Interim Federal Health Program: Survey of access and utilization by paediatric health care providers

Abstract

Background

The Interim Federal Health Program (IFHP) provides health care coverage to refugees and refugee claimants, yet remains underused by providers. The objective of this study was to assess Canadian paediatricians’ current understanding and utilization of the IFHP, and perceived barriers to utilization.

Methods

A one-time survey was administered via the Canadian Paediatric Surveillance Program in February 2020. In addition to descriptive statistics, multinomial logistic regressions were built to examine paediatrician use of the IFHP, and characteristics associated with registration and use.

Results

Of the 2,753 physicians surveyed, there were 1,006 respondents (general paediatricians and subspecialists). 52.2% of respondents had provided care to IFHP-eligible patients in the previous 6 months. Of those participants, only 26.4% were registered IFHP providers, and just 16% could identify 80% or more of IFHP-covered services. Knowledge of 80% or more of IFHP-covered services was associated with registration status (adjusted odds ratio [aOR] 1.92; 95%CI 1.09 to 3.37). Among those who knew they were not registered, 70.2% indicated they did not know they had to register. aOR demonstrated that those with fewer years of practice had higher odds of not knowing that they had to register (aOR 1.22; 95%CI 1.01 to 1.49).

Conclusions

We demonstrate that IFHP is poorly utilized by paediatric providers, with low registration rates and poor understanding of IFHP-covered supplemental services, even among those who have recently provided care to IFHP-eligible patients. Efforts to improve registration and knowledge of IFHP are essential to improving access to health care for refugee children and youth.

Graphical Abstract

Canada’s Interim Federal Health Program (IFHP) was created in 1957 to provide temporary health care insurance coverage for resettled-refugees, protected persons in Canada, refugee claimants, victims of human trafficking, and detainees (1). The IFHP provides insurance coverage for medical services such as ambulatory and in-hospital medical services, and supplementary coverage for medications, equipment, and allied health services including home care and mental health (2). The IFHP is managed federally, requiring health care providers to register and submit billings separately from their provincial health insurance reimbursement plans. In 2012, IFHP-covered services were significantly restricted by the government, leaving some individuals with no health coverage. In 2014, the Supreme Court of Canada ruled these cuts unconstitutional, and the program was restored in 2016.

In 2019, Canada received 42,491 new refugee claims, and had 87,270 pending refugee protection claims from prior years (3). Most live in Ontario and Quebec, with nearly 25% under the age of 14 (4). Refugees often arrive in Canada with a history of unstable living conditions, exposure to infectious disease, experiences of trauma and violence, and poor access to health care, and are at increased risk of self-reported health deterioration upon arrival in Canada (5). The IFHP thus provides critical access to health care (5).

Research has identified many barriers to health care for patients with IFHP coverage. Following the cuts to the program in 2012, providers have reported limited understanding of who and what are covered by the IFHP as well as difficulties with reimbursement and registration (6,7). As a result of poor provider understanding, children with IFHP coverage have, at times, been denied care by health professionals or their clerical staff, forcing their families to pay directly for insured services or forgo care (6).

Although children make up over 25% of resettled refugees and refugee claimants in Canada, no study has specifically examined the understanding and utilization of the IFHP among Canadian paediatric health providers. Most studies to date have focused on small geographic areas (6,7). This study conducted the first national survey of IFHP registration and utilization among Canadian paediatric health care providers through the Canadian Paediatric Surveillance Program (CPSP). The objective of this study was to assess general paediatricians’ or subspecialist paediatricians’ current understanding and utilization of IFHP in providing comprehensive patient care and investigate if there is an association between physician demographics and IFHP utilization.

METHODS

The CPSP, a joint project between the Public Health Agency of Canada and the Canadian Paediatric Society (CPS), is a public health surveillance platform designed to support national studies and one-time surveys on rare paediatric conditions and illness or rare complications of more common conditions. The CPSP network includes over 2,800 paediatricians and paediatric subspecialists in active practice across Canada.

To be included in the study, physicians needed to be in active practice within Canada and a registered participant of the CPSP. This sampling frame closely approximates the number of paediatricians and paediatric subspecialists in Canada (8,9). Participants were sent a personalized link.

The survey was reviewed and approved by the CPSP Scientific Steering Committee, and underwent pilot testing for clarity, utility, completion time and content validity. The 10 question adaptive survey was available in English or French, in either paper or electronic format. Survey responses were collected for 6 weeks in early 2020 with two reminders sent prior to survey closing. Consistent with standing CPSP policy, participation was voluntary and incentives were not provided for survey completion. Study purpose and investigators were provided along with the survey questions.

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 to 5, 6 to 10, 11 to 15, 16 to 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 6 months (0 to 5, 6 to 19, 20 to 50, >50, or unknown), IFHP provider registration status, and reasons for not registering. Finally, physicians were asked to identify from a list of six IFHP-covered services which services, to their knowledge, the IFHP covered.

Descriptive tables (see Supplementary Appendix 1) and figures were created for participant demographics, knowledge of IFHP-covered services, and registration status. Unless otherwise indicated, percent totals are of available data. Using multinomial regression, the adjusted odds were calculated for having provided care to an IFHP patient in the last 6 months. Certain confounding variables were included in the regression a priori. These included specialty (general vs. subspecialist), years in practice, province (Ontario, East Coast, Quebec, Prairies, British Columbia, Nunavut/Northwest Territories/Yukon), living in a large resettlement city (binary), and practice location (academic teaching hospital, private office, and community hospital, the three most popular settings). Those with missing data for confounding variables were excluded from the regression. Among those who had provided care to IFHP-eligible patients in the last 6 months, three additional multinomial logistic regressions were calculated: the odds of knowing 80% or more of IFHP-covered services, odds of being a registered provider for IFHP, and odds of not knowing they had to register for IFHP. The same confounding variables were included a priori, as well as the number of IFHP-eligible patients seen (0 to 5, 6 to 19, 20 to 50, >50). When examining knowledge of supplemental benefits, registration status was tested for contribution to the model using the likelihood ratio test. All relevant categorical variables were tested for linear trend using the likelihood ratio test.

Research Ethics Board 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). 55.7% of respondents self-identified as ‘general’ paediatricians, and 44.1% self-identified as subspecialists. Respondents were distributed across the country, with 60.1% (n=605) living in either Ontario or Quebec and 45.1% (n=454) practicing in a large resettlement city. The most common practice settings were academic teaching hospitals (51.2%), private offices (33.1%), and community hospitals (21.4%). Of those practicing in community hospitals, 22% were in a large resettlement city. There was a range of years in practice, with 21.9% having 0 to 5 years of experience, and 37.8% with 21+ years of experience (Supplementary Table S1).

Of the survey participants, 478 (47.5%) had not provided care to an IFHP-eligible patient in the last 6 months. Of these, 79.4% indicated it was because, to their knowledge, no IFHP-eligible patient had sought their services, and 16.3% indicated they did not know the health coverage status of their patients. Adjusted odds ratios (n=980) demonstrated that subspecialists (OR 0.59; 95%CI 0.42 to 0.84); those with more years in practice (OR 0.87; 95%CI 0.80 to 0.95); and those outside Ontario were all less likely to have provided care to an IFHP-eligible patient. Living in a resettlement city (OR 2.51; 95%CI 1.80 to 3.50), and working at an academic teaching hospital (OR 2.50; 95%CI 1.63 to 3.82), or in a community hospital (OR 1.78; 95%CI 1.20 to 2.65) all increased the odds of having provided care to an IFHP eligible patient (Supplementary Table S2).

More than half of respondents (52.2%, n=526) had provided care to IFHP-eligible patients in the last 6 months. The majority had provided care to 0 to 5 patients (57.6%) or 6 to 19 patients (26.6%). The majority of those who had provided care were located in Ontario (45.8%, 241). Of the 526 individuals who had provided care in the last 6 months, 26.4% (n=139) were registered IFHP providers, 51.1% (n=268) knew they were not registered, and 22.4% (n=118) did not know their registration status (Figure 1). After adjustment, those living outside of Ontario, and those in academic teaching hospitals, had lower odds of being a registered IFHP provider (Supplementary Table S3). Living in a large resettlement city was not associated with registration status.

Figure 1.

Provision of care to IFHP-eligible patients, registration status, and knowledge. n = 519 for provided care, and all data available for registration status and IFHP knowledge. *80% or greater knowledge of IFHP-covered services, as identified by selecting ‘all that apply’ from a list of IFHP-covered services.

Knowledge of the IFHP program was poor among those who had provided care in the last 6 months to IFHP-eligible patients. Among those who had provided care to IFHP-eligible patients in the last 6 months, only 16% (n=83) could identify 80% or more of IFHP-covered services (Figure 1). Knowledge of 80% or more of IFHP-covered services was associated with registration status (OR 1.92; 95%CI 1.09 to 3.37). Specialty, years in practice, province, living in a large urban centre, practice location, and number of IFHP eligible patients seen, all had no significant association with knowledge of the program.

Of the 526 participants who had provided care to IFHP-eligible patients, 22.4% did not know their registration status, while 51% knew they were not registered. Common reasons for unknown registration status included providing care regardless of registration status (68.6%), and being compensated for care regardless of registration status (25.4%). Among those who knew they were not registered, 70.2% indicated they did not know they had to register. Adjusted odds ratios demonstrated that those with fewer years of practice had higher odds of not knowing that they had to register (aOR 1.22; 95%CI 1.01 to 1.49) Location, practice setting, specialty, and number of IFHP eligible patients seen all were not significantly associated.

DISCUSSION

Providers in resettlement cities and academic teaching hospitals are more likely to have worked with an IFHP-eligible patient in the last 6 months. However, those in academic teaching hospitals are also less likely to be an IFHP-registered provider, and being in a large resettlement city was not associated with registration status. Being a registered IFHP provider was the only factor in this study associated with strong knowledge of the broad range of services covered by IFHP.

Only 26% of those that had provided care to IFHP-eligible patients in the last 6 months were registered IFHP providers. Reasons for not registering included: being paid for services rendered regardless of their registration status, providing care regardless of their registration status, and not knowing that they had to register. Knowledge of the IFHP supplemental benefits was not associated with the number of IFHP patients seen, being in an academic teaching centre, nor being in a large city.

This study found that physicians with fewer years of practice are more likely to be unaware of IFHP registration, while simultaneously are more likely to have provided care to patients who are insured under IFHP. This may be because many resident training programs do not incorporate dedicated teaching around understanding and utilizing IFHP, or residents may be training in facilities with alternate program funding models. This is consistent with other studies: through a Delphi survey, Pottie et al. (2011) identified that <50% of selected health care providers had prior training on working with immigrants and refugees (5). The majority of residency programs occur in academic teaching hospitals, which our results demonstrate are less likely to have registered providers. Additionally, our results indicate that a large proportion of respondents do not know the status of their patients. Therefore, residents are likely not being trained to ask important questions around coverage. Physicians need to have an understanding of IFHP, irrespective of their pay model, to provide equitable and comprehensive care. The only factor that predicts understanding in our study is the physician’s registration status.

Poor knowledge of the program, patient IFHP status, and poor registration rates, are issues reflective of a policy that is not meeting the needs of its intended population, many of whom face racism and systemic inequities. Paediatric patients who are covered by the IFHP are not receiving care they are entitled to because their care providers are under-utilizing this program, unsure if they qualify for supplemental services, or worse, asking for payment for a service that is covered by IFHP (6). For example, IFHP-covered mental health support was the supplemental service that physician respondents were least aware of. However, previous studies have shown that refugee youth require acute mental health care services at a higher rate than nonimmigrant youth, and face multiple stressors including potential past traumas and the stress of resettlement (10). As more resettled refugees and refugee claimants move from urban to suburban areas, it is important that all physicians are aware of the scope of coverage provided through the IFHP, and not just those in large resettlement cities (11). Finally, this issue of knowledge is not limited to health care professionals, but also applies to clerical staff who may be the patient’s first point of contact.

There are a number of research and policy implications from these results. Firstly, our study demonstrates that more paediatric providers need to understand IFHP in order to improve access to care. In the short-term, it should be considered whether a mandatory IFHP-registration policy should be in place across Canada, rather than the current opt-in approach. Secondly, residency training programs should include knowledge of health insurance systems, including IFHP pre- and post-graduate medical education. Finally, IFHP registration could be incorporated into physicians’ annual renewal through their provincial licensing bodies, such as the College of Physicians and Surgeons of Ontario. Other research should examine the knowledge of primary care providers, notably family physicians and other allied health professionals such as physiotherapists and psychologists, who are also required to register with the IFHP, and the direct impacts of better IFHP utilization on patient health outcomes.

There are a few limitations to this survey. Firstly, only physicians who provide paediatric care were surveyed therefore results may not be generalizable to other physician groups. Family physicians may be more likely than paediatricians to see this patient population. However, our results indicate that >50% of respondents had worked with IFHP-eligible patients. Furthermore, if referred to a paediatrician, it is more likely that the child may require supplemental services. Secondly, the response rate to the survey was approximately 36.5%. It is possible that those who responded were systematically different than non-respondents. However, we believe this bias was limited. Our response rate was similar to that of other CPSP surveys, with the distribution of study participants by province similar to that of the distribution of paediatricians at large, helping ensure a nationally representative sample. Thirdly, our survey does not differentiate those who work in inpatient vs. outpatient settings. Although it may be true that those who work in inpatient settings are unaware of patient billings, as it may be done by a third party, it is important for them to have knowledge of IFHP-covered services for appropriate outpatient referrals and discharge planning. Furthermore, our results indicate that 13% of those who provide hospital care (academic or community) also work in a private office, and therefore would likely require an understanding of patient billings.

The findings of this study demonstrate that registration rates for IFHP providers is low, and understanding is poor, among paediatricians who have recently provided care to IFHP-eligible patients. Although some physicians may have third parties that complete billings, registration and understanding of the program should not be dependent on the physical model of compensation. Being registered is an important predictor of understanding the IFHP program, and policy should consider incorporating mandatory registration for providers. Other important interventions could include expanding medical school and residency programs to include IFHP education in curricula, and designing educational websites and providing continuing medical education for physicians to understand the program better. Supplementary Appendix 2 highlights important information and resources about the IFHP for health care providers.

SUPPLEMENTARY DATA

Supplementary data are available at Paediatrics & Child Health Online by searching for pxab045.

Funding: This study was supported by the Canadian Paediatric Surveillance Program.

Potential 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 disclosures. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.