FRASER RESEARCH BULLETIN March 2015 52,513 CANADIANS SEEK MEDICAL TREATMENT ABROAD Leaving Canada for Medical Care, 2015 by Bacchus Barua and Feixue Ren Summary In 2014, more than 52,000 Canadians re- ceived non-emergency medical treatment outside Canada. Physicians in British Columbia reported the highest proportion of patients (in a province) receiving treatment abroad (1.6%). The largest number of patients estimated to have left the country for treatment were from Ontario (26,252). Across Canada, neurosurgeons reported the highest proportion of patients (in a special- fraserinstitute.org ity) travelling abroad for treatment (2.6%). The largest number of patients (in a specialty) travelled abroad for internal medicine procedures (6,559). One explanation for patients travelling abroad to receive medical treatment may relate to the long waiting times they are forced endure in Canada’s health care system. In 2014, patients could expect to wait 9.8 weeks for medically necessary treatment after seeing a specialist– 3 weeks longer than the time physicians consider to be clinically “reasonable” (6.5 weeks). FRASER RESEARCH BULLETIN 1 Leaving Canada for Medical Care, 2015 Introduction By learning how many Canadians receive health care in another country each year, and the type of care they receive, we can gain some insights about the state of health care in Canada and the state of medical tourism among Canadian residents. Canadians who choose to seek treatment abroad do so for several reasons, many of which may relate to their inability to access quality health care in a timely fashion within Canada’s borders. Some patients may be sent out of country by the public health care system due to a lack of available resources or because some procedures or equipment are not provided in their home jurisdiction. Others may choose to leave Canada because they are concerned about quality (Walker et al., 2009) and are seeking more advanced health care facilities, state-of-the-art medical technologies, or better outcomes. Others may leave in order to avoid some of the adverse medical consequences of waiting for care, such as worsening of their condition, poorer outcomes following treatment, disability, or death (Esmail, 2009; Barua et al., 2013). Some may leave simply to avoid delay and to make a quicker return to normal life. While there is no readily available data on the number of Canadians travelling abroad for health care, it is possible to produce an estimate of these numbers from data gathered through the Fraser Institute’s Waiting Your Turn survey and from the Canadian Institute Table 1: Average percentage of patients receiving treatment outside of Canada, 2014 BC AB SK MB ON QC NB NS PE NL CAN Plastic Surgery 0.0% 2.0% – – 0.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.3% Gynaecology 4.6% 3.1% 0.5% 0.2% 0.8% 0.5% 0.3% 0.0% 0.0% 1.0% 1.4% Ophthalmology 0.7% 0.4% – – 0.9% 1.2% 0.7% 0.2% 0.0% 0.0% 0.8% Otolaryngology 0.7% 1.0% 0.0% 3.3% 1.4% 0.2% 0.0% 1.5% 0.0% – 1.1% General Surgery 0.4% 1.3% 0.2% – 0.7% 0.1% 0.0% 0.0% – – 0.5% Neurosurgery 5.4% 0.3% 3.0% – 3.3% – – 0.0% – – 2.6% Orthopaedic Surgery 0.5% 2.1% 1.7% 0.0% 1.0% 0.1% 0.8% 1.4% 1.5% 0.5% 0.9% Cardiovascular Surgery 3.7% 0.3% – 0.0% 0.8% 1.7% – 0.0% – – 1.3% Urology 3.7% 0.3% – – 1.9% 0.3% 5.0% 3.0% – – 1.8% Internal Medicine 1.2% 0.8% 0.0% 0.5% 3.3% 0.4% 0.3% 0.0% – 0.0% 1.8% Radiation Oncology 1.6% 1.8% 5.0% – 0.5% 1.2% – 0.0% – – 1.2% Medical Oncology 2.4% 0.5% – 5.0% 0.5% 0.3% 0.0% 0.0% 0.0% 0.0% 0.9% All Specialties 1.6% 1.5% 0.9% 1.0% 1.3% 0.5% 0.8% 0.6% 0.4% 0.5% 1.1% Note: Averages for provinces and specialties with missing data should be interpreted with caution. Source: Barua and Fathers (2014), table 11. fraserinstitute.org FRASER RESEARCH BULLETIN 2 Leaving Canada for Medical Care, 2015 Table 2: Estimated number of patients receiving treatment outside of Canada, 2014 BC Plastic Surgery AB SK MB ON QC NB NS PE NL CAN 0 137 – – 35 1 0 0 0 0 173 Gynaecology 951 664 34 12 489 193 15 0 0 50 2,409 Ophthalmology 481 204 – – 1,483 2,435 54 30 0 0 4,688 Otolaryngology 97 131 0 153 768 70 0 63 0 – 1,283 General Surgery 358 724 59 – 2,031 98 0 0 – – 3,270 Neurosurgery 406 13 58 – 660 – – 0 – – 1,137 Orthopaedic Surgery 214 676 194 0 1,131 84 62 122 21 17 2,520 Cardiovascular Surgery 359 14 – 0 203 357 – 0 – – 933 1,802 81 – – 3,490 197 315 327 – – 6,212 757 301 0 95 5,011 385 9 0 – 0 6,559 Radiation Oncology 13 15 11 – 26 35 – 0 – – 100 Medical Oncology 62 14 – 37 83 30 0 0 0 0 225 Residual * 4,299 3,013 695 750 10,843 2,398 287 433 27 259 23,006 Total 9,799 5,988 1,050 1,048 26,252 6,284 742 975 48 327 52,513 Urology Internal Medicine *The residual count was produced using the average provincial percent of patients receiving treatment outside of Canada and the residual count of procedures produced in Waiting your turn, 2014 report. Source: Barua and Fathers (2014); calculations by authors. for Health Information (CIHI), which tallies the numbers of procedures performed in Canada. Estimating the number of patients leaving Canada for health care Each year, the Fraser Institute conducts a survey of physicians across Canada in 12 major medical specialties: plastic surgery, gynaecology, ophthalmology, general surgery, neurosurgery, orthopaedic surgery, cardiovascular surgery, urology, internal medicine, radiation oncology, and medical oncology.1 Included in the survey is the question: “Approximately what percentage of your patients 1 See Barua and Fathers (2014) for information regarding procedures constituting each specialty. fraserinstitute.org received non-emergency medical treatment in the past 12 months outside Canada?” The answers are averaged for each of the specialties studied in Waiting Your Turn for each province, producing a table that reports the average percentage of patients receiving treatment outside Canada (Barua and Fathers, 2014: table 11). These percentages are shown in table 1. In 2014, 1.1% of patients in Canada were estimated to have received non-emergency medical treatment outside Canada, compared to 0.9% in 2013 (Barua and Esmail, 2013: table 11). Physicians in British Columbia reported the highest proportion of patients (in a province) that received treatment abroad (1.6%), while at the other end of the scale physicians in Prince Edward Island reported that only 0.4% of their FRASER RESEARCH BULLETIN 3 Leaving Canada for Medical Care, 2015 patients travelled abroad for treatment in 2014. Across Canada, neurosurgeons reported the highest proportion of patients (in a speciality) travelling abroad for treatment (2.6%), while the lowest proportion of patients (in a specialty) travelled abroad for plastic surgery (0.3%) (see table 1). Combining these percentages2 (table 1) with the number of procedures3 performed in each province and in each medical specialty gives an estimate of the number of Canadians who actually received treatment outside the country. Results Table 2 indicates that a significant number of Canadians—an estimated 52,513 people— received treatment outside of the country in 2014. This is a considerable increase from the estimated 41,838 who travelled abroad in 2013 (Esmail and Barua, 2013). Increases between 2013 and 2014 in the estimated number of patients going outside Canada for treatment were seen in eight provinces: Ontario (from 19,118 to 26,252), British Columbia (8,146 to 9,799), Quebec (4,904 to 6,284), Alberta (5,527 to 5,988), New Brunswick (372 to 742), Saskatchewan (714 to 1,050), Nova Scotia (927 to 975) and Prince Edward Island (8 to 48). Conversely, in that period there was a decrease in the estimated number of patients who received treatment outside Canada in Newfoundland & 2 Readers should note that this calculation uses the exact values, not the rounded values that appear in table 11 in Barua and Fathers (2014). 3 Data is for 2012/13 from the Discharge Abstract Database (CIHI, 2013a) and the National Ambulatory Care Reporting System (CIHI, 2013b). For further details see Barua and Fathers (2014). fraserinstitute.org Labrador (from 486 to 327) and Manitoba (1,636 to 1,048). Table 2 also shows the estimated number of patients receiving treatment outside of Canada by specialty. For example, we estimate that approximately 6,559 Canadians travelled abroad in 2014 to receive internal medicine treatments. On the other hand, we estimate that only about 100 Canadians went abroad to receive radiation oncology treatment in 2014. Limitations Two data-related issues must be noted. First, data for the number of procedures performed in Quebec in 2012/13 was not available to Barua and Fathers (2014). As a result, they made a prorated estimate of surgeries in Quebec using the number of acute surgeries performed in the province in 2011/12.4 Second, there is a temporal mismatch between the timing of the Fraser Institute’s Waiting Your Turn survey and the CIHI’s annual data release. Specifically, procedure counts data used for Waiting Your Turn are typically one year behind (e.g., the 2012 edition of Waiting Your Turn used procedure counts from 2010/2011). While the calculations above use the temporally mismatched procedure counts to provide up-todate information, previous calculations adjusting for the temporal mismatch show that it does not appear to materially affect the trend witnessed in the overall count of Canadians. However, it does, as expected, affect the actual counts of Canadians (Esmail, 2007).5 4 This may limit comparisons with estimates from previous years for Quebec, and for Canada as a whole. 5 Specifically, the Canadian counts with the temporal mismatch for 2004, 2005, and 2006 were 49,392, FRASER RESEARCH BULLETIN 4 Leaving Canada for Medical Care, 2015 The number of patients receiving treatment outside Canada each year produced by this methodology is likely to be an underestimate. This is the result of a few factors. Most importantly, these numbers are based on specialist responses, which means that patients who leave Canada without consulting a specialist6 are not likely to be included in the count shown in table 2. The counts are also based on the number of procedures estimated to have been performed in Canada, which is less than the total number of patients consulted and less than the total number of Canadians who would have required treatment, including those who left Canada to seek it. Discussion These numbers are not insubstantial. They point to a sizeable number of Canadians whose needs and health care demands could not be satisfied within Canada’s borders. There are a number of possible reasons why this may have been the case. Some patients may have been sent out of country by the public health care system due to a lack of available resources or the fact that some procedures or equipment are not provided in their home jurisdiction. Others may have chosen to leave Canada in response to concerns about quality (Walker et al., 2009), seeking more advanced health care facilities, more state-of-the-art medical technologies, or better outcomes. 44,022, and 39,282, respectively. Accounting for the mismatch, the counts for 2004 and 2005 were 7,011 and 45,776, respectively (see Esmail, 2007). 6 In 2014, the national median wait time between referral by a general practitioner and consultation with a specialist was 8.5 weeks (see Barua and Fathers, 2014). fraserinstitute.org Another explanation may relate to the long waiting times that patients are forced endure in Canada’s health care system. For example, in 2014, patients could expect to wait 9.8 weeks for medically necessary treatment after seeing a specialist.7 This wait time (which does not include the 8.5 week wait to see a specialist) is more than 3 weeks longer than what physicians consider to be clinically “reasonable” (6.5 weeks). Thus, it is possible that some patients may have left the country to avoid some of the adverse medical consequences of waiting for care, such as worsening of their condition, poorer outcomes following treatment, disability, or death (Esmail, 2009; Barua et al., 2013). At the same time, others may have left simply to avoid delay and to make a quicker return to normal life. Conclusion In 2014, an estimated 52,513 Canadians received non-emergency medical treatment outside Canada. In some cases, these patients needed to leave Canada due to a lack of available resources or a lack of appropriate procedures or technologies. In others, their departure will have been driven by a desire to return more quickly to their lives, to seek out superior quality care, or perhaps to save their own lives or avoid the risk of disability. Clearly, the number of Canadians who ultimately receive their medical care in other countries is not insignificant. That a considerable number of Canadians travelled abroad and paid to escape the well-known failings of the 7 The Fraser Institute’s Waiting Your Turn survey measures wait times for elective treatment in most specialties. For more information see Barua and Fathers, 2014. FRASER RESEARCH BULLETIN 5 Leaving Canada for Medical Care, 2015 Canadian health care system speaks volumes about how well the system is working for them. References Barua, Bacchus, and Nadeem Esmail (2013). Waiting Your Turn: Wait Times for Health Care in Canada. 2013 Report. Fraser Institute. Barua, Bacchus, Nadeem Esmail, and Taylor Jackson (2013). The Effect of Wait Times on Mortality in Canada. Fraser Institute. Barua, Bacchus, and Frazier Fathers (2014). Waiting Your Turn: Wait Times for Health Care in Canada. 2014 Report. Fraser Institute. Canadian Institute for Health Information [CIHI] (2010). 2009/2010 Conversion Tables: ICD-10-CA/CCI to ICD-9/CCP. Canadian Institute for Health Information. Canadian Institute for Health Information [CIHI] (2012). Discharge Abstract Database, 2011-2012. Canadian Institute for Health Information. Canadian Institute for Health Information [CIHI] (2013a). Discharge Abstract Database, 2012-2013. Canadian Institute for Health Information. Canadian Institute for Health Information [CIHI] (2013b). National Ambulatory Care Reporting System, 2012-2013. Canadian Institute for Health Information. Esmail, Nadeem, and Bacchus Barua (2013). 41,838 Canadians became medical tourists in 2013. Troy Media. Esmail, Nadeem (2009). Waiting Your Turn: Wait Times for Health Care in Canada. 2009 Report. Fraser Institute. Esmail, Nadeem (2009). Waiting Your Turn: Hospital Waiting Lists in Canada, 19th ed. Fraser Institute. fraserinstitute.org Esmail, Nadeem (2007). Receiving Medical Treatment Outside of Canada. Fraser Forum (February): 5–8. Walker, Michael, Maureen Hazel, and Nadeem Esmail (2009). A Comparative Analysis of Mortality Rates Associated with Coronary Artery Bypass Graft (CABG) Surgery in Ontario and Select US States. Fraser Institute. Bacchus Barua is a Senior Economist in the Fraser Institute’s Centre for Health Policy Studies. He completed his BA (Honours) in Economics at the University of Delhi (Ramjas College) and received an MA in Economics from Simon Fraser University. Bacchus has conducted research on a range of key health care topics including hospital performance, access to new pharmaceuticals, the impact of aging on health care expenditures, and international comparisons of health care systems. He also designed the Provincial Healthcare Index (2013) and is the lead author of The Effect of Wait Times on Mortality in Canada, and Waiting Your Turn: Wait Times for Health Care in Canada (2010–2014). Feixue Ren is a research intern at the Fraser Institute. She holds a Master’s Degree in Economics from Lakehead Universityand a BA in Statistics from Hunan Normal University in China. Since joining the institute, she has co-authored an assortment of studies on fiscal policy including tax competitiveness and government debt. FRASER RESEARCH BULLETIN 6 Leaving Canada for Medical Care, 2015 Acknowledgments This edition of Leaving Canada for Medi­ cal Care is based on the methodology developed in previous editions. As such, the authors would like to acknowledge, and thank, Nadeem Esmail. Any remaining errors or oversights are the sole responsi­ bility of the authors. As the researchers have worked indepen­dently, the views and conclusions expressed in this paper do not necessarily reflect those of the Board of Trustees of the Fraser Institute, the staff, or supporters. fraserinstitute.org Copyright © 2015 by the Fraser Institute. All rights reserved. Without written permission, only brief passages may be quoted in critical articles and reviews. ISSN 2291-8620 Media queries: call 604.714.4582 or e-mail: communications@fraserinstitute.org Support the Institute: call 1.800.665.3558, ext. 586, or e-mail: development@fraserinstitute.org Visit our website: www.fraserinstitute.org FRASER RESEARCH BULLETIN 7