View 1 - Funding Systems in Ontario
Krista Davis, R.R.P., CBIS Clinical Examiner
Carrie Beatty, CBIS Clinical Examiner
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Our proudest achievement in the well being of Canadians has been in asserting that illness is burden enough in itself. Financial ruin must not compound it. That is why Medicare has been called a sacred trust and we must not allow that trust to be betrayed.
— Canadian Justice Emmett Hall (1986)

History
Thomas C. Douglas (1904-1986), known as “The Father of Canadian Health Care,” was not a doctor; he was a politician from Saskatchewan. He introduced socialized medicine (state-sponsored and salaried-physician medical care) to the province of Saskatchewan during his 44-year political career. Douglas envisioned and worked towards a universal system of health care that moved beyond provincial to national enactment and that, today, has become the envy of most countries of the world. From 1944 to 1960, the Saskatchewan government pioneered the first public hospital insurance and Medicare programs in Canada. Saskatchewan became the first province whose government enacted hospital coverage (in 1947) and medical coverage (in 1962). It began with province-wide hospital coverage and a pilot project of full medical services in the town of Swift Current. Doctors were paid salaries by the government (via taxes), which in the end proved to be more money than medical practitioners had earned in the past. It proved successful and full medical services programs were extended to the entire province in 1962 (The Centre for Canadian Studies at Mount Allison University, 2001).

In 1958, the Hospital Insurance and Diagnostic Services Act was passed, providing government-sponsored hospital coverage to all Canadians. In 1964, a royal commission recommended a national health care system modeled on the Saskatchewan plan, extending the 1958 Act to include health care with full medical coverage. In 1968, the Medical Care Act was passed providing universal health insurance to all Canadians. Doctors work on a fee-for-service basis, billing not the patient but a third party – the Canadian government. Canadian physicians have lobbied effectively to secure their position as private practitioners and not salaried employees of the government. In 1984, the Canada Health Act replaced earlier hospital and medical coverage acts. As stated in the Canada Health Act, the federal government is committed to maintaining Canada’s world-renowned health insurance system. This system is universally available to permanent residents, comprehensive in the services it covers, accessible without income barriers, portable within the country, and publicly funded. Each province and territory administers its own health care plan with respect to these five basic principles of the Canada Health Act (The Centre for Canadian Studies at Mount Allison University, 2001).

Ontario Hospital Insurance Plan (OHIP)
In Ontario, the Ontario Hospital Insurance Plan (OHIP) ensures that residents, regardless of their socioeconomic status, are provided access to healthcare. This system provides 32 million people, who are spread out over 10 million square kilometers, equal access to government-funded health services (Connolly, 2002). The federal government finances about 40 percent of the cost, provided the provinces set up a system satisfying federal norms (Lemieux, 1989). General or specific provincial taxes fund the remaining costs. The Ontario Health Premium (OHP), which came into effect July 1, 2004 is an example. The OHP is based on individual taxable income and is collected by the Canada Revenue Agency, generally through automatic payroll deduction. For the year 2005 and subsequent tax years, for individuals with a taxable income over $20,000, annual premiums will cost the individual taxpayer between $300 to $900 in additional taxes (Mercer, 2004).

Acquired Brain Injury (ABI) affects approximately 18,000 Ontarians a year and about 8,000 of these brain injuries are a result of traffic collisions (Ontario Brain Injury Association, 2003). Treatment and rehabilitation for acquired brain injury is highly specialized and can last for a long period of time. The most severe cases may require life-long supports. Such treatment and support can be extremely costly. Direct and indirect costs associated with ABI are estimated to be $1-billion annually in Ontario and more than $3-billion annually in Canada (Miojevic, 2002). In short, ABI tends to be one of the insurance industry’s worst nightmares and disputes over what constitutes reasonable and necessary treatment are not infrequent.

Ministry of Health and Long-Term Care
When a person is injured in a motor vehicle accident, funding will be provided through automobile insurance. The provincial legislation dictates the Statutory Accident Benefit Schedule (SABS). SABS requires the automobile insurer to pay for non-professional healthcare services such as personal support, attendant care services, and community and homemaking services. These services may be provided at home or in community settings such as supportive housing units, long-term care facilities, and chronic care hospitals (Ministry of Health, 2002c).

Automobile insurers should arrange non-professional health services for their clients and pay the service provider directly. After statutory accident benefits have been exhausted or the level of service required exceeds specified maximums, the Ministry of Health and Long-Term Care may consider funding these services. Such funding is subject to assessment of the client and applicable Ministry limits. Typically, Ministry funded non-professional services are provided through local Community Care Access Centers (CCACs), long-term care facilities, or other third-party agencies. Clients who may require these services include those suffering serious or catastrophic physical injuries, closed head or acquired brain injuries, and the elderly (Ministry of Health, 2002c).

If a person is injured in an accident caused by someone else’s negligence or wrongdoing and the person makes a claim for damages or initiates a lawsuit, the Ministry of Health and Long-Term Care can recover its costs for healthcare and treatment. Each year, the Ministry recovers over $12 million from insurance companies through subrogation. Subrogation is a legal term unique to Insurance Law. It means “the right to recover
costs for injury caused by the fault or negligence of another person” (Ministry of Health, 2002c). The Ministry’s right to subrogation is enforced through legislation.

The most common examples of personal injury accidents for which the Ministry recovers healthcare and treatment costs are (Ministry of Health, 2002b):
• Slips and falls
• Boating, air and rail accident
• Product liability or manufacturing defects
• Medical malpractice or professional negligence
• Dog bites
• Municipal liability
• Assaults
• Some motor vehicle accidents
• Class actions

The Ministry’s right of recovery applies to any incident regardless of the location. This includes other provinces and foreign jurisdictions that allow subrogation or other reimbursement rights.

The Ministry can recover costs for:

• OHIP insured services including
o Physician services
o Practitioner services such as chiropractic, physiotherapy
o Hospital services includingin/outpatient, acute and chronic care
o Air ambulance; out-of-countryout-of-province medical and hospital services

• Extended care services typically administered through CCACs in a home, health facility or school including
• Professional services such as nursing, physio/occupational/ speech therapy, social work or a nutritionist
• Non-professional services such as:
Homemaking services including house cleaning, laundry, banking, shopping, preparing meals
• Personal support or attendant care/outreach services such as assistance with personal hygiene and activities of daily living
• Long-term care accommo- dation and services in nursing homes, charitable homes and homes for the aged (Accommodation costs cannot be claimed in other facilities such as
supportive housing. See Ontario Disability Support Program “ODSP” below.)
• Community support services such as meals and transportation, caregiver supports, adult day programs, home maintenance and repair, social or recreational services (Ministry of
Health, 2002b)

The Ministry of Health and Long-Term Care pays for:

• Medical costs (all physician services)
• Some practitioner costs (e.g. chiropractors)
• Hospital services
• Mental health facilities
• Air ambulance
• Some professional health services such as nursing provided in the home, school or community
• Any other ministry-funded services not covered under the Long-Term Care Act

Automobile Insurers * pay for:

• Community Support Services
- Meals and transportation
- Caregiver support
- Home maintenance and repair
- Social or recreational services
• Homemaking Services
- House cleaning, laundry
- Preparing meals
- Banking, shopping
- Attendant Care/Personal Support
- Assistance with personal hygiene
- Assistance with activities of daily living

[ * Up to specified maximum limits (e.g. $3000 - $6000 per month and $72,000 per year to a maximum of $1 million if a catastrophic injury for attendant care; $100 per week for homemaking) ]

Reference

From “Who Pays for Healthcare: Injuries from Motor Vehicle Accidents” by Ministry of Health and Long-Term Care, 2002. Copyright 2002 by the Queen’s Printer for Ontario. Reprinted with permission of the Ministry of Health and Long-Term Care.

The Ministry recovers the cost from insurance companies (or at-fault parties) for all OHIP-insured health services provided up to the time of settlement or judgment. It also claims the costs for future insured healthcare services that a person who is injured may need. Where a person who has been injured has been assessed for long-term care services and benefits, funding is provided on a bridge or interim basis until settlement funds have been received (Ministry of Health, 2002b). Subrogation does not apply for future non-professional healthcare services or benefits such as attendant care, personal support and homemaking. The person who is injured must include a claim for the cost of these services in his or her personal claim for damages. Once settlement funds are received, he or she can then purchase these services directly.

There are 43 CCACs in Ontario, two of which are hospital-based. Forty-one of the 43 are statutory corporations of the government of Ontario. The remaining two are governed by integrated health service agencies. CCACs are run by Boards of Directors and the Government appoints Executive Directors. CCACs provide a simplified point of access to care for more than 400,000 people each year. Some of these services are provided on a short-term basis to help people returning home from the hospital, to support people through their recovery from an illness or accident, or to assist people with disabilities or chronic health problems on a long-term basis. CCACs arrange and authorize visiting health and personal support services in peoples’ homes, authorize services for special needs children in schools, manage admissions to long-term care facilities and provide information and referrals to the public about other community agencies and services. Services coordinated through CCACs include nursing, physiotherapy, occupational therapy, speech-language therapy, dietician services, social work, personal support and homemaking. CCACs’ services are available to eligible Ontario residents of any age and are fully funded by the Ministry of Health and Long-Term Care (Ministry of Health, 2002a).

CCACs employ case managers who assess client eligibility for visiting health and support services, develop, monitor and adjust service plans as required, and authorize services. In addition to the professional services available on a contract basis, CCACs provide
additional support for clients who receive in-home professional health services by purchasing or renting medical supplies, as well as dressing, hospital and sickroom equipment, and laboratory and diagnostic services. Also, in limited circumstances, arrangements can be made for the provision of drug benefits to eligible persons (Ministry
of Health, 2002a).

Ministry of Community and Social Services
The Ministry of Community and Social Services (MCSS) administers the Ontario Disability and Support Program (ODSP), which was designed to meet the income and employment support needs of people with disabilities. As well, the program provides health-related benefits to people with disabilities. Basic health-related benefits include prescription drug coverage and basic dental care. Individuals with disabilities who require professional support systems, such as specialized housing in residential group homes, are required to pay personal room and board expenses from this disability pension. The Government of Ontario (specific to the ODSP) reports for the month of June, 2004 a total of 283,677 beneficiaries of the Ontario Disability Support Program in the “All Family Structures” category, of which 157,114 beneficiaries are single (Ministry of Community and Social Services, 2003).

Blended Funding
At times, an individual whose injury is not covered by automobile or workplace insurance may use blended funding. An example of this type of funding would be an individual who acquired a brain injury while skiing. All costs while in the hospital would be covered by OHIP (or the equivalent hospital insurance plan of the province). Once the individual is discharged from the hospital and requires a post-acute supported living setting, he/she may be eligible for attendant care funding through the Ministry of Health and Long-Term Care or through private settlement funds. As mentioned earlier in the article, room and board costs are the responsibility of the individual and he/she may apply for funding assistance from ODSP. Need for professional services of licensed
therapists, such as Occupational Therapists, Physiotherapists, and Speech Language Pathologists would be assessed and, if needed, funded through the local CCACs. While psychological services are not funded through the local CCACs, individuals assessed as appropriate to live in residential group homes operated by approved providers of Supportive Housing Programs have a specific portion of their “care” dollars designated for psychological services. Supportive Housing programs are funded by the Ministry of Health and Long-Term Care.

As you can see funding is available from many sources. Knowledge of eligibility and how to seek these sources of funding is essential to receiving the supports and services needed after a brain injury.

References

The Centre for Canadian Studies at Mount Allison University (2001). Canadian medicine: Doctors and discoveries. Retrieved August, 2004, from www.mta.ca/faculty/arts/canadian_studies/english/about/study_guide/doctors/delivery.html

Connolly, G. (2002, November 18). Canadian health care: The universal model evolving. Retrieved August, 2004, from http://www.cehat.org/rthc/paper4.htm

Hall, E. (1986, April 3). Speech to the Manitoba Health Coalition.

Lemieux, P. (1989, March). Socialized medicine: The Canadian experience. The Freeman. Retrieved August, 2004, from
http://www.theadvocates.org/freeman/8903lemi.html

Mercer Human Resource Consulting (2004, May 19). Ontario budget’s perscription for healthcare. Communique’, 1-2.

Ministry of Health and Long-Term Care (2002a). Community care access centres. Retrieved August, 2004, from
http://www.health.gov.on.ca/english/public/contact/ccac/ccac_mn.html

Ministry of Health and Long-Term Care (2002b). Personal injury accidents: Recovering healthcare costs. Retrieved August, 2004, from
http://www.health.gov.on.ca/english/public/pub/ohip/injury.html

Ministry of Health and Long-Term Care (2002c). Who pays for healthcare: Injuries from motor vehicle accidents. Retrieved August, 2004, from
http://www.health.gov.on.ca/english/public/pub/ohip/motorvehicle.html

Ministry of Community and Social Services (2003, November 21). Ontario disability support program. Retrieved August, 2004, from
http://www.cfcs.gov.on.ca/CFCS/en/programs/IES/OntarioDisabilitySupportProgram/default

Miojevic, M. (2002, Summer). The integrated rehabilitation system: Towards better support for people with TBI. Abilities Magazine. Retrieved August, 2004, from
http://www.abilities.ca/abilities/archive.html?article=1885

Ontario Brain Injury Association (2003, December 31). How to reduce insurance premiums without compromising the coverage for accident victims.
Retrieved August, 2004, from Ontario Brain Injury Association Web site http://www.obia.on.ca/autoinsurance/autoinsur12103.pdf

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