Saving the integrity of the Ontario health care system

Here is an interesting article from Canada:

A Canadian citizen was denied reimbursement by the Ontario Health Plan for a liver transplant in 1999 after “two well-respected transplant centres in Ontario said he was not a suitable candidate for a liver transplant”. Toronto General Hospital told him “his chances of survival were slim” and “he had just six months to live.” This is the kind of review and tough decision that systems with limited resources must face, whether public or private. So, is there a problem? Well, based on the information reported in this case, I think yes.

This patient sought advice from other physicians, and that’s where the story gets interesting. A team of doctors in London, England gave him an entirely different medical opinion. However, the Ontario Health Plan refused to change its original decision, repeating that he “wasn’t a candidate”. One of the Ontario hospitals added that the “procedure had never been performed” – anyway, not “in adults” – and anyway, not “at that hospital”.

After the patient had the operation in England and survived, thank you, he sued the Ontario health plan for reimbursement – and lost, the case is under appeal.

The Ontario Health Plan’s defense is that the operation “was considered in Ontario to be experimental” and that “the state did not deprive him of anything, specifically of seeking treatment overseas.” Strangely enough, Ontario also argued that “liver transplants in Ontario are available in a timely fashion”. For everyone except poor Adolfo, I guess. Water, water everywhere and not a drop to drink - eh?

This story raises many questions that are not explored. Was the original reason for Ontario’s denial truly based on clinical factors? Was it a competent review? How much might the decision have been influenced by the Ontario hospitals’ admitted ignorance of the life-saving procedure? How much might the review authorities in Ontario have been influenced by the expected cost, in ruling that the patient was “not a good candidate” for the operation? Is Ontario truly as inflexible as the article implies in regard to its own medical guidelines? Why didn’t the patient go to a different Canadian hospital - I thought in Canada one has free choice of hospitals? Was the Ontario Health Plan responsible for the “tainted” blood transfusion in the first place? If not, who was; is there no accounting for such liability in the Canadian health care system?

Finally, in the case that is being appealed, the judges wrote that limiting the funding of out-of-country medical treatments to those that are generally accepted in Ontario ensures public funds are not spent on treatments that are "inconsistent with the ethics and values of the Ontario medical profession and the Ontario public. This safeguards the integrity of the health care system." Maybe. And maybe more information is needed before the public knows for sure whether this episode is about integrity or about money.