Managing Health Costs Out of a Finite Pool

"It's a hard pill to swallow, to be injured like I was by a somewhat minor operation, and to have your life destroyed by it. To then have to battle the whole government machine adds a whole other layer of anger and frustration."
"The pain was so extreme [from her unsuccessful foot operation] that I couldn't imagine a life with it."
"I think it's fundamentally unjust [that the Ontario universal health care plan will not reimburse patients for self-selected out-of-province surgery]. There is no process in place that allows for fairness in funding."
Michelle Fernandes, former broadcast executive, recreational runner

"It's a blatantly rigged process. I've seen too man people pay all these outrageous taxes over the years, and then the system completely fails them."
Dr. Jeff Brock, CEO MedExtra

"There are a number of places [shady quasi-medical enterprises] that will take people with late-stage disease and 'give it a shot'."
"Sometimes there is a disingenuous promise from another [medical] centre [outside Canada]."
Terry Sullivan, health-policy professor, University of Toronto

The Ontario Liberals are projecting overall spending growth of just 1.2 per cent on hospitals, doctors and other services – an increase that is less than half the size of last year’s and well short of inflation and population growth.    (Kevin Van Paassen/The Globe and Mail)

 

The issue for the Ontario Health Ministry in deciding what will be covered by the finite funds used to ensure that provincial residents obtain their universal health care needs in coverage that scoops up most, but not all needs associated with furnishing that health care, is to limit what they perceive as coverage for extraneous, unauthorized services. There are wait times for many surgical procedures that are not considered of an emergency linkage.

And sometimes patients become impatient and look for treatment outside Canada. Aside from those interminable-seeming surgical wait times, often the type of treatment sought may be experimental in nature and not approved by Health Canada, from stem-cell therapies obtainable in Mexico, to multiple-sclerosis procedures in Poland whose actual merit in answering the medical-health needs of patients is questionable, or research does not support these procedures.

The Canadian medical community and the services provided are conventional in nature, services proven over time to be successful. In the United States there are fewer constraints where the medical system tends to be more entrepreneurial in the sense that often claims are made for successful interventions that are not merited by reality, but they tend to draw people in who believe they will be  helped.

Dr. Sullivan with University of Toronto was a former Ontario Health Ministry official who argues from experience that the system used by Ontario in its health policies formulations is capable of adequately identifying cases deserving of funding. Michelle Fernandes who looked elsewhere than within Canada to solve her problem that resulted from an operation that had not been successful, disagrees.

She had been a director of research at a media firm, had run competitively in the Chicago marathon, taken part in 400-kilometre cycling events and was in generally fit health.She developed ankle bone spurs and an operation was scheduled in 2005. The surgeon inadvertently damaged a number of nerves leaving her in excruciating pain that left her little option but to leave her job since she was effectively bedridden for three years.

She was in so much pain that at age 47 and unable to sleep, she contemplated suicide. No Canadian specialists she consulted felt they could help her. And then she contacted a surgeon in the United States and made arrangements for surgeries to take place there. At a cost of $200,000. Little wonder it seems unfair to her that through no fault of her own, her health dreadfully impaired by a surgeon whose technique was lacking and yet the Ontario Health Ministry refuses to reimburse her.

A provincial appeal board upheld the government's position. When Canadians seek out health care in another country, the provinces are loathe to pay for services received. Patients are enjoined to seek official approval from the ministry for funding before undertaking a foreign medical service. Under the Health Ministry's rules foreign treatment must not be of an experimental nature and nor should the service be of a kind available in Canada.

In fact, the Ministry itself often sends patients outside Canada in reflection of any service gaps in the province. As for pre-authorization of payment for services received abroad, very few applications ever get approved, explained a former lawyer for the Ontario Health Insurance Program. And when patients appeal their OHIP denial of funding, the Health Services Appeal and Review Board turns down 82 percent of those cases.

Through her general practitioner Ms. Fernandes consulted "dozens and dozens" of specialists; neurosurgeons and orthopedic surgeons in Ontario and other provinces, to no avail, leading them to the conclusion they would be required to look for the needed help outside Canada.

In 2006 the first of ten surgeries took place for Ms. Fernandes with a peripheral-nerve specialist at Johns Hopkins University in Baltimore. Imaging was used to identify the location of the damaged nerves which were then removed one by one. Each time this occurred Fernandes' condition was improved.

Now, a doctor who had received training under one of the Johns Hopkins surgeons' collaborators is at the present time in practise in Toronto. And it is this practitioner whom Fernandes relied upon for her latest surgery, at medicare's expense.