Kristina and David Reid with their three-year-old son Liam, in their Whitby home on Wednesday, June 27, 2012.They were unable to obtain funding from OHIP to save their son's sight, who suffers from a rare disorder that can only be treated properly by a specialist in Detroit.
Credits: Veronica Henri/Toronto Sun/QMI Agency
Their stories always break your heart.
Remember little Liam Reid? The tot from Whitby, just east of Toronto, needed eye surgery in Detroit to save his sight.
His parents have already coughed up $50,000 for treatments because OHIP (the Ontario Health Insurance Plan) won't pay for out-of-country care.
What about Erika Crawford?
The Brantford, Ont., teen suffers from Ehlers-Danlos Syndrome (EDS), an inherited incurable disease that affects the connective tissue. A sudden movement of her neck could kill her.
Her family set out for Maryland this week for life-saving surgery with a doctor who specializes in EDS.
Again, Fiona, 17, is up against the bureaucrats at OHIP, who've turned down her family's request for out-of-country coverage.
Lawyer Perry Brodkin represents a number of patients seeking out-of-country OHIP coverage. He says recent changes to the regulations on out-of-country care have made it almost impossible for patients to get OHIP coverage.
As of April 1, 2011, patients had to find a specialist to request out-of-country care. Prior to that, family physicians could do so. And if a specialist in this province says they can perform the procedure, then OHIP coverage outside the country will automatically be denied.
That's what stands in the way of coverage for people like Erika. She needs very specialized neurosurgery. While her family -- and several other EDS patients -- say the U.S. doctor is the only one qualified to do the surgery, OHIP says otherwise.
"If there's a physician in Ontario - a neurosurgeon - who had provided written confirmation that he or she is available to provide the service, it doesn't matter if that neurosurgeon has never performed the neurosurgery on a particular person with that particular illness or disease, all the neurosurgeon has to do in this case is raise his or her hand and say, 'I am available to provide the service,'" Brodkin says.
And OHIP is off the hook.
That change was made after the Brad Remigis case. In 2010, the Health Services Appeal and Review Board (HSARB) ordered OHIP to pay an estimated $200,000 for neurosurgery in Phoenix for the Ontario teen suffering from a rare brain lesion.
Most patients aren't aware of another change made by the NDP government 21 years ago.
"Prior to Oct. 1, 1991, you could go anywhere in the world and get health care," Brodkin said. "You didn't have to get prior approval - you just went."
With medical tourism a fact of life, patients often turn to him after the fact to help them get reimbursement from OHIP.
It doesn't work like that.
You must get prior approval for surgery.
Talk to OHIP, visit their website before you head overseas, he says.
"If you're even thinking about accessing health care outside Canada - even thinking - you must have an Ontario specialist complete and submit a request for prior approval," says Brodkin, who's offered to go over the paperwork with the Crawfords pro bono to see if there's anything they can do.
It's not just surgeries that aren't covered.
New drugs often aren't paid for by OHIP.
More and more frequently, the provincial Committee to Evaluate Drugs turns down certain therapies -- often because they're not cost-effective.
"Frequently their recommendation in recent time tends to be negative, "do not list," because the price point is so high or there are risks of the drugs being used for purposes other than the one proven through the clinical trial," says Dianne McArthur, the executive officer of Ontario Public Drug Programs.
The committtee studies the cost-effectiveness of the drug and weighs it against its effectiveness compared to current treatments.
The bottom line is you may think you're insured for out-of-country care and the most recent drug therapies. Think again.
These days, it's not so much a doctor you need in the operating room, it's a lawyer.
How are Erika and Liam surviving OHIP?
I caught up with Erika's mom, Michelle, just as the family was gassing up for the drive to Maryland.
"I got a phone call last night to say that Erika needs to see anther specialist prior to surgery," Michelle explained.
Through church and school fundraisers -- and donations from QMI readers -- the $30,000 they need as a deposit with the hospital in the U.S. is covered.
"That's a start, and we'll just keep on going. Now we have another doctor, so another bill," she said.
"We're very disappointed that the health care system hasn't helped us out.
"We pay taxes. We're Canadian citizens. It's very frustrating. We want to help inform the medical system about Erika's disease so other children get help," she said.
And Liam's doing just great, says mom Kristina. They don't have to go back to Detroit until March of next year. They have nothing new to report on the OHIP front, but Liam's eyes appear to have stabilized.
Now that's something to really give thanks for this weekend.