When Nan Normand’s husband had quintuple bypass surgery, it cost them $1,500. It wasn’t the operation that was pricey, but the travel. The couple went from Kenora, a small city near the Ontario-Manitoba border, to Hamilton for the surgery. The trek included flights and a multiple-night stay.
Normand was unlucky: Manitoba had temporarily stopped accepting most Ontario heart patients, so they couldn’t go to the much closer Winnipeg, and they were delayed by about three days by an ice storm once they hit Hamilton.
But the Normands aren’t the only ones paying significant out-of-pocket costs for health care. Patients in parts of Northern Ontario often travel upwards of 100 kilometres for surgery, procedures like chemotherapy or to see specialists.
The Northern Health Travel Grant helps offset some of the costs that come with that, with the goal of increasing access to care for people in those areas. Yet it doesn’t cover everything. Normand and her husband received $2,625 from the program, about $1,500 of which was for her husband, with the rest for her costs as his companion. Despite staying in a $40-a-night medical hostel, “our true expenses were approximately $1,500 over that,” she says. “The only way we were able to do it is because we’re middle income and we have credit cards.”
Increasing access to services
Normand is one of the over 200,000 Ontarians who apply for assistance every year. The program, which costs the province $53 million a year, is available to people living in 10 districts, including Kenora, Manitoulin, Parry Sound, Sudbury and Thunder Bay. The average reimbursement is $272.
- Approaches to Improving access to specialists in rural regions: Ontario & Germany
- Remote First Nations communities without a safety net during emergencies
- Maternity services disappearing in rural Canada
The grant helps residents from those areas who are referred to specialists or need services that aren’t available locally. They have to go to the closest option, which might mean Manitoba for some. They are reimbursed 41 cents per kilometre after the first 100 kilometres for travel, and an extra $100 for accommodation if the closest option is more than 200 kilometres away. One companion can also apply for a grant.
Other provinces have similar programs, including Manitoba, Newfoundland and the Northwest Territories. In B.C., the Travel Assistance Program offers discounted rates at hotels and subsidized transportation. Others places, including Alberta, don’t offer any reimbursement.
Ontario’s program started in 1985 as a set rate based on the distance from the patient’s residence to the treatment centre or specialist. Since then, it has seen a number of changes: In 1991, concerned that the grant was encouraging patients to travel south instead of seeing northern specialists, the Ministry of Health and Long-Term Care reduced the minimum one-way distance to 100 kilometres in Northern Ontario or Manitoba, and 200 kilometres in the rest of Ontario. And in 1994, it was modified so patients had to see the closest specialist. In 2007, the government increased the mileage allowance to 41 cents per kilometre, up from 34.25 cents. They also added $100 for accommodation for each trip.
The grant made headlines in 2000, when a group of patients filed a complaint with the Ontario Human Rights Commission (it was settled or withdrawn beforehand, never being heard by the tribunal, but that year, the minister of Health and Long-Term Care promised to review both programs). They argued it was unfair that Cancer Care Ontario covered food, hotel and transportation costs for patients from Southern Ontario, while the Northern Health Travel Grant only covered a portion. The Cancer Care program was much smaller, only covering patients who were referred away from their home centre for radiation treatment.
Is it time to raise the rates?
Though the grant reimburses some of the costs, it’s not meant to cover everything. There’s no payback for meals, and the $100 accommodation allowance is a flat rate, whether you stay one night or a week.
“It’s not based on any rational formula that I can see,” says Carolyn Hudson, a friend of Normand who also lives in Kenora and has used the grant. “Give me a mileage plus accommodation that actually covers it, that isn’t just a figure someone in Toronto has picked out of the air.”
People who can’t afford the travel skip services, ask their doctors if there for other options, or hold barbecues or dances to raise the money. France Gelinas, MPP and the NDP Health and Long-Term Care critic, says she hears of fundraisers for families who can’t afford their part of travel expenses at least once a month.
“The goal of it is good, it helps a bit, but it still leaves serious barriers to access for many families,” says Gelinas, who believes the payback amounts are now out of date. “If the goal of the program was to address some of the barriers to access, then over time some of those barriers have grown back.”
There’s also the issue of how long it takes to get paid back. The government announced it would try and make payments faster in 2007, and it says it now takes four to six weeks for people to be reimbursed.
But Michael Mantha, MPP for Algoma-Manitoulin, says it often takes longer, and that the turnaround time is creating difficulties for people
It sometimes takes as long as six months for people to be reimbursed, he says. “When you’re on a fixed income or a very low income [and these funds are delayed], it’s very difficult to make ends meet,” he says. He’s thinks it’s particularly difficult for patients who undergo regular treatment, like chemotherapy, and have to re-apply for the grant every time.
The ministry says cases are processed within the six-week timeframe, with the exception of “a small number of circumstances where an application was not completed properly or where eligibility comes into question.” Phil Graham, director in Primary Health Care at the Ministry of Health and Long-Term Care, also points out that non-profit organizations like the Canadian Cancer Society, the Kidney Foundation and Ontario Works front travel grant money to needy recipients, then collect the funds from the government afterwards.
The Ontario Ombudsman receives about 11 complaints a year about the travel grant; in 2013/14, they had seven. They’re mostly around people who have been denied coverage, says Linda Williamson, director of communications for the Ombudsman. A recent example was a woman who had to travel 193 km for a colonoscopy and couldn’t get the accommodation allowance because she was under the 200 km minimum. “We spoke to the ministry about this, and said that they needed to be more flexible about what was covered,” says Williamson.
The ministry is now developing an independent Medical Appeals Review Committee that will look at denied applications upon request. (Right now, an internal review committee does this and makes sure the policy wasn’t misinterpreted and the person wasn’t wrongfully denied reimbursement.) That new committee will look for cases that warrent exceptions, so people will have another option than the Ombudsman.
Replacing travel with telemedicine
One option for patients who have to travel long distances is to try telemedicine instead.
The Ontario Telemedicine Network has encouraged doctors and patients to do just that. A marketing campaign is underway that promotes telemedicine to care providers, with a focus on follow-up visits. The Ontario Medical Association and the Ministry of Health and Long-Term Care have worked with the telemedicine network to help increase awareness of the option.
“A lot of travel grants are provided for the purposes of follow up care,” says Rob Williams, chief medical officer for the network. “And there’s usually minimal to no physical examination.” If a physical exam is needed, a nurse in the patient’s town can provide it and report back to the specialist during the appointment.
Initial consultations, pre-surgical assessments and pre-op assessments also work well virtually, says Williams.
Telemedicine means patients who would normally use the grant save time and cut down on their expenses, says Williams, whose patients have told him the grant covers at best 20% to 25% of the cost to them. “From a clinical perspective, they’re getting equal value and equal clinical attention, so it’s probably the same, just a lot more convenient.”
A special agreement in place with Manitoba ensures patients can access the same specialists they would regularly see, even if they’re in places like Winnipeg, through telemedicine.
Part of what needs to be done, says Gelinas, is for doctors in Southern Ontario to be more aware of the lengths patients from parts of Northern Ontario must go to for their appointments, so the doctors can think about other options like virtual consultations.
Williams agrees. Physicians in the north are “quite aware of the travel burden,” he says. “But in southern Ontario, there still is work to be done.”