In retrospect, Steve Rider would have taken out a loan if necessary to access gastric-bypass surgery in the United States that likely saved his life.

Battling a lifelong weight problem, Rider had struggled through every diet and workout regime going. At 48, 445 pounds still sat heavily on his six-foot, five-inch frame and the consequences were showing. With Type 2 diabetes, high blood pressure and cholesterol, and an oxygen mask worn nightly for his sleep apnea, Rider knew time was running out to find a lasting solution.

“People said, 'just back away from the table,'” he recalls. “But it’s not that simple.”

When his accountant told him about the OHIP-covered weight-loss surgery available from the Barix Clinic in Ypsilanti, Michigan, he checked it out.

The website has an information link for Ontario residents on its home page.

“Nobody had ever suggested the solution of bariatric surgery before,” he says. When Rider asked his doctor about accessing similar services locally, “my doctor didn’t know anyone to refer me to.”

Instead, the doctor facilitated the paperwork provided by the American specialty clinic so Rider could have the surgery covered by OHIP.

Long waits, unavailable procedures and poor physician access are driving record numbers of Ontarians to seek treatment south of the border and sometimes overseas.

A Metroland Special Report on Cross Border Care shows:

- A 450 per cent increase in OHIP approvals for out-of-country care since the beginning of this decade, a period of explosive growth in new technologies and therapies not covered or available here. The province agreed to fund 2,110 procedures or treatments in 2001, and 11,775 last year.

- Patient demand has created a new breed of health-system navigators, known as medical brokers, who find U.S. options for the growing number of Ontario patients who elect to pay for medical services south of the border.

Medical brokers negotiate discount rates with U.S. centres to get Ontarians faster diagnostics, second opinions and surgery.

Brokers say that for every patient sent south by the Ontario government, there may be up to 10 others who go — and pay — on their own.

- Ontario’s spending on out-of-Canada medical services has tripled in the last five years. Payments in 2010 will balloon to $164.3 million, from $56.3 million in 2005. The province said in last month’s economic forecast it needs to increase health spending by $700 million to cover “higher than anticipated” OHIP costs, including services outside the province.

While out-of-country spending is a small part of the $11 billion OHIP pays for all patient services a year, the increase is significant, Ontario’s health minister says.

“Are we looking at ways to reduce out-of-country? Absolutely yes,” said Deb Matthews, who became health minister last month.

Matthews says her ministry is taking steps to improve services and access across Ontario so fewer patients will need to go to the U.S.

At the same time, though, the ministry continues to negotiate preferred rates for Ontario patient visits to U.S. health centres, the Metroland investigation shows:


- Ontario has become a major contractor — a bulk buyer — of American health services this year.
Since spring, the ministry has entered into funding contracts with U.S. hospitals, imaging clinics and residential treatment centres. It has these “preferred provider” contracts in place with about 40 American medical providers now — and is accepting solicitations from others. Contracts cover diagnostics, cancer care, bariatrics and adolescent behavioural disorders.

The ministry says the agreements ensure “more immediate services for patients whose health is at risk.”

It has declined to release details of any of the agreements.

- The province does not track the number of Ontarians who cross the border for care on their own, never seeking government pre-approval or reimbursement.

But major U.S. medical centres contacted by Metroland — including Detroit’s Henry Ford Health System and the Mayo Clinic — say both government-funded and private-pay patient lists are growing.

The Mayo Clinic, which sees about 600 Ontario patients a year, says top reasons include wait times and diagnostic evaluations “when they’ve exhausted options in Canada,” says Mariana Iglesias of the Minnesota-based clinic.

OHIP’s pre-approved funding program for out-of-country care is supposed to fill gaps in health care for high-risk Ontarians.

But patients who use the system express repeated concerns — about the time it takes to get OHIP approval, and to appeal if refused.

“I really believe they make it as difficult as possible,” says Janet Nancarrow of Ottawa who is preparing for an OHIP appeal hearing for her 34-year-old daughter, Lisa, who is taking part in a clinical drug trial at the Mayo Clinic.

Her doctors and family say the trial is her only option short of end-of-life palliative care. With no outside help, Nancarrow said, she had to research precedent cases, find expert witnesses and keep up with enormous paperwork — all while accompanying her daughter back and forth to Minnesota for treatments.

“They shouldn’t put families through this,” she said.

- Ontario continues to struggle with wait times. This month, almost 140,000 people are on wait lists just for CT scans and MRIs.

- Wait-time insurance policies have emerged as the industry caught on to public angst. While no industry figures exist to indicate the level of consumer take-up of the coverage, plans are available to reimburse costs of private treatment when policyholders are forced to wait more than 45 days.

Ontario says it has made strides to reduce waits for the priority procedures it monitors. But the Ontario Health Quality Council — which the ministry set up to review provincial progress — says more needs to be done.

“Many Ontarians still wait too long for urgent cancer surgery, MRI scans … and specialists,” the council says in its 2009 report.

Ontario NDP leader Andrea Horwath says the OHIP out-of-country surge has taken on momentum, and that government must stop the southbound flow.

“The government needs to reinvest the dollars that they’re shoving out the door to private providers of health care in the States, and invest that in providing services here at home,” she said.

But in the meantime, patients like Rider see the cross-border option as the best way to overcome their health issues.

Without the OHIP coverage, the Wasaga Beach man says he would not have pursued surgery in the U.S, but has since seen the value in the option regardless of cost.

During the pre-surgery process, Rider did discover similar service in Ontario, but they came with several months wait just for the appointment with the specialist.

“I was told it would take two years to have it done,” he recalls.

Since his April 21 surgery, which reduced his stomach to the size of a golf ball, Rider has lost approximately 188 pounds and is learning new nutritional skills.

Although he has 30 pounds left to lose to reach his goal, he has tested within healthy ranges for his blood sugar, blood pressure and cholesterol, and is awaiting the test that will have him pack away the oxygen mask.

Christine Elliott, Ontario Progressive Conservative health critic, says she wants to know what’s being funded “to know if there are specific trends … to look at the system of delivery of care and where changes need to be made.”

Sheila Acker of the Henry Ford Health System says the Detroit area medical centre has seen its Ontario patient population grow.

Many come for bariatric services (weight-loss surgeries for the dangerously obese, through gastric bypass or banding) provided through one of the preferred-provider contracts the ministry has arranged. But Acker says not having OHIP funding has not precluded people from coming.

“If they are concerned about a health issue and know it will be a long wait, we’re 10 minutes from the Windsor border. If they don’t want to wait for their procedure, that’s who we’re seeing.”
- New technology that’s unavailable in Ontario is also an issue, especially in genetics.

Genetic tests — in which a person’s chromosomes are examined — are widely used now to predict disease and help diagnose illness.

Out-of-country requests to OHIP for such testing have increased 200 per cent in five years.

That’s because Ontario has not kept up, said Dr. Suzanne Kamel-Reid, head of laboratory genetics and director of molecular diagnostics at Toronto-based University Health Network.

“The number of tests available in the U.S.have increased, and we in Ontario haven’t kept up with having the same amount of tests available,” said Kamel-Reid.

Matthews, the health minister, says this is a high-priority issue the government is trying to remedy.

She said the ministry has identified the five highest-volume genetic tests, and is trying to improve access to them here.

When a person has metastatic colon cancer, for example, a test can be done for the presence of a mutation in a specific area of a specific gene. That helps doctors know whether the patient will respond to certain therapies.

But out-of-country care focuses most heavily on patients, not tests.

- Requests by Ontario patients for funding of care across the border have more than doubled in four years. Last year, more than 12,000 applied to OHIP for pre-approval of U.S. procedures, including cancer and cardiac care, up from 5,800 applications in 2005.

Patients also go south because they say they want to be assured their Ontario diagnosis was correct.

Doctors say they understand why some patients balk at finding an option here.

“It’s a socialized system and for 97, 98, 99 per cent of people for their regular, everyday little problems, it’s reasonably good,” says Jeffery Brock, a Montreal emergency physician and cofounder of MedExtra, a Canadian firm that helps patients co-ordinate their care. “You have something that’s a little bit more complex, you want a bit higher standard of care, it’s really not available.”

U.S. medical facilities, such as Baltimore’s Johns Hopkins Hospital, and the UCLA Health System in Los Angeles, say they are seeing more patients from north of the border with complex problems they cannot have solved at home.

“It is growing, mainly in terms of patients that have really highly unique issues, high-complexity cases, and also with people and patients who receive a diagnosis and then would like to make sure it’s the correct diagnosis,” said Raffaella Molteni of Johns Hopkins.

Wait times:
Ministry of health figures show the number of people on official wait lists, on Nov. 1:
MRI scans: 74,867
CT scans: 61,506
Cancer surgery: 5,086
Hip replacement: 3,890
Knee replacement: 8,684
MRIs and CT scans have been among the most-requested U.S. procedures for years — due to long Ontario wait times and proximity to U.S. border-city clinics.
The province reported that the wait for an MRI was 109 days at the end of September. The province’s target wait time is 28 days.

Border cities
Border cities, such as Buffalo, N.Y., are used to medical visits from Ontarians seeking a variety of medical care, some funded through OHIP, and some private pay.
Buffalo’s Roswell Park Cancer Institute is an OHIP-preferred provider that takes Ontarians with pre-approval for three specified types of cancer care.
One of the treatments is for advanced skin cancer. Over a three-year period, OHIP paid for about 70 Ontario patients to receive interleukin 2 treatment for metastatic malignant melanoma.
All the treatments covered by OHIP at Roswell are offered in Ontario. But the province says it sends patients to the Buffalo centre when they are not able to be treated in a timely fashion in Ontario.

Pre-approved OHIP Spending on Out-of-country procedures
09-10 — $164.3 million (estimate)
08-09 — $127.9
07-08 — $101.4
06-07 — $70.1
05-06 — $56.3

Links
Ontario Wait Times

Health Services Appeal and Review Board

Ontario Health Quality Council