Submission to the Assembly of First Nations and First Nations and Inuit Health Branch Regarding Non-Insured Health Benefits Medical Transportation

Transcription

1 Submission to the Assembly of First Nations and First Nations and Inuit Health Branch Regarding Non-Insured Health Benefits Medical Transportation Benefit October 2016

2 Role of Friendship Centres in Non-Insured Health Benefits The Ontario Federation of Indigenous Friendship Centres (OFIFC) is a provincial Indigenous organisation representing the collective interests of 28 member Friendship Centres located in towns and cities throughout Ontario. The vision of the Indigenous Friendship Centre Movement is to improve the quality of life for Indigenous people living in an urban environment by supporting self-determined activities which encourage equal access to, and participation in, Canadian society and which respects Indigenous cultural distinctiveness. The OFIFC administers a number of programs and initiatives which are delivered by local Friendship Centres in areas such as health, justice, family support, long term care, healing and wellness, and employment and training. The Friendship Centres represent the most significant off-reserve Indigenous social service infrastructure across Ontario and employ hundreds of program workers and support staff on the ground in urban communities. Friendship Centres are in a unique position to provide insight on non-insured health benefits (NIHB) and its issues from a specifically urban perspective. In concurrence with the Regroupement des centres d amitié autochtones du Québec (RCAAQ), the OFIFC conducted interviews in January 2016 with our Life Long Care and Health Outreach workers to gather their experiences supporting urban community members with their NIHB needs. This paper will be a composite of their direct front-line experiences with NIHB. Our Friendship Centre workers are supporting urban First Nations and Inuit community members with NIHB (herein referred to as clients ) by providing administrative support, advocacy, and service delivery. Administrative: Friendship Centres are helping people, both First Nations applicants and service providers, to navigate the NIHB system, including providing information on benefit entitlements and eligibility, ensuring they have all required documentation for pre-approvals and reimbursements, and helping to fill in necessary forms. They arrange medical appointments, travel and accommodations. Advocacy: Friendship Centres advocate to Health Canada s NIHB program, health professionals and service providers on behalf of community members on their benefit entitlements. They advocate on issues of client pre-payment for services, appropriate services and comprehensive coverage, benefits appeals, and wait times for benefit approvals or reimbursement. Service Delivery: Community members turn to the Friendship Centres for specific services to support, supplement or replace their NIHB benefits. For example, Friendship Centres offer Indigenous language translations, they have provided medical escorts and transportation when suitable alternatives were not available, and keep a cache of medical equipment and supplies when NIHB support is unavailable or limited. 1

3 Challenges with NIHB s Medical Transportation Benefit The policies, procedures and management of the NIHB program are obstructing urban First Nations and Inuit s access to health services as well as impairing their health outcomes. While the program is intended to bridge the gaps between health services and achieve health equity by providing additional coverage for First Nations and Inuit, the manner in which it is being administered creates additional barriers to health care by increasing the burden of bureaucracy for clients and creating a second tier health service system based on income and race. The challenges are preventing urban First Nations and Inuit people from accessing timely and comprehensive health care and causing unnecessary hardship and stress throughout the process. It is our intent to highlight the broad challenges of NIHB in all benefit areas, including medical transportation, as experienced in our urban Indigenous communities in order to rectify the ongoing barriers to equitable health care. Administration The Friendship Centres outlined the following challenges regarding the administration of NIHB, including its policies, management and delivery of health benefits, to its urban First Nations and Inuit clients. Wait Times: The long wait times of medical transportation benefit approvals and service reimbursement are a significant barrier for NIHB users and service providers. Clients are reporting waiting too long for approvals on their NIHB medical transportation service requests, lengthening the time their health issue goes unaddressed and unalleviated. Medical transportation approval is often sent just prior to scheduled appointments, placing a burden on clients to make last minute arrangements. This lack of foresight from NIHB results in cancelled or rescheduled appointments, leaving individuals with delayed or limited access to medically necessary services. Prolonged wait times can also have drastically negative impacts on an individual s health outcomes where assessments and tests regarding complex chronic care are needed. Clients and service providers are waiting an inordinate amount of time (three to six months on average) for reimbursement from NIHB for services rendered. When individuals rely on the travel grant, they must incur the costs ahead of time and wait for reimbursement through NIHB. Clients cannot afford to pay for follow-up treatment until they have been reimbursed for the initial transportation to services and service providers do not want to follow up with clients until they have been paid for their initial services. NIHB Benefit Coverage: NIHB provides medical transportation on an individual basis and is contingent on a client s proximity to medical services, the urgency of the health need and pre-approval by the Health Canada regional office. The amount of funding NIHB offers for transportation and travel accommodations is so minimal that clients have difficulty covering all the costs associated with travel in the northern regions of the province. Medical transportation is not provided for appointments and services located within a client s home community. The lack of suitable transportation options within and between cities leaves community organizations, such as Friendship 2

4 Centres, as a primary point for accessing medical transportation, which places a burden on program resources, few of which are able to specifically provide transportation for medical services. NIHB s travel grant is not available to urban Indigenous individuals in southern Ontario where health services are being regionalized through the province, forcing individuals to travel further for specialized and routine care. Inflexible Policies: The NIHB policies are inflexible and difficult to understand for clients. NIHB polices do not respond well to emergency or crisis situations; it places the burden of cost on the client. For example, if someone has a heart attack and must be medically evacuated to another city, NIHB will pay for the client but not an escort, leaving the client alone and in a fragile condition. In one instance, NIHB refused coverage for a medical escort for an elderly man with cataracts to accompany him to the city for his surgery. The Friendship Centre covered the cost to send an employee with the man three times for his medical appointments. The requirement that clients must get their forms signed at every appointment to confirm they attended the appointment can be challenging if they forget. If they forget to have the form signed: they will not be reimbursed; NIHB will not issue a return ticket if they travelled out of town; and NIHB will not issue any NIHB approvals in the future. Clients have been stranded out of town and denied further benefits for a minor administrative error. The limited reimbursement options prevent many Indigenous clients from pursuing NIHB services in the first place. For clients, especially youth, without a bank account or fixed address, it is difficult for them to submit reimbursement forms for cheques (which requires an address) or direct deposit. Thus they will not seek out NIHB (and often pass on receiving medical care until the situation becomes more serious) because they cannot be sure to be reimbursed for their benefits prepayment. Regarding NIHB s benefits coverage, feedback received from Friendship Centres indicated that medical transportation is the most complex process for clients to navigate. The approval and coordination of travel and accommodations creates further stress on the patient. In the past, Friendship Centres would commonly provide loans to clients to pay for transportation when the cost could not be covered in advance by NIHB or the client. This practice has largely been abandoned due to the length of the reimbursement process and NIHB s unwillingness to designate Friendship Centres as third-party providers. NIHB System Navigation: The NIHB system is difficult to understand and navigate for clients and the Friendship Centres. The NIHB bureaucracy and its processes are difficult to understand for the average user, deterring people from usage and from filing benefits appeals. The website is very difficult for Friendship Centre workers and clients to navigate. It is especially difficult for Indigenous people whose first language is not English. People find themselves being passed around from person to person at the NIHB offices; no one wants to take responsibility for services support. 3

5 When Friendship Centres advocate on behalf of clients, they also find the Health Canada s NIHB office to be very unhelpful and their uncooperative approach adds to the amount of time needed to address clients NIHB issues, taking away from time spent on their Friendship Centre programming. Service Providers NIHB limits access to service providers and limits the services health professionals and providers are able to deliver to NIHB clients. Clients can only address one issue with their doctor at a time, so clients are forced to repeatedly go to the doctor s office (in town or out of town) and must repeatedly apply for travel grants and arrange appropriate accommodations. Accountability and Transparency Health Canada and its NIHB Program are not transparent as to how decisions are made nor do they report to the First Nations and Inuit communities on their decision-making process for approvals or during appeals. Friendship Centres are seeing inconsistencies in approvals and differences in coverage between community members for the same types of health issues and same requests for services and benefits. No explanation is ever provided nor has NIHB provided any criteria for their approvals and appeals process. Most disturbingly is how the whole NIHB system, its approvals/rejections, delivery and appeals process, is administered and controlled by NIHB employees. Approvals or rejections of NIHB benefits are made by NIHB employees at Health Canada and no reasons are given. When rejections are appealed, the appeals decisions are made by NIHB employees at Health Canada. NIHB has identified itself as the payer of last resort and its conduct and minimal coverage policies indicates a mandate to save money which runs counter to the program s intent of increasing health access. There are no external non-nihb representatives nor any First Nations or Inuit representation to hold NIHB accountable to the communities they serve. At the very minimum, First Nations and Inuit representation should be present during the appeals process so NIHB is not evaluating its own decision-making process. Economic Barriers The economic barriers as well as the stigma of poverty associated with NIHB were identified as severely onerous for Indigenous community members and are a significant obstacle to medical transportation services. As NIHB is a payer of last resort offering minimal service coverage and limited payment range, NIHB has created a two-tiered system of health care based on race and income. Only registered First Nations and recognized Inuit people qualify for NIHB and those in the lowest income brackets can expect minimal coverage or to not be able to afford care at all. Considering the average income of Indigenous people in Ontario is about $27,944 compared to $39,655 for non- Aboriginal people, 1 NIHB is placing undue economic and health burdens on the majority of NIHB users. 1 Statistics Canada., Census of the Population (Ottawa, ON: Statistics Canada, 2006). 4

6 The full or partial pre-payment of NIHB services is particularly burdensome on lowincome community members and it compromises their access of medical services, treatment, medication and equipment. As they have little budgetary flexibility to allocate funds to their health service needs nor can they afford to wait NIHB s six to eight week time period for reimbursement, many clients are forgoing the extra costs of preventative health and management services until their health issues reach a crisis state. When NIHB will only partially cover the cost of medical transportation and accommodations, clients must either decline treatment because of the associated cost, or find other means of payment. When NIHB only covers a portion of total cost, finding and coordinating additional finances adds to the time it takes for clients to receive the health service. Recommendations The OFIFC recommends the following to improve the NIHB system: Short-Term 1. Improve transparencies within the application and benefit criteria and appeals process. a. The appeals process should be conducted with representatives from the Indigenous communities to ensure fairness in decision-making. b. Standardize and make public the criteria for decision-making on NIHB rejection and approval requests. c. NIHB should be monitored and held accountable to the federal government and First Nations and Inuit communities for the services it offers. 2. Update NIHB program materials to ensure complete, comprehensive information is available. a. Simplify the website to make it easier to navigate. b. Simplify all forms to be user-friendly. c. Provide information in multiple Indigenous languages (e.g. Cree). 3. Launch an education campaign for all health professionals and service providers on NIHB that includes cultural competency training on urban Indigenous people. 4. Remove potential barriers for patients accessing benefits (e.g. prepayment requirements, quantity/frequency limits, dosage limits). 5. Improve the timelines for approvals, appeals and reimbursements for clients and service providers. 6. Offer various reimbursement methods of clients (e.g. direct deposit versus cheques). 7. Remove 6 month re-application requirement and develop a system of ongoing approvals for services for clients expected to require NIHB support indefinitely. 5

7 Medium Term 8. Strengthen relationship with provincial Ministry of Health of Health and Long-Term Care-led programs to improve alignment (e.g. Ontario Drug Benefit Program, Ontario Health Insurance Plan, Ontario Works, Ontario Disabilities Support Program). 9. Provide incentives for health professionals to adopt and implement organizational policies and procedures that accommodate Indigenous people. Long-Term 10. Develop comprehensive program to address capacity issues related to the provision of services to urban First Nations and Inuit. 11. Integrate bioethics review into NIHB process. 6