Interim Federal Health Program: Survey of use of supplemental benefits by paediatric health care providers

Abstract

Objectives

The Interim Federal Health Program (IFHP) provides temporary healthcare coverage to refugees and refugee claimants. Previous research demonstrates that paediatric healthcare providers poorly utilize the IFHP, with low registration rates and limited understanding of the program. The objective of this study was to examine paediatric provider use of IFHP-covered supplemental benefits, and their experience with trying to access these benefits.

Methods

A one-time survey was administered via the Canadian Paediatric Surveillance Program in February 2020. Of those who had provided care to IFHP-eligible patients, descriptive tables and statistics were created looking at provider demographics, and experience using the IFHP supplemental benefits. A multinomial logistic regression was built to look at provider characteristics associated with trying to access supplemental benefits.

Results

Of the 2,753 physicians surveyed, there were 1,006 respondents (general paediatricians and subspecialists). Of the respondents, 526 had recently provided care to IFHP-eligible patients. Just over 30% of those who had recently provided care did not access supplemental benefits as they did not know they were covered by the IFHP. Of those who had tried to access supplemental benefits, over 80% described their experience as difficult, or very difficult.

Conclusions

Paediatric providers have a poor understanding of IFHP-covered supplemental benefits, which is cited as a reason for not trying to access supplemental benefits. Of those who do try to access these benefits, they describe the process as difficult. Efforts should be made to improve provider knowledge and streamline the process to improve access to healthcare for refugee children and youth.

The Interim Federal Health Program (IFHP) is a federal Canadian program established in 1957, whose intent is to provide temporary healthcare insurance coverage for resettled refugees, protected persons in Canada, refugee claimants, victims of human trafficking, and detainees (1). In addition to insurance for medical services covered by most provincial healthcare plans, the program has coverage for supplemental services including medical equipment, medications, and allied-health services similar to coverage given to social assistance programs by provincial and territorial governments (2). In 2012, the program underwent cutbacks including leaving some entirely without coverage, and others with reduced coverage for medications, and allied-health services. These cuts were ruled unconstitutional in 2014 by the Supreme Court of Canada (2). Although the program was restored to pre-2012 levels of coverage in 2016, there has been resulting confusion about who and what is covered by the IFHP. This result is patients being denied care, or families being asked to pay for covered services (3). Recent data has shown that few providers are registered with IFHP and even fewer know what is covered: in a national survey of paediatricians across Canada (n = 1006), of those who had provided care to IFHP-covered patients (n = 526), only 26.4% (n = 139) were registered IFHP providers, and 16% (n = 83) could identify 80% or more of IFHP-covered services (4).

Although previous research has examined general understanding and use of the IFHP amongst paediatric providers, little is known about how providers understand or utilize the supplemental benefits covered by the IFHP, or what their experience is when accessing these benefits. As many of these benefits are of significant clinical importance to patients, it is useful to understand how these benefits are accessed and utilized, in order to improve rightful care for individuals who have IFHP coverage. We first examined healthcare provider characteristics and their use of supplemental benefits. We then examined ease of access and any barriers to accessing supplemental benefits.

METHODS

The methods of this survey have been discussed in detail in a previous paper (4). In brief, the survey was distributed by the Canadian Paediatric Surveillance Program (CPSP), a public health surveillance program that is a joint project between the Public Health Agency of Canada and the Canadian Paediatric Society. The CPSP network includes over 2,800 paediatricians and paediatric subspecialists. To be eligible to receive the survey, providers needed to be in active practice within Canada, and a registered participant of the CPSP. The CPSP collects information under two pieces of federal legislation—the Public Health Agency of Canada Act and the Department of Health Act. Patient consent is not a requirement for public health surveillance.

The ten-question survey was available in English or French, in electronic or paper format. Survey responses were collected for 6 weeks in early 2020. Participants were asked to self-describe their specialty, provide the first three digits of their postal code, select all relevant practice locations, and indicate number of years in practice (0-5, 6-10, 11-15, 16-20, and 21+ years). Using the first two characters of the postal code, it was determined whether or not the participant lived in a large resettlement city: Vancouver, Calgary, Edmonton, Winnipeg, Toronto, Ottawa, and Montreal. If they did not live in one of those cities, location was categorized using the first digit of the postal code, by province. Participants were asked about the number of IFHP-eligible patients seen in the prior six months (0 to 5, 6 to 19, 20 to 50, >50, or unknown), and IFHP provider registration status.

Of those who had provided care to IFHP-eligible patients in the last 6 months, they were asked further questions about their experiences with supplemental benefits. Firstly, they were asked whether or not they had tried to access supplemental benefits in the last 6 months and, if not accessed, were asked to select all that apply for reasons why, and could provide their own reason. Of those who did try to access supplemental benefits, they were asked to rate their experience as ‘very difficult’, ‘difficult’, ‘easy’ or ‘very easy’. Those who ranked the experience as ‘very difficult’ or ‘difficult’ were asked to select all that apply for reasons why, and could also provide their own reason. Finally, providers were asked to select from a list of options for where they would go to for information should they have questions about the IFHP, with a free text space if they knew of another option.

A descriptive table was created for participant demographics (for those who had provided care to IFHP-eligible patients in the last 6 months). Unless otherwise indicated, percent totals are of available data. Using multinomial regression, the adjusted odds were calculated for having tried to access supplemental benefits in the last six months, for all those participants with complete surveys. Certain confounding variables were included in the regression a priori, as they had been included in the previous analysis examining IFHP registration and use (4). These included specialty (general versus subspecialist), province (Ontario, East Coast, Quebec, Prairies, British Columbia, Nunavut/Northwest Territories/Yukon), living in a large resettlement city (binary), practice location (academic teaching hospital, private office, and community hospital, the three most popular settings), number of IFHP-eligible patients seen (0 to 5, 6 to 19, 20 to 50, >50), and IFHP registration status. Those with missing data for confounding variables were excluded from the regression. All relevant categorical variables were tested for linear trend using the likelihood ratio test.

REB approval was granted by The Unity Health Research Ethics Board: #20-189.

RESULTS

Out of 2,753 participants who received the survey, 933 responses were received electronically and 73 responses were mailed in (36.5% response rate). A total of 526 respondents had provided care to IFHP-eligible patients and were therefore included in this study. 54% (n = 283) were general paediatricians, while the rest were subspecialists. The majority were located in Ontario (46%, n = 241) or Quebec (23%, n = 119). The majority (79% n = 415) practiced primarily in one clinical setting, and over half (59.6%, n = 313) were based in academic teaching hospitals (Table 1).

Table 1.

Participant demographics

	Percent % (number)
Specialty
General	54.0 (283)
Subspecialty1	46.0 (243)
Location
Province~
Alberta	11.8 (62)
British Columbia	5.5 (29)
Manitoba	4.9 (26)
New Brunswick	1.0 (5)
Newfoundland and Labrador	1.0 (5)
Nova Scotia	4.9 (26)
Ontario	45.8 (241)
Quebec	22.6 (119)
Saskatchewan	1.0 (5)
Other/Unknown	<2.0 (7)
Urban vs. Rural¥
Urban	97.3 (512)
Rural	< 5.0
Practice setting
Number of locations2
One	78.9 (415)
Two	14.6 (77)
Three or four	6.3 (33)
Academic teaching hospital	59.6 (313)
Private office	26.3 (138)
Community hospital	22.7 (119)
Hospital-based ambulatory clinic	12.0 (63)
Community health centre	11 (110)
Dedicated clinic for refugees or Other	< 5.0
Years in practice3
0–5 years	24.9 (131)
6–10 years	16.5 (87)
11–15 years	12.4 (65)
16–20 years	14.6 (77)
21+ years	31.4 (165)

^~7 missing province location.

^¥11 missing urban vs. rural, based on postal code.

²1 location missing.

³1 years in practice missing.

Of the 526 physicians who had provided care to IFHP-eligible patients in the last 6 months, only 12% (n = 65) had tried to access supplemental benefits. Subspecialists were less likely to have tried to access supplemental benefits compared to generalists (aOR 0.49, 95% CI 0.26 to 0.91). Those in academic teaching hospitals were more likely to have accessed supplemental benefits (aOR 2.51, 95% CI 1.05 to 6.00). There was no association between the provider having tried to access supplemental benefits with IFHP registration status, province, whether or not the provider was in an urban centre, years in practice, or number of IFHP-eligible patients seen.

The most common reason for not accessing supplemental benefits was that they were not clinically indicated (76%, n = 325). However, 30% (n = 138) of those who had recently provided care to IFHP-eligible patients indicated that they did not access supplemental benefits because they did not know they were covered through the IFHP. Less common reasons for not accessing supplemental benefits included: the process was managed by social work (14%, n = 63), resources were covered by another means, (2%, n = 7) and finally, less than 1% indicated that the reason for not accessing supplemental benefits was that it was time-consuming.

Of those who had accessed supplemental benefits (n = 65), 82% (n = 54) rated the process as very difficult, or difficult, while only 18% (n = 12) indicated that it was ‘easy’. No participants indicated that the process was ‘very easy’.

Of those who rated the process as very difficult or difficult, 83% indicated that the process was difficult due to administrative barriers and paperwork. Other common reasons for indicating the process as difficult or very difficult included: providers were unsure what was covered (80%, n = 43), and that it was time-consuming (70%, n = 38). Another important reason was that relevant service and supply providers were not registered for IFHP (46%, n = 25). Less common reasons for it being difficult was that it was unclear who qualifies (39%, n = 21), and requests for services being denied despite them being covered (19%, n = 10) (Table 2).

Table 2.

Percentage of respondents who identified a factor as contributing to why trying to access IFHP supplemental benefits was ‘difficult’ or “very difficult

	Percentage (n)*
Difficult process (e.g., paperwork, administrative barriers)	83.3 (45)
Unsure what was covered	79.6 (43)
Time consuming	70.4 (38)
Service and supply providers were not registered for IFHP	46.2 (25)
Unclear who qualifies	38.9 (21)
Requests for services denied despite being covered by IFHP	18.5 (10)

^*n = 54.

Of those who had recently provided care to IFHP-eligible patients, there were a number of different sources that providers indicated they would use for more information. Respondents were divided as to whether they would ask another non-physician colleague for more information about the program, search the government of Canada website, search the IFHP administrator website, or ask a physician colleague. Of those who would ask another colleague, the majority (68%, n = 97) indicated that they would consult a social worker, whilst a small percentage (6%, n = 8) indicated they would speak with a refugee centre/program/coordinator.

DISCUSSION

Only 12.4% (n = 65) of the providers who had worked with an IFHP-eligible patient in the last six months tried to access supplemental benefits. Our results would indicate that there are two interconnected processes occurring simultaneously. Firstly, physicians do not know supplemental benefits are covered by the IFHP, which is one of the most common reasons for supplemental benefits not being accessed. The second relevant issue is that among those who do know about the IFHP-covered supplemental benefits, they find the process difficult, including the fact that relevant allied-health providers were not registered. Our results seem to indicate that this does not deter people from trying to access supplemental benefits, as less than 1% indicated they did not access supplemental benefits as it was time-consuming. Furthermore, supplemental benefits are not being accessed by other means for this population, as only 2% (n = 7) indicated IFHP supplemental benefits were not used as there was another system in place.

This study builds upon previous research which demonstrates poor provider understanding and use of the IFHP (4). Although this program is intended to help refugees, it is likely not meeting the needs of its population, as providers under-utilize, and are uncertain about supplemental benefits, and the process to access these supplemental benefits is described as difficult. This results in patients being unsure if they qualify for supplemental benefits, perhaps not being offered relevant services, or even being asked to pay for a service that is covered by the IFHP (3). It is well known that refugees may experience deteriorating health after arrival to Canada, and the 2011 guidelines emphasize that appropriate healthcare must include adequate treatment of chronic conditions, vision, and dental health, all covered by the IFHP (5). These supplemental benefits play an important role in children’s health, such as physiotherapists providing therapy for children with cerebral palsy, or speech language pathologists intervening at a critical age in life to improve language development, aiding with school performance, and quality of life (6,7). The need for access to these supplemental benefits is even higher in the time of COVID, as the pandemic has amplified health inequities for refugees, who are currently facing worsening mental health concerns, and a rising number of challenges in accessing care, including the need to navigate virtual care, and language barriers during virtual appointments (8).

Our results show improved awareness and understanding of the IFHP amongst physicians and other allied-health team members may improve access to the program, and improved utilization of supplemental benefits. As previously argued, important interventions to improve knowledge of the IFHP could include expanding educational initiatives in medical school and residency, and designing educational websites for physicians (5). However, a single insurance program that provides universal care to all eligible persons would likely provide better ease of access to care. Our results would indicate that educational initiatives and information should be spread across resources and tools, as providers were rather evenly split as to where they would go for more information, including another physician colleague, another provider (mostly social work), the Immigration, Refugee and Citizenship Canada (IRCC) main webpage and the IFHP administrator website/hotline. Educational initiatives should include relevant service and supply providers as many are not registered with the IFHP, making access to supplemental benefits difficult. Furthermore, allied-health team members such as pharmacists, physiotherapists, and occupational therapists should be included in these educational initiatives, as they deliver many of the IFHP-covered services. Finally, patients themselves should be educated about what IFHP covers, and interpretation services be made available in all healthcare settings to allow patients to advocate for themselves. Small interventions to improve knowledge about what is covered could make accessing supplemental benefits easier. Interventions at an administrative or government-level could improve streamlining the process so that it has less administrative burden, and it is less time-consuming. Furthermore, as previously argued, registration rates for both providers and relevant service and supply providers should be increased. Such initiatives could include mandatory registration upon opening a practice (5). Registration is free and can be done online or through a paper requisition (9). A previous study demonstrated that whether or not a provider was registered with the IFHP was the only factor associated with knowledge of the program (4). This may be because the process of registering prompts the provider to have a better understanding of the program.

There are a few limitations to this survey, which have been previously discussed (4). In brief, given that only paediatric providers participated in this survey, the results of this survey may not be generalizable to other groups. Secondly, the response rate was 36.5%, so respondents may be systematically different than non-respondents. However, those that did respond may be more likely to know about IFHP, and be interested in the topic, and therefore skew our results and overestimate knowledge and use of IFHP. Finally, there may be an element of recall bias, as providers were asked to reflect on their experiences in the past. However, we believe this was limited as they were only asked to recall their experiences from the last 6 months, and only those that had recently worked with IFHP patients were included in the analyses.

The findings of this study demonstrate that poor knowledge of IFHP-covered supplemental benefits is an important factor in preventing providers from trying to access supplemental benefits. Furthermore, it demonstrates that providers have a difficult time in trying to access supplemental benefits due to administrative barriers, a time-consuming process, and that relevant service and supply providers are not registered. Efforts should be made to improve provider (physician and allied-health) knowledge of the program, provider registration rates and streamlining the means by which providers can try to gain access to supplemental benefits for their patients (5). Taking these measures is essential to improve refugee-youth access to healthcare. There are also potential future and unpredictable waves of refugees given ongoing geo-political forces, for which we should be prepared. It is therefore essential that these reforms begin on a timely basis.

FUNDING

Canadian Paediatric Surveillance Program

CONFLICTS OF INTEREST

MR was the co-founder of the Canadian Doctors for Refugee Care, a group that advocated for access to health care for refugees from 2012-2016. The group is no longer active. There are no other conflicts of interest.