January 20, 1999
To:Emergency & Protective Services Committee
From:Commissioner, Works & Emergency Services
Subject:Non-Emergency Patient Transfer Services
Purpose:
The purpose of this report is to inform the Emergency & Protective Services Committee and
members of Council regarding the role and responsibility Toronto Ambulance as specified
under the Ambulance Act of Ontario and its Regulations pertaining to the transportation of
non-emergency patients within the City of Toronto.
Funding Sources, Financial Implications and Impact Statement:
There is no direct financial impact arising out of this report, however, future recommendations
pertaining to licensing and regulations private patient care transfer services and the enactment
of the changes to the Ambulance Act Regulations may have a marginal impact on
expenditures related to the delivery of out of hospital care and transportation within the City
of Toronto.
Recommendations:
It is recommended that:
1)the following report be received for information by the Emergency & Protective Services
Committee.
Background:
At its meeting on January 19, 1999, the Budget Committee received deputation from the
operator of Direct Care Patient Transfer Services. This firm is one of several unlicensed and
unregulated private transfer providers operating within the City of Toronto. In his deputation
to the budget Committee, the deputant indicated the City of Toronto could save up to $14
million in the funding of its land ambulance service if the non-emergency transfers currently
provided by Toronto Ambulance are brokered to private patient transfer services. This
calculation was based on formula of multiplying the 60,000 patient transfers currently
provided through Toronto Ambulance by an average cost per call of $240.00.
The deputant further stated that the qualifications of the staff engaged in providing private
patient transfer services are identical to the level of training Toronto Ambulance paramedics
and that all patient transfers currently provided by Toronto Ambulance could be safely moved
by alternate means. The deputant concluded the shift of non-emergency transfers to private
firms could free up ambulances for more important emergency calls and result in reduced
expenditures on the cost of providing ambulance service within the City of Toronto.
Comments and/or Discussion and/or Justification:
Currently Toronto Ambulance moves approximately 60,000 non-emergency patients on
annual basis. Non-emergency transfers encompass movement of patients from institutions to
institutions or specific medical treatment, homes to institutions for treatment and/or
admission, and from institutions to home following discharge. Approximately 50,000 of the
60,0000 patients are transferred during the period Monday to Friday from 7 a.m. to 7 p.m. The
balance of the transfers, approximately 20% or 10,000, are transferred during the weekend or
at night.
Toronto Ambulance has organized its non-emergency transfer program to handle the bulk of
the patient transfers on the Monday to Friday basis. Currently, there are approximately 40 staff
engaged in this program operating between 10 and 12 ambulances per day. The total costs of
providing non-emergency transfer program on a Monday to Friday basis is approximately $3.3
million, inclusive of salary, wages, vehicle costs and relating operating expenses. The balance
of the non-emergency transfers, or approximately 10,000 per year, are handled out of the
regular ambulance fleet and weekends and nights. These transfers are provided in the marginal
surplus capacity that exists within the deployment plan. It would suggest that the overall costs,
savings and/or expenditures related to providing non-emergency transfer services by Toronto
Ambulance is $14 million is not a correct calculation based on the manner in which Toronto
Ambulance has organized its non-emergency patient transfer program.
Further, if the Ambulance Act and its Regulations permitted all transfers to be serviced by
private transfer providers, the total savings to the City of Toronto and the ambulance services
could be less than $3.3 million. This would only account for resources assigned to the
non-emergency patient transfer program on a Monday to Friday basis. There would be no
savings derived by eliminating transfers on weekends and nights as these transfers are carried
by utilizing marginal surplus capacity within the emergency ambulance fleet.
Private fee-for-service transport companies raise an important public policy and social justice
issue. The elderly, the ill and the disabled rely heavily on our non-emergency services, which
are provided without user fees from the municipal tax base. Any transition to "user pay"
services imposes a disproportionate burden upon those who can least afford it.
While the City itself might shed $3.3 million by ending its non-emergency ambulance
services, we should be acutely aware that it would download that cost directly on those least
able to afford it. If City policy creates a service accessible only to the wealthy, we would set a
dangerous precedent in "two-tiered" health care, with a public system for the poor, and a
private system for the well-to-do.
Similarly, contracting out this portion of our business, while paying for it from city taxes,
would fail to make use of our paid-for infrastructure and introduce the cost of the private
firm's profit as a new and avoidable cost.
The Ontario Ambulance Act and its Regulations, both current and proposed, place a
significant restrictions in the ambulance operator being able to delegate the responsibility of
patient transfers in non-licensed ambulance services. The Act and its Regulations defined a
licensed ambulance service and this does not include private patient transfer services within
its definition.
In addition, the proposed Regulations defined the type of patient that can be transported by
means other than a licensed ambulance service. Essentially, a patient that requires medical
management, medical monitoring or has been determined by a medical practitioner to require
medical supervision during transport, cannot be carried by a private patient transfer service.
Patients who are eligible would only include patients who are otherwise healthy but because
of some underlying physical restrictions, cannot be moved by wheelchair, vehicle, taxi and/or
private car.
The Ambulance Act and its Regulations prohibit a licensed ambulance service from charging
a non-emergency transfer services. The current rate for a private patient transfer service within
the existing unregulated environment is approximately $65.00 to $80.00 per trip within the
boundaries of the City of Toronto. These rates change depending on the distance travelled
from the point of pick up. One of the issues to be reviewed as part of process of regulations
and licensing of these providers will be the establishment of a rate structure that is fair and
equitable.
Of the total number of non-emergency patients transported by Toronto Ambulance between
10% and 20% could fall under the category of being eligible for transport by private transfer
services. This figure is based on an assessment of calls completed by Toronto Ambulance in
previous years.
Since 1995, the number of non-emergency transfers serviced by Toronto Ambulance has
remained stable at approximately 60,000 per year. It is recognized that the number of
non-emergency patients have increased over this period and it is believed that much of this
increase has been distributed amongst the existing 8 to 10 private unregulated providers
operating within the City.
The Ambulance Act and its accompanying Regulations, combined with the rules and
guidelines governing the types of patients that can be transported by private service providers
will not result in a significant change in the demand placed on Toronto's ambulance service.
Marginal reductions of 10% to 20% in the overall volume currently serviced by Toronto
Ambulance will be offset by expected increases in emergency demand on an annual basis.
Projections by the Emergency of Health, Emergency Health Services Branch, supported by the
Ernst & Young review of ambulance services in 1996, indicated a 2% increase in emergency
demand compounded annually over the proceeding 10 years. Any surplus capacity generated
through reduction in non-emergency demand would be necessary to partially offset projected
increase in emergency calls.
The proposed regulation and licensing of non-emergency private transfer providers by the
municipality will ensure that those patients deemed eligible by a medical practitioner would
be guaranteed a safe and competent transportation and a fee structure approved by the
municipality. It should be recognized that even though the regulation and licensing of these
providers could offer an alternative to the municipal ambulance service, the fact remains that
restrictions on eligibility still exist through the Ambulance Act and its Regulations.
Conclusion:
It is the intent of this report to provide members of Council with information concerning the
regulations and standard that affect that transportation of patients within the City of Toronto.
Medically essential transfers where there is a requirement for medical monitoring and medical
supervision of patients will continue to be provided by Toronto Ambulance and only those
patients who are deemed to be stable by a medical practitioner and/or designate could be
transferred by a private alternative service provider.
Contact Name:
R.L. Kelusky
Phone: 397-9241
Fax: 392-2115
R.L. KeluskyBarry Gutteridge
General ManagerCommissioner
Toronto Ambulance Works and Emergency Services
