Manitoba Health ordered to reimburse man with ALS for virtual appointment with out-of-country specialist
Dated health insurance act and regulations from the '90s lack references to virtual health care
A Manitoba man with a terminal illness has won a battle with the government over outdated rules that prevented him from being reimbursed for a virtual appointment during the pandemic.
Manitoba Health based its denial of the man's appointment with an out-of-country specialist on rules "written in the early 1990s when the advanced technological age, in which society now finds itself, did not yet exist," a health appeal board said in a written decision ordering the province to pay.
The man, whose identity is protected due to patient privacy laws, was told he had two to three years to live in early 2019 when he was diagnosed with bulbar amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease. The disease leads to paralysis, gradually leaving patients unable to eat, drink or speak and eventually taking away their ability to breathe.
As of the appeal hearing date in March, the man couldn't speak anymore and needed a tube to eat.
Around the time of his diagnosis, the man's local specialist told him he wouldn't find effective treatment within the province and advised him to seek care outside Canada, which he did in December 2019.
Manitoba Health covered this in-person visit with an out-of-country ALS specialist but then wouldn't pay for two follow-up virtual appointments, one in February 2020 and the second in November. The board's April decision concerns the second consultation.
The department specified it would cover the man's future in-person appointments with the out-of-country specialist, but the appeal board noted that would be "out of the question" given the man's deteriorating health and the risk of COVID-19.
Case counts across Canada and the U.S were spiking in November last year and are rising again amid a third wave.
Manitoba Health said it denied the patient's request to insure his second appointment, which cost around $900, because he didn't meet conditions under the Health Services Insurance Act. Manitoba Health told the board virtual consultations with out-of-country specialists aren't insurable. Telemedicine appointments also need to take place in approved locations like hospitals or personal care homes, not at home, where the patient was for both virtual appointments.
In an April 7 written decision, the appeal board said Manitoba Health strictly based its decision to deny benefits on the dated act and its regulations. While they don't refer to virtual appointments, the Manitoba Physicians Manual of April 2020 does, the decision says.
"[Telemedicine] is a service being offered to Manitobans and the absence of a regulatory basis is not an issue," the appeal board wrote.
Since March last year, local doctors have been able to bill the province for virtual services provided to Manitobans that include telephone consultations and video conferencing.
Pandemic pushing shift to virtual: Rasmussen
"I think the decision was an appropriate one," said Diana Rasmussen, executive director of the ALS Society of Manitoba. "Technology is changing, and I think that COVID has actually pushed us to look at doing things in other ways virtually.
"People with ALS, you know, they have been dealt a horrible diagnosis and therefore they need all the help that they possibly can [get]."
CBC Manitoba asked Health Minister Heather Stefanson whether the legislation should be updated to accommodate necessary out-of-country virtual medical services that Manitobans can't access locally.
"Manitoba Health and Senior Care is reviewing the decision by the Manitoba Health Appeal Board regarding their recent decision in this case," a spokesperson for Stefanson said in an email Wednesday.
"While virtual care has been used in some form for many years, the number of patients accessing services by phone or computer and the number of health-care providers offering appointments and care in this way has increased dramatically throughout the pandemic," Chief Nursing Officer for Shared Health Lanette Siragusa said in a news release last month.
Manitoba Health processed over three million claims for virtual doctor's appointments between March 2020 and April 7, 2021, a provincial spokesperson said Wednesday.
From 2018 to 2020, Manitoba Health processed thousands of out-of-country claims. The department settled more than 7,100 out-of-country physician claims in 2018-19, with more than 2,400 outpatient visits and almost 2,300 inpatient days for emergency care, and more than 6,800 out-of-country physician claims in 2019-20, with almost 9,700 outpatient visits and more than 2,300 inpatient days. It's unclear how many were for services Manitobans couldn't access locally.
The appeal board said Manitoba Health, which can make exceptions as to where the virtual appointments take place, could make one in this case, given the man's situation and inability to access the services he needs in the province. Manitoba Health's ALS specialist resigned in September 2019 and was replaced by an internal medicine physician without neurology or ALS experience, the decision reads.
In an email to the appeal board, the man's wife wrote, "It is obvious to us that in the absence of an ALS specialist in Manitoba, that Manitoba Health should support or pursuit to continue care via a virtual visit at [an out-of-country hospital] at least twice yearly, and provide funds for the two prior visits."
According to the ALS Society, approximately 430 Manitobans have the disease at any one time. Rasmussen said some seek care in other provinces or outside the country but it's not very common.
"If they wish to seek a second opinion, then obviously that is something that would be discussed with their own physician," she said.
"Certainly anything that can be improved, we will be fully supportive of that in trying to make things easier for people who are in situations where they cannot travel."