Spotlight 3/3

Patient Ombudsman receives many complaints each year from patients, residents and caregivers challenging fees charged for uninsured health services including private and semi-private accommodation, co-payments in chronic care and long-term care homes, and fees charged to uninsured patients.

Patient Ombudsman has completed three investigations, including two in 2022/23 that make recommendations aimed at improving policies and processes related to fees and billing. One area that hasn’t been explored in prior Patient Ombudsman reports is the fees charged for ambulance and medical transportation services.

Many people are not aware that ambulance services are not fully funded by OHIP, or that they may be eligible for an exemption from the co-payment. A standard $45 co-payment is charged by hospitals when OHIP-insured patients receive medically necessary ambulance services, unless one of the prescribed exemptions apply. Those exempted from the co-payment include patients:

• receiving benefits under the Ontario Works Act, the Ontario Disability Support Program Act or the Family Benefits Act;
• receiving general welfare assistance or family benefits;
• being transferred from one hospital or health care facility to another for insured, medically necessary treatment;
• receiving a professional service (e.g., nursing, physiotherapy) through Home and Community Care; or
• living in a long-term care home, a home for special care or a home or residence for psychiatric patients.

If ambulance services are not deemed medically necessary, the patient is responsible for the full cost – $240 for non-medically necessary land ambulance – regardless of the patient’s circumstances. Medical necessity is determined by the patient’s physician, but is not defined in policy, legislation or regulation. Patient Ombudsman has been informed by many hospitals that the need for transportation on a stretcher does not, on its own, indicate medical necessity for ambulance services. Ambulance services are specifically designated and staffed for a higher-intensity level of care. Ambulance services are regulated by legislation and stretcher transport services (including associated costs) are not regulated or covered by OHIP and, unlike ambulance services, there is no provision for exemptions from payment for inter-facility transfers or when the person receives social assistance. As a result, it’s not unusual for patients who come to hospital from a long-term care home by ambulance for a health emergency to have their ambulance costs fully funded under the co-payment exemption. When the person is discharged, even if stretcher transportation is required, the patient may be charged an unregulated cost of hundreds of dollars. Patients or family members are often told that it’s their responsibility to arrange transportation with a private stretcher transport service provider.

In 2022/23, Patient Ombudsman received 14 complaints involving concerns about the fairness of fees charged for ambulance services or other types of medical transportation. Some of the complaints reflected concerns about being charged the $45 co-payment despite learning that the patient met the criteria for an exemption. Others reported questions or concerns about being charged the full cost of stretcher transportation when being transferred between hospitals or from hospitals to long-term care homes. Patient Ombudsman has noted that some hospitals consider the patient’s circumstances and are prepared to waive the fees or cover the costs for patients moving between health care facilities, while others argue that the charges are permitted within the current policy and are not willing to waive fees.

Patient Ombudsman has been receiving complaints about the cost of stretcher transport services since the office opened in 2016. It is inequitable that there is a significant difference in cost (up to hundreds of dollars) based solely on the fact that a designated ambulance is determined to be medically necessary. It seems unfair that frail patients who require stretcher transportation must assume significant costs regardless of their ability to pay, while patients that are well enough to be transported by car do not have to pay or pay much less. Ultimately, it is a government policy decision in terms of how and whether costs for non-emergency transport services are regulated. In the absence of policy or regulation, decisions will continue to be made on a case-by-case or hospital-by-hospital basis.