Breaking down some of the big issues with NWT medical travel

Slow decisions, denied escorts, and a lack of funding are some of the medical travel issues routinely raised. What is the GNWT doing to address them?

The territory’s medical travel policy covers transportation costs to get people from one place to another for necessary medical care. It’s based on the principle that the cost of medical travel should not be an economic barrier to insured health services for NWT residents.

But at a briefing last week, MLAs heard the existing policy often falls short in providing compassionate care and timely decisions for patients.

Here are some of the main takeaways from the briefing.

What does the medical travel policy cover?

The policy comes into effect only when no other insurance plans are accessible.

“One of the fundamental challenges in the Northwest Territories is the complexity of the medical travel benefits and the number of different insurance plans that are accessed by residents,” said health minister Lesa Semmler.

That includes medical travel benefits from employer-sponsored plans, such as those available to GNWT employees and federal employees; private third-party insurance; the Métis Health Benefits Policy; and the federal Non-Insured Health Benefits (NIHB), which is available to eligible First Nation members and Inuit.

When none of these insurance providers are eligible, the NWT’s Medical Travel Policy is the payor of last resort.

To have your medical travel covered by the policy, you must:

• be an NWT resident;
• have a valid NWT health card;
• have a medical referral from within the NWT; and
• have approval from the Medical Travel Office prior to travel.

High-income residents have a co-pay amount up to $400 for certain expenses, while low-income residents are fully covered under the policy. The policy defines “low-income” as an individual with an income of $70,000 a year or less; individuals who are married or common-law with a combined income of $85,000 a year or less; or individuals with one or more minor children living within their household with a combined income of $100,000 a year or less.

The GNWT is responsible for administering its own NWT Medical Travel Policy, and also shoulders much of the administrative work for the federal NIHB.

What are the main issues with medical travel?

In a presentation delivered at Wednesday’s briefing, representatives from the Department of Health and Social Services and the NWT’s health authority outlined several common issues with the existing policy, including:

• escort decisions;
• valid medical referrals;
• prior approvals;
• flying out early; and
• preferred airlines and accommodation.

MLAs also flagged the lack of clear policies for specific situations, decisions being made too slowly to do any good, and non-medical personnel being final decision-makers about whether or not a person requires a medical escort.

Why aren’t escorts approved? Why does it take time?

Non-medical escorts can also have certain expenses covered, in order to accompany people who are travelling for care.

To be authorized for a non-medical escort, the person who’s going for care has to meet one of these criteria:

• they are under the age of 19 and require an escort;
• they are breastfeeding an infant and require an escort;
• they are pregnant and must travel outside their home community to deliver their baby and request an escort;
• they have a mental or physical disability of a nature that they aren’t able to travel unassisted;
• their referring healthcare provider indicates that the person travelling for an initial diagnosis or initial appointment for a life-threatening illness requires a non-medical escort to assist with understanding their plan of care and/or treatment options;
• they require an escort for interpretation during travel; or
• their attending physician at the treatment facility provides a written request for a non-medical escort to participate in a treatment program, so the escort can learn how to care for the patient following discharge.

However, for NIHB, approval for non-medical escorts comes from Ottawa, which the briefing heard has caused issues.

Monfwi MLA Jane Weyallon Armstrong said sometimes, even in cases where the medical practitioner has approved an escort for medical travel, approval from Ottawa doesn’t come in time for travel. “Maybe it’s due to the bureaucracy, or the time difference with the Ottawa office,” she said. “Sometimes the medical escort does not arrive at the other end.”

“That’s a major issue, especially for those with language and mobility issues,” said Weyallon Armstrong. “It is a nightmare for many.”

Semmler noted that administrative staff in Ottawa work Monday to Friday, 8:30am to 5pm, and don’t have anything set up for requests that may come in after-hours or on weekends.

“We need to make sure that we have an agreement with NIHB that those types of escorts could be approved in a quicker manner,” Semmler said.

“If you’re seeing a practitioner on a Friday and they’re saying you need to travel Monday… and they need an escort, you may not get that approval for that ticket to fly out on that Monday.”

 “We don’t have the control to force them to make those approvals faster,” Semmler said. “But is that something that they can delegate to us, within a criteria, so that we can make those [decisions], so that we know that they’ll be reimbursed?”

What’s the policy for escorts with emergency medevacs?

Yellowknife North MLA Shauna Morgan asked what happens in situations where people in life-threatening conditions are medevaced out: are there any circumstances under which escorts can go with that person?

“I’ve certainly heard from both constituents who are patients or family of patients, but also from physicians who also feel that it would be really important to have close family members there when someone is in a life-threatening condition or you have to make an end-of-life decision,” Morgan said.

Semmler responded that situations like these are “one of the more common issues.”

However, when somebody is being medevaced, that doesn’t activate the medical travel policy.

“Our travel policy only covers the travel costs of getting somebody to and from an appointment,” Semmler said. “If they don’t fall under that, and they’re not approved through NIHB, there’s isn’t a mechanism, we don’t have a policy.”

The medevac gets people to care. Then, if it’s determined they need someone there with them, an escort can be flown down.

“We can’t put escorts on the actual air ambulance,” said Tim Van Overliw, a health authority representative. “It’s only very rare cases where there’ll be eligibility for an individual on the air ambulance.”

Escorts will be flown down if the person who was medevaced to care is leaving the hospital and needs an escort to get home. They’ll also fly down escorts in “cases where that initial medevac turns into an initial life-threatening diagnosis, or another diagnosis which fits under the policy.”

“It really, truly is case-by-case,” Van Overliw said.

Who decides if an escort is needed?

Escort approvals come from administrative staff, not from healthcare providers.

Van Overliw said that separation exists so “instead of just allowing any clinician to approve a non-medical escort … we’re able to align all the recommendations against some type of principle or policy.”

This allows for consistency regardless of who’s requesting the non-medical escort, Van Overliw said. “Sometimes we have a transient workforce that may not be aware of policy, may not be aware of how even the system works to the full extent.”

But it causes a disconnect when healthcare providers advocate for patients to have a non-medical escort, and that request then gets turned down by admin.

“It comes off as arbitrary at the end of the day when you have your doctor, your nurse, all these people pulling for you and saying, ‘We’re trying to help. We’re saying this person needs to be here, and we’re advocating to the Medical Travel [Office]…. to get the exemption for you,’” said Range Lake MLA Kieron Testart. “And then the administration comes back and says, ‘No, we’re not going to do it.’”

“As long as we have non-medical personnel being the final decision makers,” he said, “I think you’re always going to be in [this] situation.”

What’s the special purpose allotment fund?

Semmler said that while the GNWT has been administering the federal NIHB program, the territory hasn’t been fully funded for it. The GNWT itself has “been having to pay for a lot” of the federally insured health service, the minister said.

Assistant deputy minister Perry Heath said what is called a special purpose allotment fund covers the shortfall that emerges through federal underfunding of the NIHB program.

For example, Heath said, if an airline ticket costs $2,000, the GNWT is currently paying $1,600 and NIHB is paying $400.

Last year, Heath said, the GNWT thought Canada was going to begin covering much more of that gap. Instead, the GNWT says it ended up being about $7 million short, partly due to the increasing cost of airline travel. Heath said the GNWT expects “probably double that” this year if a new agreement is not signed soon.

Ideally, there would be full cost recovery, Heath said, so that for a $2,000 airline ticket, the federal government covers 100 percent.

Can people appeal a decision about medical travel?

Yes, you can appeal medical travel decisions.

Testart asked how often appeals were upheld. Van Overliw said he didn’t have the exact number on a year-to-year basis, but shared that “my anecdotal experience over the last eight years under this program is very little do come back as appealed against the actual policy.”

“[The] majority are usually requests that are beyond the policy parameters,” Van Overliw said.

Could Indigenous governments administer medical travel policy themselves?

“We have heard Indigenous governments express that they are interested in administering NIHB, but only if it’s fully funded and the policy issues are addressed,” Semmler said.

A big part of the motivation to getting the federal government to the point of full cost recovery for the NIHB program is that it would enable these Indigenous governments to take over.

“We’ve heard from multiple Indigenous governments that they think they can do a good job of delivering this program, that they understand the pressures in their particular community, particular region,” said Heath.

“But we’re not in a position to be able to hand the burden of a deficit program over to them.

“The intent is, if we can reach an agreement with full cost recovery, it’s a springboard for other groups to take over administration.”

Patients don’t want to travel. What other tools is the GNWT looking at to reduce medical travel? 

“In what ways are we considering options, tools that we could put in our system to make sure that we’re reducing unnecessary medical travel as much as possible?” Morgan asked.

Morgan mentioned suggestions from the NWT’s physicians’ association, such as the use of e-consultation so clinicians could consult with specialists down south, or making sure clinicians in the NWT – including locums and temporary staff – have up-to-date orientation on what tests and treatments are available here.

“Sometimes they don’t even know, and they’re sending people down south for things that we could be doing here,” Morgan said.

Semmler said the GNWT has heard many stories of people who travelled up to three or four days to reach an appointment, only for it to take less than five minutes.

Sometimes, the briefing heard, doctors in Alberta aren’t considering that the patient sitting in front of them may have come from Yellowknife or Behchokǫ̀. They may tell patients they need to come back in six weeks for a follow-up appointment. Later, the Medical Travel Office may change their appointment, so that instead of going to Alberta, they’re seeing a doctor that is travelling into their community. But it can make patients “frustrated,” Semmler said, “because they were told that they needed to go.”

The GNWT is reviewing this, Semmler said. “Maybe it’s changing some of those jobs that are triaging those systems.”

As more reviews take place into why people are travelling for care, and the increasing costs become apparent, “those are key drivers for us to prioritize some of those other areas where we’re reducing the amount of travel,” Van Overliw said, “and ensuring care is closer to home.”

Is the policy going to change any time soon?

Obviously, there are some issues.

Semmler said the GNWT had heard “there are policy or process barriers that may impact the ability of individuals to receive the support they expect while travelling for care.”

Currently, Heath said, the GNWT is taking feedback and producing what he called a “gap analysis” of medical travel policy, looking at things like escort criteria, per diem rates and medical relocation.

“The intent around that gap analysis is to pull together a policy paper that talks about all these things,” Heath said.

The gap analysis will let the GNWT decide what it is going to review or change, and is designed to help it understand the implications “if we’re going to get what we would describe somewhat as a compassionate policy.”

One possibility is the GNWT may stop administering the NIHB program entirely, a prospect that Dehcho MLA Sheryl Yakeleya called “alarming.”

Semmler responded: “Why it is an alarming thing is that … for so many years, we haven’t been fully recovered for this funding, and so it is costing the GNWT every year that we administer this program on behalf of the federal government.

“That’s money we can put back into other programs … At some point, do we continue to just administer it, or do we turn it back over to them?”

The Department of Health and Social Services entered into a new agreement with Indigenous Services Canada in March this year. The department is now working with Indigenous Services Canada to come up with a new agreement, in which the GNWT hopes ISC will take on the full cost of the NIHB program.

“Policy issues with NIHB stem right on back to 1988,” Heath said. “They’re not going to happen overnight. But in the agreement, in the framework, we’re actually going to have a process to be able to iteratively change the policy and update it with Canada and make improvements going forward.”

“We’re hoping that we’ll have an agreement in principle by the end of August,” Semmler said. “That way we can make a decision whether or not we’re going to continue to administrate NIHB on behalf of the federal government.”

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