals
across Canada, was approached about the possibility of establishing
some arrangements among its members for repatriation of injured
or sick Canadians stranded abroad. With its close to forty member
facilities strategically located across Canada, theoretically
this entity could facilitate repatriation admissions of Canadians
into their provincial health systems. In the context of Canadian
hospitals offering such a specially designed service to care for
the needs of sick Canadians abroad, Jeff Lozon, ACAHO President,
stated, "Hospitals do not have the staff to cover current
beds and they cannot have the beds to reserve right of admission
for Canadians abroad.’ He stressed that ‘such arrangements
would look like a special set of Canadians were getting special
access to hospitals."
in Canada when the supply of hospital beds fails to meet prevailing
demand, patients are triaged for admission to available beds.
Remembering that hospitals in Canada are dependent on funding
from their provincial governments, any attempt at short-circuiting
this triage system could have political implications for hospitals
authorities. Under the Canada Health Act the admission to a hospital
of a Canadian patient from abroad has to be treated the same as
a local community admission. In some designated trauma centres
there may be instances where patients in transit are under some
care by the receiving centre. Generally, the only time a Canadian
hospital is obliged to be involved in caring for a patient is
when the patient is inside the hospital’s emergency department.
situation has to be recognised by assistance companies responsible
for transferring patients to Canada. Murray Martin, President
and CEO, Hamilton Health Sciences Corporation, reported that as
CEO of the Vancouver General Hospital he witnessed an American
Medi Vac air transport ambulance company delivering a patient
to the ER department and try to depart without proper transfer
of responsibility. The Medi Vac crew did not realize that such
admission are triaged along with all other ambulance deliveries.
This lack of understanding about how the Canadian health system
operated resulted in the air ambulance having to remain on the
ground at Vancouver airport for several hours.
with periodic tidal waves of demand in his ER he only has one
ER) one hospital administrator argued that the hospital needs
of Canadians outside of Canada are the problem of travel insurers.
However, he acknowledged that sick patients, have to be admitted,
somehow, when they arrive at the ER, regardless of where they
come from. The possibility of repatriating a patient who becomes
a chronic case, which is a drain on a hospital’s resources,
as well as the possibility of infectious disease being introduced
to hospitals from abroad, may also discourages Canadian hospitals
from serving such admissions. Furthermore, some hospital medical
staff personnel are not too interested in receiving patients who
have been ‘worked on’ by doctors in other countries.
the challenges travel insurers have in trying to find a hospital
for Canadians injured abroad, Dr Ron Mayer, VP & Chief Medical
Officer, World Travel Protection, Toronto says, ‘It is easier
to get a foreign patient into a Canadian hospital than it is to
get a Canadian patient admitted from a foreign country.’
This is because Canadian hospitals and
admitting physicians see a foreign admission as a source of revenue
that supplements their provincial health ministry allocation.
Most Canadian hospitals have little experience in the pricing
of such admissions. Some tend to price their services by comparison
with similar admissions in US hospitals.
the compassion that resides in the system, Dr Mayer said, ‘When
a Canadian is sick in the US. with no insurance there is a definite
effort on the part of local hospital admission physicians to get
the patient back to Canada to avoid US. hospital costs. Such efforts
are usually initiated under the guidance of the patient’s
relatives, the family physicians and possibly a travel insurance
company. Similarly when a Canadian is in a less than adequate
hospital in some part of the world, a hospital admissions physician
may try extra hard to find a place in their hospital.’
Mayer cautions that this compassion in serving a sick Canadian
in a foreign land is reduced when the patient has travel insurance
and is in a US hospital. "Often the admitting physician in
Canada advises that the patient stays where he or she will receive
better care than if they were in any Canadian hospital."
Under these circumstances, the travel health insurance company
has to pay for the costs of providing hospital care in the US,
which is somewhat of a dilemma for the travel insurance industry.
portability of health services is one of the guiding criteria
of the Canada Health Act. With respect to Canadians being in need
of hospital services while outside of Canada, the Act specifies
that "the provinces should provide payment on the basis of
the amount that would have been paid by the provinces for similar
services rendered in the province, with due regard, in the case
of hospital services, to the size of the hospital, standards of
service and other relevant factors."
reality is that each province pays a different amount and nowhere
near the cost of a stay in a US. hospital. Ontario pays a per
diem rate of $400.00 British
Columbia pays $75.00.
dilemma facing the Canadian travel insurance industry is that
this failure of provincial health insurance plans to meet their
obligations in covering hospital care abroad, and the decision
of the federal government to ignore such infractions, has been
the basis upon which the travel health insurance industry in Canada
has grown. To advocate that the provincial governments live up
to their obligations with respect to covering the cost of Canadians
in foreign hospitals may reduce the need for private travel health
insurance. Without informing the electorate Canadian governments
have transferred the cost foreign hospital care to the private
insurance companies. In the meantime, the travelling Canadian
consumer gets stuck with higher premiums as well as higher taxes.