December 16, 2018 - When it comes to health care accessibility, the residents of Northwestern Ontario don’t exactly have it easy. There is only one hospital in the area capable of providing major surgeries: the Thunder Bay Regional Health Sciences Centre (TBRHSC). For individuals outside of Thunder Bay, say Kenora, driving six hours to a major hospital is not a quick task. Toronto is a plane ride away for more advanced surgeries or procedures, although this may not be wallet-friendly for everyone. Thankfully, the City of Winnipeg and its regional hospital are a mere two hours west of Kenora, but there’s just one problem – it’s in a different province.
The Road to Medicare
Provinces to adopt Medicare by year (source: provincial and territorial Ministries of Health)
*When Nunavut came into existence in 1999 it appropriated and took responsibility of the NWT Health Care Insurance Plan within its territory to create the Nunavut Health Care Plan, meaning Nunavut has never been without Medicare1
In 1979 there was a federal review of health care delivery in Canada, which led to Parliament passing the Canada Health Act (CHA) in 1985. The Act created a configuration through which the Federal government would split health care costs with the provinces as long as they met federally to set conditions. Most notable to Northwestern Ontario is the portability provisions, requiring a provincial health plan to pay for services across provincial lines. Every province except Quebec is also a part of a series of bilateral billing agreements ensuring out-of-province (OOP) patients do not have to pay up front. OOP physicians however, can choose to not use reciprocal billing but to bill a patient directly. The patient must then submit for reimbursement by their provincial provider.
Based on this alone, under the CHA, it has always been possible for those from the Northwest to get emergency services in Manitoba. But what about non-emergency services? In order for a physician in Ontario to refer a patient to an out-of-province hospital for these types of services the physician must arrange the referral and file a form with the provincial government. Each year, Manitoba provides approximately 20,000 health care services of all types to Northwestern Ontario residents 2. Manitoba-based care is available for most services, however due to bureaucracy and issues with system capacity, for some services such as chemotherapy, patients must be referred within the province to Thunder Bay. Therefore if sending a patient to Winnipeg will negatively impact that hospital’s system capacity, a patient will instead be referred to Thunder Bay3. These issues will sometimes lead to people being referred to a hospital that is further away, something no patient likes to hear. As a result, there have been calls for the most western parts of Northwestern Ontario to be absorbed into the Manitoba health care planning regime to avoid this.
Despite these barriers, continued progress is being made in health care cooperation between Ontario and Manitoba. On May 4, 2018 both provinces entered into a five-year Memorandum of Understanding4 which ensures Manitoba provides Northwestern Ontario residents access to Winnipeg-based acute care services at the same rate as Manitobans 5. In return, the Ontario government provides Manitoba “top up” funding to offset the cost of services not covered through existing arrangements. This funding is provided on a per-patient or “per-patient-day-of-service” basis. For a standard out-patient visit, this rate is $50 per service. Manitoba invoices Ontario for the services, and Ontario agrees to pay within 60 days6. However, while this agreement reduces the cost of inter-provincial health care and cuts down on bureaucracy, it does not (and cannot) address issues of system capacity. This issue can only be addressed by expanding health care services and hiring more doctors and nurses.
Another notable feature of the MOU is the framework for Manitoba to provide clinically or operationally necessary transportation services to Northwestern Ontario residents. The costs for these services are then reimbursed by Ontario7. Manitoba also benefits from the agreement: Manitoba physicians can use Ontario’s CritiCall system for emergency patient transport to ensure efficient transition of emergent care patients between Manitoba and Ontario. Health care providers in Manitoba may be required to obtain additional professional licences in the province of Ontario in order to provide “clinical escort team services,” but Ontario agrees to pay Manitoba for the licencing fees8. Another aspect to the MOU are interprovincial working groups which were established to further improve procedures and protocols. The Joint Winnipeg Regional Health Authority and North West LHIN Working Group is composed of members from health authorities in Manitoba, the North West Local Health Integration Network, and health care providers in both provinces. The Manitoba-Ontario Working group is composed of further representatives of the two provinces9.
Interprovincial health care has come a long way since the Canada Health Act was first created, and strides are continually being made to improve patient treatment. Clinicians in Ontario and Manitoba are working together to improve existing protocols based on a “patient first” principle – putting the patient’s medical needs as primary concern, rather than provincial jurisdiction or cost of care. Regardless of how the two provinces choose to cooperate and integrate their care, it is certain that those in the Northwest will benefit from it.
Dawson Mihichuk was an Experience North student summer placement with NPI for the summer of 2018.
- Office of the Nunavut Department of Health. 2018. pers. comm.).
- Manitoba Ministry of Health. 2018. pers. comm.)
- Northwest LHIN. 2018. pers. comm.
- Her Majesty the Queen in Right of the Provinces of Ontario and Her Majesty the Queen in Right of the Province of Manitoba. Manitoba-Ontario Memorandum of Understanding. Kingston and Winnipeg: Ontario Ministry of Health and Long-Term Care and Manitoba Ministry of Health, Seniors, and Active Living, 2018.
- Northwest LHIN. 2018. pers. comm.
- Manitoba-Ontario Memorandum of Understanding. 2018.
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