Canadian physicians’ responses to cross border health care

Canada, like many countries, is experiencing an increase in the number of patients who seek health care outside of its borders. Canadians who do so generally fall into two categories. If they require health care that is not available close to home or in their own province or territory they may be able to access health care in another province or out of country (often the USA) through a system of prior approval that is organized and administered by provincial/territorial ministries of health. Referred to as “out-of-country care” (OOCC), this is funded by provincial/territorial public health insurance plans and usually involves insured procedures for which there is a delay which poses catastrophic health risks to the patient [1]. Medical “tourism” (MT), the second category, is planned and organized by the individual without the involvement of public health insurance plans [2]. (We put “tourism” in quotes since, despite the adoption of this term, the primary reason for such travel is medical treatment, not tourism). MT “refers to cross-border health care motivated by lower cost, avoidance of long wait times, or services not available in one’s own country” [2], with the patient funding his/her health care out-of-pocket. MT travel for the purpose of health care results from a patient’s personal choice and decision to seek medical care abroad in the absence of a physician’s formal referral for care or approval from public health insurance plans [3, 4].

Between 2004 and 2009, the annual growth rate of imports of health care services (referred to as imports because they are purchases of medical services and goods made by resident Canadians while they are abroad) was 1% [5]. Imports of health care services as share of total health expenditure in 2009 stood at 0.24%. The figures only provide a rough guide to growth rates in medical tourism. However, as a highly publicized component of trade in health services in which Canadians have an interest as demonstrated through media reports, an apparent growth in the medical tourism industry’s infrastructure, and a variety of list servs, MT appears to be on the rise [6]. This rise reflects, in part, the globalization of health care, in which (generally) private health care providers seek to increase their revenues, maintain bed-occupancy rates and/or support development of high-technology medicine by attracting fee-paying (out of pocket, privately or publicly insured) international patients [1]. Many low- and middle-income countries are engaged in promoting MT, often with the direct support of their governments which regard health care exports as a means of generating foreign currency earnings. That many of these countries have poor health care access for their own citizens raises important questions of equity and ethics, beyond the scope of this article but part of a separate study with which some of the authors are associated (RL, VR, CP). Our focus in this article is how Canadian physicians, who are responsible for the care of Canadian patients, engage in or otherwise feel about this perceived growth in medical travel, whether through out-of-country care or medical tourism. To address this issue, we collaborated with the Canadian Medical Association (CMA) to conduct an on-line survey, described below. The CMA is a voluntary national professional association which represents 70% of the practicing medical profession in Canada.

631 of the 3,169 physicians in the e-panel completed the survey. This represented a response rate of approximately 20%, considered excellent by the CMA based on comparisons with past e-panel surveys. The results of the responses received are presented in both numeric and percentage forms where appropriate. Percentages with decimals have been rounded to the nearest whole percent. On occasion, respondents provided multiple answers to a question, contributing to a number of responses greater than the total number of respondents.

Just over half (54%) of respondents were specialists;^a the rest were general practitioners. Figure 1 shows respondents by province of practice.

The survey questions encouraged physicians to reflect on their experiences with MT and OOCC, and have provided some insights into physician concerns with medical travel. In summary, over a quarter of the sample of physician respondents had determined that one or more of their patients needed OOCC provided by provincial/territorial health insurance plans, and had applied for OOCC on their behalf. The rate of approval experienced by respondents was less than half for the 48% of those who responded, and fully successful in just over a quarter of the responses. The most common OOCC treatments received were diagnostic procedures followed closely by treatment for life threatening conditions, and the overwhelming majority of treatments were received in the United States.

Regardless of the procedure sought, respondents reported that their patients engaged in medical tourism because they considered waiting time for treatment in Canada was too long. An OECD report indicated that among 11 countries surveyed in 2010, Canada experienced some of the longest waiting times for health care; 59% of Canadians surveyed reported waiting four weeks or more to see a specialist, while 25% waited four months or more for elective surgery [5]. In 2012, nine out of ten Ontarians living in the eastern region of the province waited an average 343 days for hip replacement, making this the most poorly performing region in an already poorly performing province [8]. These wait times may not necessarily pose medical risks but, as one respondent in the physician survey wrote, patients experience “…anxiety re: waiting [even if] not founded on reality”.

The second most-reported reason for MT was because specific treatments were not available in Canada. In some provinces this applies to certain types of bariatric treatment which may only be available elsewhere in Canada than the patient’s home province, or outside the country. But bariatric care may also be supported through OOCC, as in Ontario. Demand for bariatric care through publicly-funded OOCC may have had some influence on recent decisions in Ontario to restructure bariatric services and increase domestic access [9].

An additional area of MT was for MS-related therapies. The respondents reported a large number of patients going abroad for such therapies, the majority mentioning procedures for Chronic Cerebrospinal Venous Insufficiency (CCSVI), also referred to in common parlance as liberation therapy or the Zamboni procedures. Due to lack of evidence of its efficacy, CCSVI treatment for MS is not currently funded by the public health care system in Canada [10]. In June 2011, the federal Minister of Health announced government funding for Phase I/II clinical trials on CCSVI [11] and by November, 2011, the government announced that it was ready to accept research proposals for these trials [12]. These steps suggest that public rather than physician demands had some influence on decisions to investigate care that is not available in Canada.

For both types of medical travellers (MT and OOCC), the top-ranked service sought abroad was diagnostic procedures which included CAT scans, MRIs and radiography. On the one hand, there is reason, as the literature and some of the respondents suggest, to believe these procedures may be overused [13‐15]; on the other, prompt access in cases of medical necessity can allow patients to progress along the treatment spectrum. At the same time, the proximity of the United States, Canada’s border neighbour, which is well equipped to provide private diagnostic procedures, appears to be a critical factor in uptake.

Physicians’ perceptions regarding their responsibilities towards medical tourists, particularly their follow-up treatment are important to note. Though limited in number, there are some published studies indicating that returning patients can suffer significant problems sustained as a result of treatment abroad [16‐20]. Our results suggest some differences of opinion within the e-panel regarding the provision of follow-up treatment to patients who have independently sought, paid for and received treatment outside the country. Several respondents were clearly uncomfortable with having to provide follow-up care for procedures performed by other practitioners, and for which they frequently lacked adequate information.

Out-of-country care and medical tourism are examples of how health care is becoming increasingly globalized. Both forms of cross-border care introduce some risks but may also generate efficiencies in health care delivery in Canada. Both risks and benefits, however, remain difficult to quantify given the paucity of hard data, especially with respect to MT. A sizeable number of physicians in our survey determined that their patients required OOCC and applied for public health insurance coverage (although approval was not guaranteed). By making requests for OOCC, physicians are responding to inadequacies that they perceive in the Canadian health care system. These inadequacies may well be most efficiently and cost-effectively filled by OOCC.

The main reasons for medical tourists seeking treatment outside Canada (to the best of respondents’ knowledge) were length of time waiting for treatment and treatment not being available in Canada. However better overall care, expertise, attention, treatment and results, and a desire for second opinions were also cited reasons for Canadians seeking care as medical tourists. These reasons reveal different kinds of issues with respect to the perceived quality or superiority of skills elsewhere. The availability of some novel therapies elsewhere but not in Canada, can also suggest that Canada is lagging behind many countries in terms of ‘state-of-the-art’ practice. However, medical tourism does appear to pose greater risks due to a greater number of unknowns for the patient including the security and safety of countries and the quality of care in their facilities, the regulation of practitioners and liabilities, the types of procedures and post-interventional follow-up or lack of it, and the effects of possible transmission of multiple drug, extremely drug and pandrug resistant bacteria/pathogens. For some of our respondents, MT raises worrying questions of who should bear responsibility and costs for complications arising from a personal decision to seek care in another country. Other studies have also raised concerns about the negative impacts that MT can bring about for health care access for population groups in some MT countries [21].

Hard data and further research in OOCC and MT could help identify the volume and impacts of these forms of medical travel on Canadian citizens and the Canadian health care system. Canadian physicians who witness through their patients the processes and experiences of OOCC and MT, would likely benefit from better support and information from health ministries, and streamlining of approval processes, but primarily from having access to timely services and treatment for their needy patients.

^aParticipants were not asked to indicate their area of specialization.