January 18, 1999

To:Emergency and Protective Services Committee

From:Barry Gutteridge

Commissioner, Works and Emergency Services

Subject:Regulation and Licensing of Medical Transportation Services

Purpose:

To advise Toronto Council of Bill 86, 'An Act to provide for better local government by updating and streamlining the Municipal Elections Act, the Municipal Act and related statutes'. This legislation empowers municipalities, at their option, to effect both service standards and regulation of Medical Transportation Services. Despite Medical Transportation Services being defined in legislation, without such municipal regulation, providers are free to operate without consistency or measurable objectives for public safety. In addition, through Toronto Licensing, as with other vehicles offered for hire in the municipality, consideration may be given to licensing the owners and drivers of medical transportation vehicles.

Funding Sources, Financial Implications and Impact Statement:

License fees set at cost recovery levels for medical transportation services would have a neutral funding impact on Toronto Licensing. However, there will be resource implications to implement and sustain the processes of license issue and enforcement. At least thirty medical transportation services are in operation province-wide, with approximately ten to twelve operating in the Greater Toronto Area. Regulating and licensing these providers will ensure a safe and acceptable level of service and an appropriate alternative for citizens requiring transportation by other than ambulance services as defined under regulation.

Recommendations:

It is recommended that:

(1)the City Solicitor and Commissioner of Urban Planning and Development Services, in consultation with TorontoAmbulance, define and construct regulations and set standards (see attached draft guidelines) that will regulate Medical Transportation Services within Toronto;

(2)a process of public meetings and focus groups be established in the community to provide the public and other service providers and stakeholders with an opportunity for input and comment on the regulatory, licensing process, or formal business;

(3)the City Solicitor evaluate the Municipality's risk/obligations/options around the regulation/licensure of this new transportation sector; and

(4)the appropriate City officials be vested with the necessary authority to give effect thereto.

Council Reference/Background/History:

The omnibus legislation, Bill 86 received Royal Assent: December 19, 1996. Part X.2, section 191.6(1) amends the Highway Traffic Act, empowering municipalities to regulate Medical Transportation Services by setting standards in relation to the operation of those Services. Since 1994-1995, twenty eight to thirty Medical Transportation Services have come on-stream across the province with ten to twelve operating in the Greater Toronto Area. Section 191.6(3) provides for fines of not more than $10,000 on conviction of contravention of such a bylaw. Section 191.7 ensures that the Minister of Transportation may make regulations designating the types of services and vehicles.

Furthermore, Part III Section 59(10) of Bill 86 also amends the Ambulance Act as follows:

Ambulance Act

"Ambulance" means a conveyance used or intended to be used for the transportation of persons who,

(a) have suffered a trauma or an acute onset of illness either of which could endanger their life, limb or function, or

(b) have been judged by a physician to be in an unstable medical condition and to require, while being transported, the care of a physician, nurse, other health care provider, emergency medical attendant or paramedic, and the use of a stretcher;

"ambulance service" means a service, including the service of dispatching ambulances, that is held out to the public as available for the conveyance of persons by ambulance.

A) Comments and/or Discussion and/or Justification:

Impacts:

a)The new definitions contained in the Bill 86 Ambulance Act amendments (see above). If all three ambulance transport criteria, i.e., unstable, stretcher required and patient in need of an escort were applied literally, this could polarize more requests for non-emergency ambulance service to the medical transportation sector.

b)Declining non-emergency call volumes. Note: 1994 non-emergency call volumes decreased significantly. It is feasible that 5-6000 per annum have moved to the Medical Transportation Services sector since their inception.

c)Ambulance service must maintain it's 'ready status' for emergency response. Although hospitals prefer to use ambulance services because it is less costly, tight time demands for diagnostic and other specialized procedures, see them opting to use Medical Transportation Services whom they perceive as more sensitive and responsive to those non-emergency but time-sensitive needs.

d)More frequently Ambulance Call Reports are being signed-off as non-essential by the medical community, which in turn results in the generation of a $240.00 billing.

e)More uninsured or ineligible ambulance billings of $240.00. Due to the more specific new Ambulance Act definitions, more calls for service provided by ambulance but deemed ineligible for Ontario Health Insurance co-payment could cause a further shift of non-urgent call volume (possibly 5-15%) to the Medical Transportation Services sector as their average local transport billing rate by comparison is $60-80.00. Many institutions are not aware that Medical Transportation is unlicensed/unregulated.

f)Billing issues aside, non-emergency and non-essential calls traditionally part of the ambulance service mandate, could shift to Medical Transportation Services. Already, they are perceived as faster (anecdotally) than the ambulance response to non-urgent transportation requests

.g) In an environment of increasing emergency call demand, overall acuity of illness and static health care funding envelopes, the option to use Medical Transportation Services could be seen as more attractive by institutions and the general public thus increasing pressure on governments and institutions to fund this alternative level of service.

h)For inter-institutional transfers, the normal ambulance fee of $45.00 is waived. Already, Medical Transportation Services bills submitted as third party claims to medical insurers are frequently paid, indicating that no real distinction is drawn (at least by insurance providers), between the two types of service.

i)From an institutional sector perspective, Medical Transportation Services represent an optional/partial solution to blocked acute care beds and missed 'time-sensitive' medical/diagnostic appointments or subsequent sub-acute or rehabilitation admissions elsewhere in the system. Development of regulations and standards would enfranchise the medical transportation sector as bona fide service providers.

j)Aging population/demographic demands will inevitably increase pressure on the land ambulance system to perform more essential non-emergency services.

k)Future co-shared opportunities might include non-emergency billing or fee for service, apportioned between Institutions, Municipalities, Patients and the Provincial Government.

History:

a)Since 1994-1995 28-30 Medical Transportation Services have come 'on-stream' across the province with 8-10 operating in the Greater Toronto Area.

Actions:

a)Draft Ministry of Health Medical Transportation Services Safety Guidelines March 21, 1997 (attached)

b)Background sent to Shirley Mathi at Legal Services and Carol Ruddell-Foster at Licensing June 10, 1998 for review and consultation. Note from Shirley Mathi: TTC have exclusive mandate for transportation in Toronto.

c)Toronto Fire Department charge $300.00 for 'assist' calls from Medical Transportation Services providers. See Toronto Fire Department Advisory May 25, 1998 (also attached) from Chief Speed.

Types of Patients/Client Eligibility:

a)Medical Transportation Services: Patient must be in stable condition but unable to tolerate sitting or standing, thus precluding wheelchair transport option. Could include frail, elderly, especially without own wheelchairs.

B) Discussion: Cross-Sector Community Transportation Dispatch/Brokerage

Ambulance service, medical transportation services, specialized accessible transit (including Wheeltrans) and community transportation (not for profit and volunteer) resources, accessible and otherwise, represent the continuum of transportation options available for medically necessary, through non-essential services available in the community.

A suggestion originating with the Toronto Social Planning Council in 1997 is that "a group investigate shared dispatching" potential between Wheel-Trans, Toronto Ambulance and other selected agencies (e.g. Canadian Red Cross).

Low-priority requests for transportation service received by Toronto Ambulance Communications Centre could, subject to the necessary protocols, be redirected elsewhere within this continuum. Specifically, per Bill 86, those patients not requiring all three ambulance transport criteria i.e., patient stable, stretcher not required and not in need of an escort (as defined e.g. by a physician, other health care provider EMA, paramedic etc.)

In theory, it would be possible for one agency with the appropriate technical platform and expertise to receive and devolve all types of transportation requests to the appropriate level of resource, e.g., the 9-1-1, emergency number or similarly in the private sector 967-1111 central number for pizza. Devolution would of course be contingent upon the necessary education, orientation of users/stakeholders and their 'top-down' buy-in, together with an elective transportation algorithm crafted for public consumption and education.

The structure of this model would also need to demonstrate flexibility and encourage acceptance by the partners, including institutions i.e. by providing dedicated transfer coordinators to optimize 'bed to bed' or 'door to door' service. This would facilitate single or block bookings for groups requiring transportation service and access to all categories of service provider, on time without overlap or duplication.

Regulation of medical transportation services, followed by focus group sessions including the community transportation sector, accessible transit and out-of-hospital providers would represent a definitive first step in the development of scope of practice guidelines, public information and education material design and distribution to raise public awareness of and how to access the transportation options available.

Billing, cost-sharing and cost-recovery mechanisms, geared to the level of service provided, would be a necessary next step. Other communities, Upper Tier Municipalities are investigating the feasibility of setting the fees for medical transportation e.g. at $45.00. This would narrow the disparity between fees charged.

C) CTAP:

This one time inter-ministerial program started out with $3 million, at < $50,000 per approved project and approximately sixty proposals from community groups around the province. The objective, through the collaborative efforts of the inter-sectoral working groups, is to improve local access to transportation through more efficient and effective use and coordination of currently available resources.

Ongoing Community Transportation Action Program (CTAP) projects have shown that new partnerships are resulting in better utilization of elective transportation resources overall. Most have aimed at matching the right client with the right resource to achieve the best possible efficiencies, price and quality.

The CTAP Program extended July 13, 1998 by Transportation Minister Tony Clement, now expires September 1999. Sustainability of services may then be in question. The Ministry of Health Long Term Care Division does provide transportation funding, i.e. the long term care division funds many agencies and institutions in the province to provide transportation services to their own residents and clients. No municipal funding is received. Some not for profit sector agencies and volunteer transportation services are also variably dependent on grants and donations to help provide these services.

D) Conclusions:

The provincial government's decision to devolve regulatory authority for Medical Transportation Services to municipalities may represent an opportunity to enhance public safety by setting standards for the safe operation of those services already operating within the community.

The City of Toronto, by virtue of its licensing authority could opt to impose appropriate minimum standards to ensure that the safety of medical transportation vehicles, adequate insurance coverage and driver qualifications are both met and maintained.

Contact Name:

R.L. Kelusky, 392-2200

R.L. KeluskyBarry Gutteridge

General ManagerCommissioner,

Toronto AmbulanceWorks and Emergency Services