This article originally appeared in the Summer 2023 issue of the Ontario Medical Review magazine.
Temporary COVID-era initiative improved health-care access, ensured physicians were paid for their services
Pediatrician Dr. Shazeen Suleman was visiting a Toronto refugee shelter in the summer of 2022 when she met a child who had arrived in Canada as an asylum seeker and had never seen a doctor.
Dr. Suleman knew immediately that the child had a serious genetic condition that can cause heart and blood issues. She quickly arranged urgent bloodwork and appointments with multiple specialists so the child could get the care they needed.
She was able to treat them and others in the refugee shelter and be paid for her work, through an initiative called the Physician and Hospital Services for Uninsured Persons Program. The Ontario government established the program in March 2020 as a temporary measure to reduce the spread of COVID-19 by ensuring that any uninsured person in Ontario had access to medically necessary services performed in hospital. It also covered limited physician services performed in the community.
If the program had not existed, “there’s a very real possibility that the first time I would have seen that child would have been in the ICU or in the emergency room or worse, not at all,” said Dr. Suleman, who is part of St. Michael’s Hospital, Unity Health Toronto.
But the government ended the program on March 31 of this year, resulting in barriers to care for patients without health insurance and meaning doctors will once again not be paid for treating them. This is why the Ontario Medical Association and physicians like Dr. Suleman are working to convince the government to reinstate the program or replace it with a similar, long-term initiative.
“The day it was announced the program would end, I felt physically sick thinking of the children who don’t have insurance,” Dr. Suleman said. “They’re not just numbers. I see their faces in my mind and my heart is breaking.”
An Ontario Medical Association analysis found that 7,000 Ontario physicians provided 400,000 care episodes to patients without insurance during the program.
“The abrupt discontinuation (of this program) could be detrimental to the lives of some of our patients,” Dr. Cathy Faulds, chair of the OMA Board of Directors, said in an email. “During the pandemic, the ability to treat and manage patients, regardless of their ability to pay, expedited access to care for many marginalized and vulnerable populations.”
“The day it was announced the program would end, I felt physically sick thinking of the children who don’t have insurance. They’re not just numbers. I see their faces in my mind and my heart is breaking.” — Dr. Shazeen Suleman
The issue of compensation for treating uninsured patients, identified as one of its top two priorities by the OMA’s Compensation Panel, was approved by the board of directors in June. The OMA is also working with the Ontario Hospital Association and other stakeholders to produce solutions to present to the provincial government.
The challenge of treating uninsured patients began long before the pandemic. According to a 2016 Wellesley Institute report, Health Care Access for the Uninsured in Ontario, there could be as many as 500,000 uninsured people in the country, many of them in Canada’s largest province.
Patients without OHIP coverage include newcomers waiting for permanent residency status, some temporary foreign workers, international students with limited health-care coverage and undocumented people with no official immigration status.
It also includes marginalized Ontarians who may be unable to obtain or renew their health card due to situations that make it difficult to go through the application process, such as homelessness, mental illness, language barriers or lack of transportation to a Service Ontario centre. OHIP cards must be renewed every five years.
Studies have shown that these patients often experience poorer health outcomes. While this may partly be due to precarious living conditions, it can also be attributed to limited access to health care. A study in Refuge: Canada’s Journal on Refugees, describes how those without insurance delay seeking care out of fear of the cost or deportation, and they report barriers to accessing care when they do seek it.
A 2016 study called Emergency Room Visits by Uninsured Child and Adult Residents in Ontario, Canada analyzed emergency department visits by insured and uninsured patients over a nine-year span. It found that uninsured patients were 43 per cent more likely than insured patients to be triaged as severe. They were also more likely to leave the emergency department without treatment or to have died on arrival or in the emergency department.
Health-care equity for all people living in Ontario is one aspect of this issue. The other is ensuring that doctors who treat uninsured patients are fairly compensated for their work.
Dr. Faulds points to the 7,000 physicians who were paid for services under the Physician and Hospital Services for Uninsured Persons Program. Now that it has ended, “they would not be paid for their work going forward. This is not equitable nor fair remuneration for health-care providers.”
Under the program, physicians in the community could bill OHIP using temporary k-codes, while care provided in a hospital was reimbursed by the hospital at the same rates as OHIP. Hospitals were reimbursed by Ontario Health for both operational and physician costs.
Dr. David Esser, a physician surgical assistant at the Scarborough Health Network, said it is especially frustrating to treat an Ontario patient who has been unable to renew his or her health card. “Some patients just don’t have the resources or ability to go and do the work that is required to get the card, even though it’s documented that they’ve had a card,” he said.
“You feel you’ve been taken advantage of when you are expected to step up and do this for free. Then the flip side is, if you want to pursue payment, how do you speak to somebody about this who is having hardships?
“It is frustrating to have the program end because it allowed us to freely provide services patients required and not have to worry about chasing after them or all the paperwork involved.”
Dr. Ritika Goel, a family physician in Toronto who has worked extensively with uninsured people, said the program helped patients who were afraid of seeking care finally feel like they belonged. “COVID-19 gave us this unplanned natural experiment where we were able to do the right thing and provide people the care that they needed when they needed it.”
Dr. Goel said prior to the program, patients without health insurance who went to a hospital were asked for money up front or received care and then were sent a bill for thousands of dollars.
“Those scenarios, unfortunately, happened quite regularly before this program. And we’re starting to hear of similar stories again,” she said. “I am thinking of an elderly man who had quite a serious infection who left the emergency room because he was asked for $500. There was a middle-aged man who mentioned that his family had gone into debt back home so that he could access a surgery for a tumour. I’ve heard cases of pregnant women asked for cash while they were in labour.”
“COVID-19 gave us this unplanned natural experiment where we were able to do the right thing and provide people the care that they needed, when they needed it.” — Dr. Ritika Goel
The elderly man with the infection instead went to Dr. Goel’s office and through her decade-long advocacy efforts, she ensured he received the complex care he needed through a specialist and the residents at their clinic, even though he couldn’t pay. “Providers often have to do a ton of advocacy. And that is when the patient is working with a clinic that understands the system. Many in the health-care system don’t know what to do when someone shows up without a health card.”
While other programs exist for patients without insurance, they have limitations. The Interim Federal Health Program covers health care for groups such as refugee claimants, victims of human trafficking or resettled refugees. The type and length of coverage depends on an individual’s immigration status and health-care providers must sign up to provide care through the program.
Ontario has a network of about 100 Community Health Centres, not-for-profit organizations that provide primary care and health promotion programs. Their mandate is to provide health care to those who otherwise have barriers to accessing services.
Some CHCs have determined that uninsured residents are a priority population and receive funds from the Ministry of Health to cover non-CHC services for these clients (for example, lab tests and specialist visits). But not every CHC receives funding to provide this comprehensive care.
“Community Health Centres are limited because there are not enough of them, so there are long wait lists,” Dr. Suleman said. “There is also limited access to specialists. If a patient needs to see a specialist, that can be very difficult. If they need to get blood testing or other investigations done, that can be very difficult.
“There are some incredible and generous people who donate their time to see children without insurance in their offices. There are community groups that band together to provide pop-up clinics and support. But these are all small attempts to patch this hole that was filled during this program.”
Dr. Suleman said providing timely care to more people also benefits the health-care system. “Preventive medicine and primary care are more effective in the long run, being able to provide care when it is needed, at the time it is needed, in the place that it is needed in the community, rather than in the acute-care setting,” she explained.
OMA analysis of physician billing data for the community aspect of the Physician and Hospital Services for Uninsured Persons Program found that it was highly cost-effective, given the significant costs of hospitalization that result from delaying care. The analysis found that physician fees in the community were about $15 million from the program’s inception to March 2023. The hospitals’ costs to cover physician fees and operations for the program have not been made publicly available.
Dr. Esser believes the program proved that health-system access needs a rethink. He said people in marginalized groups are disproportionately affected by lack of access to health care. “These populations need an extra touch that we’re not quite delivering on. But we have the capacity as a society to really look after these people and it will benefit us all.”
Dr. Faulds said the OMA is committed to working with the Ontario government to fill this gap in equitable access to care. “Developing a system to facilitate OHIP cards for the marginalized and vulnerable is the path forward,” she said. “The barriers for citizens who are not housed or have disabilities impairing them from completing the current processes need to be removed.”
Dr. Suleman said she is grateful for the OMA’s support on this cause. “I think it’s important for the public and policy-makers to hear from our association. We are the ones who see families and see the consequences.”
Dr. Goel encourages physicians to reach out to their MPPs in support of a permanent program for uninsured patients and to speak to their hospital administrators to ensure hospitals are advocating to have this policy reinstated or a new program created.
“This experiment allowed us to see how the policy that’s the right thing to do also makes economic sense because people sought care when they needed to seek care instead of waiting to develop complications,” she said.
“We are quite hopeful that there will be an effort to build a permanent program that takes into account the learning from this experience.”
Abigail Cukier is a Hamilton, Ont.-based writer.