Fabio Ynoe de Moraes, Radiation Oncologist and Associate Professor at Queen’s University, shared a post on LinkedIn:
“Hundreds of Ontarians have been sent to the U.S. (and a few other countries) for care since 2018 under OHIP’s Out-of-Country Prior Approval Program. An exclusive analysis found more than $212M in taxpayer-funded care abroad, with about 95% of approved cases performed in the U.S. (mainly NY, CA, MI). The overall approval rate was about 54%; in about 80% of approvals the service simply doesn’t exist in Ontario. Proton therapy was the top expense in 2024 (about $2.4M for 29 courses). Requests for complex gender-affirming surgery climbed to 139 in 2024 (versus. about 41/year, 2018–2023).
Context that matters for oncology and rare care
- Proton therapy (PBT): Canada is the only G7 country without a clinical PBT centre. Patients access PBT via out-of-country approvals; consultation services have emerged to triage who benefits.
- Policy movement exists: Ontario announced $5M (Apr 2022) to plan a hospital-based PBT facility at UHN; Alberta issued an RFI (Sept 2025, due Oct 1)to explore provincial PBT services and potential pan-Canadian access.
- When services localize, costs drop: CAR-T is a clear precedent—once programs opened in Canada, out-of-country spending fell sharply. Provinces now manufacture or reimburse CAR-T domestically, though coverage is still uneven.
What this signals (beyond the headlines)
- Volume and value alignment: PBT is expensive capital, but so is exporting patients. If even 10–20% of RT cases could benefit dosimetrically (peds CNS, skull base, select adult sites), a hub-and-spoke PBT model with transparent indications could be cost-effective at national scale.
- Interprovincial before international: A real-time directory of centres of excellence (with service SLAs, case-mix/outcome dashboards) would keep more patients in Canada and shorten time-to-care. (Think: a “national referral grid” spanning oncology, complex surgery, eating-disorder inpatient care, gender-affirming surgery.)
- Learning health system by design: Every funded out-of-country approval should feed a public registry tracking time-to-treatment, toxicity, PROs, cost-per-episode and the counterfactual (what would in-Canada care cost/achieve?). We did this informally with CAR-T; it should be standard.
A practical, 12-month action plan
- Publish the ledger: Quarterly public reporting of out-of-country approvals, indications, destinations, total cost (medical + travel), and outcomes.
- Stand up a national PBT pathway: Confirm site(s), case definitions, and pan-Canadian access rules; align with existing consensus statements; pre-specify value metrics (late effects, neurocognition, re-irradiation rescue).
- Interprovincial MOUs: Route low-volume complex procedures to Canadian centres with demonstrated volume/outcomes before authorizing foreign travel.
- Wraparound supports for families: Standardize travel/lodging stipends and virtual schooling for pediatric oncology families to reduce the hidden costs of prolonged out-of-country care.
- CAR-T playbook for PBT: Treat PBT like we treated CAR-T—plan, localize, measure, iterate—so out-of-country spend naturally declines as capacity matures.
Bottom line: Out-of-country care is a lifeline—and a signal. The data point to a solvable capacity gap: build selective high-value services (starting with PBT) inside a coordinated Canadian network, measure what matters, and keep patients closer to home.
Source investigation (CBC): Over $200M sent abroad since 2018; about 95% to the U.S.; about 54% approval rate; PBT = top 2024 cost; gender-affirming surgery requests rising. Policy steps already on the table: Ontario’s $5M PBT planning grant (2022); Alberta’s 2025 PBT RFI exploring services for all Canadians.”
More posts featuring Fabio Ynoe de Moraes.