On June 10, 2011, the Ontario Liberal government proposed to regulate non-emergency patient transfers via legislation establishing quality and safety standards for transfers between health care institutions in non-emergency situations. This followed on the heels of some harsh criticism of the patient transfer industry from the provincial Ombudsman, Andre Marin.
In fact, problems with the for-profit patient transfer industry have been reported to the government for some years. Such reports began when the Ontario Progressive Conservative government introduced legislation in 2000 requiring hospitals to forego the use of ambulances and Emergency Medical Services (EMS) to move patients between hospitals or long-term care facilities if the patient was in stable condition.
This led to a drastic increase in the for-profit patient transfer business. While EMS is largely provided by highly regulated, not-for-profit public organizations, patient transfer operations are usually run by for-profit businesses. These businesses generally make their trucks looks like ambulances and the public often thinks they are ambulances. But they are, of course, not ambulances and there is little regulation of these private businesses.
Problems, Problems, Problems
· In 2000, the Auditor General recommended that the Ministry of Health and LTC work more closely with municipalities and hospitals in the development of standards for non-ambulance medical transfers.
· In 2002, the Ministry of Health & LTC hired IBI Group to look into the patient transfer services industry. That report outlined serious concerns around risks to patients because of the lack of standards.
· The May 2004 Report of the Land Ambulance Acute Transfers Task Force indicated that regulating medical transport services was the minimum required action to ensure patient safety. The report’s recommendations suggested that new provincial regulations on medical transport services were needed to ensure patient safety and operator accountability.
· In 2005, the Auditor General recommended that the Ministry should work jointly with the municipalities and hospitals to “develop and put in place standards for non-ambulance medical transport services to address passenger safety.”
· In the spring 2005, the Ministry appointed a lead for the transformation of medical transportation in the province. A working group was established to make recommendations to the Ministry on the future governance and delivery of non-ambulance medical transport services and on the use of appropriate transport services for inter-facility transfers.
· In 2006, the Legislature’s Standing Committee on Public Accounts requested an update on the development of standards.
Even after all this, the government went backwards.
· In 2007, the Auditor General reported this galling response to his 2005 recommendation for standards: “The Ministry of Health and Long-Term Care (Ministry) indicated that non-ambulance medical transportation services are part of the Ministry of Transportation’s mandate. While the Ministry told us that it was aware of meetings between the Ministry of Transportation and the Medical Transportation Association of Ontario (which represents the non-ambulance medical transportation industry) the Ministry was not involved in these meetings. At the time of our follow-up, the Ministry indicated that it was engaged in dialogue with the Ministry of Transportation regarding the regulatory framework for such medical transportation services, and it planned to continue this dialogue with this and other relevant ministries in order to reassess the regulatory framework and standards in use and determine if they are adequate.”
The issue goes public
Things began to happen, however, in December 2009, when a CBC radio documentary on the Ontario patient transfer industry was first aired. Here are some of the findings of the journalist who made the documentary, Tina Pittaway:
· The number of Ontario patients being transferred by for-profit companies expanded drastically in the last decade as a result of changes made to the Ambulance Act by the Progressive Conservative government of Mike Harris.
Legislation was introduced in 2000 requiring hospitals to forego the use of ambulances to move patients between hospitals or long-term care facilities
if the patient was in stable condition.
· Despite assurances prior to the legislative changes from then Minister of Health Elizabeth Witmer and her parliamentary secretary Tim Hudak, now the leader of the Ontario Progressive Conservative Party, minimum standards for staff or equipment were never developed by the ministries of health or transportation,
nor have they been developed under the Liberal government of Dalton McGuinty
· The province picks up the tab for 50 percent of the costs of the transfers using ambulances and the EMS system. The other 50 percent is covered by patients, hospitals and municipalities. For transfers through the private transfer industry, the province doesn’t pick up any part of the tab; the costs are charged to hospitals, municipalities and patients. Downloading these costs from the provinces books was a key motivator in the Harris changes to the Ambulance Act.
· While some of the attendants interviewed for the CBC report were qualified paramedics, many had no medical training beyond a basic CPR certificate and were paid in the range of $11 to $13 an hour. Workers within this industry who express concern to their dispatch operators about their patients’ safety
are routinely suspended or fired. Unlike EMS ambulances, which are staffed
with fully trained and certified paramedics, these companies are not required
by the Ministry of Health of Ontario to meet basic minimum requirements in training or ability. It is the only ministry of health in the country that does not regulate these services.
· In interviews since 2009, workers have recounted such experiences as trucks catching on fire and lug nuts shearing off wheels. In both of those cases, patients were aboard the trucks. One worker said she was ordered by her dispatcher to drop off a homeless patient in a back alley of Toronto. Workers, many of whom requested anonymity, also recalled cases in which patients who required oxygen during transit were denied it, either because a dispatcher ordered the transfer despite the attendant’s protests that the tanks were empty, or the attendants didn’t know the patient required oxygen.
· When asked if patients have the right to refuse to be transported aboard these private transfer vehicles, Minister of Health Deb Matthews said they do. However, since ambulance transportation is not insured under the Ontario Health Insurance Act, patients and their families would be charged $240 for the cost of the transfer.
· In 2002, the Ministry of Health, then under Tony Clement, hired IBI Group to look into the patient transfer services industry to get an understanding of how
the system was performing in the wake of the legislative changes made to the
Ambulance Act. That report outlined serious concerns around risks to patients because of the lack of standards. Despite assurances prior to the legislative changes, minimum standards for staff or equipment were never developed by
the ministries of health or transportation, nor have they been developed under the Liberal government of Dalton McGuinty.
· Regulated ambulances that transport infectious patients are taken out of service after each transport to go through a deep clean, whereby all equipment, surfaces and stretchers are disinfected. There are no such requirements for private companies.
· Patients are frequently exposed to infectious patients transported alongside them inside these vehicles, by staff who have no training in infection control precautions.
· “A catastrophe could happen, and we could get transmission of contagious disease,” said Dr. Ignatius Fong, head of Infectious Diseases at St. Michael’s Hospital in Toronto, in 2009. “Many of the situations is what we think occurs
only in third world countries and developing countries where they don’t have
the resources, don’t have sterilization. But that it’s really occurring right now in Ontario, Canada, it’s bothersome.”
· Patients who require oxygen during transport are not receiving it, sometimes resulting in catastrophic effects on their health. Kathleen Goldhar’s four-month-old son, Nathan, nearly died in 2006 as a result of a transfer from Sick Kids Hospital to Toronto East General, during which both attendants sat in the front
of the truck, leaving Goldhar, her mother and her seriously ill baby in the back. Goldhar said she was told by nursing staff at the hospital that Nathan, sick with
a severe respiratory infection, should have been administered oxygen throughout the trip.
· Individual hospitals, which are ultimately responsible for the safety of patients admitted to their facilities, sign contracts with the companies that provide these services.
· Due to the sheer volume of non-urgent patients that require transfers, the private companies can’t handle all the cases. So even today, about 70 per cent of non-urgent patients are still being transported in regulated ambulances.
The Ombudsman followed up the CBC documentary with his own report on this industry. He was equally scathing.
Ontario residents would be better off taking a taxi to a hospital than one of the privately owned vehicles used to transfer hundreds of thousands of non-critical patients each year, provincial watchdog Andre Marin told the Canadian Press.
The Ombudsman said he was “blown away” by the stories he heard while investigating non-emergency medical transfers. “Of all the cases that I’ve done since I’ve been ombudsman, this is a case where I’ve rarely seen such incontrovertible and conclusive and convincing evidence early on, that was really not in dispute,” he said. Marin said he received more than 60 complaints about private companies providing medical transfer services.
It’s allowed private companies to charge hundreds of dollars per patient for transports
in old, beat-up ambulances operated by “kids” with no medical training, he said.
“They place people’s lives in serious jeopardy,” Marin said. “These vehicles - that for
all intents and purposes are ambulances - are completely without any rules,” Marin said. ”It’s astounding.” There have been other complaints about lack of infection controls, and even parts falling off unsafe vehicles. Marin said complaints had been circulating for at least 10 years, but fell on deaf ears until now.
Marin, who launched his investigation in January 2011, said what he found was so compelling that he halted the probe and asked Premier Dalton McGuinty directly for immediate action. ”Of all the cases that I’ve done since I’ve been ombudsman, this
is a case where I’ve rarely seen such incontrovertible and conclusive and convincing evidence early on, that was really not in dispute,” he said.
The government responded as if this was a new problem: “We became aware that people thought they were in an ambulance when they weren’t, they thought that the driver had skills that they didn’t have,” Health Minister Deb Matthews said in an interview. “So regulating to make sure that they meet certain standards is what we
will do. Exactly what those standards will be is something we’re going to be working on.”
NDP health critic France Gelinas commented on the government’s announcement: “Anybody who had the health file knew about this, and they did nothing for the eight years that they were in power…Now they say, ‘Re-elect us so we will act.’ My answer to this is: where were you for the last eight years?”
As the legislature has stopped sitting and will not sit until after the fall election, the implementation of this policy will depend on whoever is elected in the provincial election October 6. A Progressive Conservative or NDP government will not be bound by a Liberal government promise.
The Liberal government is only promising to set ‘core standards’ for non-emergency patient transfers between health care facilities, so even if passed, it sounds like the government is limiting expectations regarding how much regulation will be placed on this sub-sector.
So far, there has been no public discussion by the authorities about bringing this work back within the public EMS system. Likely, there are concerns about costs and offending business interests.
Opening the door for MORE privatization?
This story is one more example of how privatization by a reckless government can bring disaster to health care. The Progressive Conservative government of the day turned the work over to (unregulated) private operators, who cut corners and paid non-union wages, with sorry results for health care.
It is, however, possible that legislation could increase the roles that non-emergency patient transfer organizations play. While governments must be seen to take steps to improve the patient transfer industry, it is possible that modest legislation could be used to justify more EMS work be given to the for-profit patient transfer industry.
This is an especial concern as corporations step up their aim to take over more public services, and governments increasingly trying to reduce its deficit and its costs by moving public sector work to non-unionized and low paying providers. Moreover, if most transfers are still being done by EMS, significant work could be lost from the highly unionized EMS sector.
With the growing regionalization of health care services, patients transfers between health care facilities is a growing business, and is likely to continue to grow. The government estimates there are already between 400,000 and 500,000 non-emergency patient transfers per year.
The Liberal government has promised consultations, but there is no word yet on when that might occur. The Legislation cannot be passed until after the election October 6, and will depend on the next government.