Canadian Medical Association Journal 1996; 154: 1412-1414
© 1996 Albert Shu
A woman needed a hysterectomy and was admitted to a Toronto hospital. She presented her provincial health card to the hospital staff and they billed the Ontario Health Insurance Plan (OHIP) for the operation. Not long afterward, the same health card was used for the birth of a child at another hospital. Although that anecdote may be apocryphal -- there is no record of such an occurrence in government records -- it lives on in the folklore of Ontario health care.
But for Margaret Buffington, head of the Special Investigations Unit of the Ontario Ministry of Health, health care fraud in the province is indeed a serious problem. "It could be innocent in the sense that you think it's not going to hurt anybody," she said. "So you lend out your card rather than having friends pay for health care. It is fraud, however, and [includes] everything from [lending a card] to a much more structured industry set up with the specific purpose of pulling money out of the OHIP system."
During the New Democratic Party's (NDP) term of office, investigators took less than a year to document hundreds of cases of health care card fraud. Public outrage, combined with the need to bring health care costs under control, made fraud a major political issue in Ontario, and Ruth Grier, the former health minister, introduced initiatives to clamp down on it. At the centre of the program was a new photo health card that the ministry began issuing in February 1995.
[Since this was written, the government has changed and so have priorities. In spring 1996, after reviewing the financial situation, the Conservative government of Mike Harris said it intended to develop a single identification card for use by several ministries, including health. -- Ed.]
Concern over mismanagement in health care administration isn't new. In 1987, the provincial auditor criticized the health ministry for dispensing more than 25 million active OHIP numbers in a province with only 9 million residents. In spring 1990, the Liberal government issued personal red-and-white plastic health cards as a fraud-prevention measure. The program cost $40 million, and was expected to save $150 million over 10 years by limiting unauthorized use of health cards.
But once again, more cards were issued than there were Ontario residents. The control mechanisms that were supposed to accompany re-registration were abandoned in favour of speedy completion of the project. Once that happened, anyone who could supply an old OHIP number was issued a new one. The 1992 auditor's report noted that, despite all the expense and effort, the number of health cards in circulation still exceeded the Ontario population by more than 300 000.
By then, the health care system had the additional problem of relying on a card bearing only a name and number. When people present the health cards to a doctor or hospital, no corroborating identification is required.
The fraud problem was particularly acute in cities close to the US, where 37 million people have no health insurance. According to Ontario doctors who work in these cities, many former residents who moved to the US kept a mailing address in Canada in order to obtain a health card. Some Americans who own cottages in Ontario form another group of abusers: because they have an Ontario address, they can obtain a health card. Other cases involve out-of-country visitors borrowing valid OHIP cards from friends and family members for medical treatment in Canadian emergency wards.
Police say that Ontario health cards sell for about $1000 in Toronto's black market, and are often used to get additional pieces of identification. When she announced the photo card, Grier said difficulties caused by the red-and-white card were the reason for the change.
The new card displays Ontario's provincial flower, the trillium, against a green background. It has several security features designed to reduce misuse and deter counterfeiting:
Grier said it was not feasible to have computer chips that could store patient records on a health card; more important were the card's new security features and careful re-registration of Ontario residents. To get the new card, residents must register in person and provide original documents to prove eligibility. The former government estimated that re-registration and the issuance of almost 11 million new cards would take 3 years and cost about $100 million.
But lost in the debate about the new card's ability to fight fraud is the question of whether large-scale fraud even exists. Although the exact amount of fraud affecting the red-and-white cards is unknown, estimates have ranged from $20 million to $690 million annually.
Before the 1995 election, Mike Harris said a report commissioned by the health ministry estimated that approximately 60 000 ineligible people from outside Ontario received health care services through OHIP between November 1992 and March 1993, at a total cost of $85 million. Grier was less conclusive. "I think it's a very real problem, [but] I don't think anybody has an accurate handle [on how big it is] because obviously if we knew the amount of fraud, then we would know how to stop it."
Grier said forensic consulting firms estimated the new health card would prevent about $65 million in fraud annually. "The card is the key to a $17 billion health care system, a system that for too long has been neither secure nor controlled," she argued. Other security measures implemented by the NDP included:
Dr. Kevin Moran, a family physician in Toronto who has worked in emergency wards for more than 3 years, agreed that a better health card was long overdue. "The Liberals didn't put any security features into the red-and-white health card," he said. "I found it quite shocking that so much money was wasted on the old health card with no security features -- the Ontario fishing licence had a lot more security features and carried heavier fines for misuse than the health card did."
In fact, the Ontario Recreation Card contains the height, weight, sex and birth date of the cardholder, and fines for misuse can be as high as $500 000. The maximum fine for misuse under the Ontario Health Insurance Act is $5000.
Moran said the immediate impact of the new photo health card would be obvious: "It'll improve the situation in that you'll have a bit more of a chance to recognize the patient by looking at the picture right on the card. Previously all we had was a name and it's very easy to pass it off to someone else if you don't have any idea what the person looks like."
But Moran had reservations about new rules putting more responsibility on doctors to monitor fraud. "You work 8-hour shifts, and basically you're running the entire time," he said. "Usually things are so busy and hectic, you don't even have the staff to provide the necessary care that people need, let alone time to investigate to see if the cards are valid or not."
Moran said a new health card with a photo is needed, but he felt the NDP government was playing to Ontario voters. "Canadians have a very special place in their hearts when it comes to health care," he said. "Any kind of fraud tends to infuriate them when it involves health care.
"Even if they were losing $1 million a year, they would gladly spend $10 million to prevent it. The government took a lot of heat in the media for a lot of cases of fraud and this is its response to it."
Buffington said a lot of fraud used to go unreported. "If we lay a charge in Toronto, London or Thunder Bay and it's front-page news that so-and-so came across the border, used the friend's card, went to the hospital, and that person is now doing jail time, then people [wouldn't] think quite so lightly of [pursuing] that kind of activity," she said. "All of a sudden, it would hit home that this is a contravention of the [law] and the Ministry of Health is prosecuting these cases."
She said a crackdown has deterrent value that can't be measured and brings much needed attention to health care fraud. "People see the amount of money going out to health care and they're very concerned about it," Buffington said. "It makes them upset to think that it's their tax dollars paying for things they shouldn't be -- that wasn't necessarily the public's view 20 years ago."
As more public attention is put on health care fraud, more cases will be documented, she said -- not necessarily because of an increase but because more people will report it. She likened the situation to violence against women in the 1980s: once a crime becomes socially unacceptable, it always appears to be on the rise because of greater social awareness.
Moran felt that if the government really wanted to address escalating health care costs, it would focus on a problem much bigger than fraud. "We cannot afford to be looking after every single ache that the Canadian public has and there should be some kind of restriction on the misuse or abuse of the health care system by patients," he said. "It's the only area we haven't addressed, and it would save a lot more money than attacking health care fraud or anything else."
He hoped the publicity given to fraud will filter down to new ways of controlling health care costs -- namely, addressing the issue of overuse of the system by Ontarians.
How much money is lost in health care fraud may never be known, but one thing is certain: new health cards will not be the last word in fighting fraud. "If the Ministry of Health was smart enough to be able to design so many security features in the card, it stands to reason that another group of people would be able to deal with that in a way they would be able to defraud the system if they wanted to," observes Buffington. "You're never going to do away with user fraud completely with this particular card, or any other card, for that matter."