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Help Suzanne Aucoin
Nov. 17, 2006 - National Post
OHIP WINS APPEAL, NOT PAYING FOR TREATMENT - WOMAN SPENT $52,000 ON DRUG
NOT
COVERED BY PROVINCE
Kelly Patrick, National Post (Page A6)
Friday, November 17, 2006
The panel that reviews Ontario Health Insurance Plan (OHIP) rejections
yesterday dismissed an appeal by a St. Catharines woman who had hoped to
recover more than $52,000 she paid out-of-pocket for intravenous cancer
treatment.
The ruling is particularly interesting, the woman's lawyer says, because it
exposes the folly of regulations that allow OHIP to pay for the treatment at
a Buffalo hospital, but not at a New York state private doctor's clinic -
even though the treatment costs twice as much at the hospital.
"What's galling here is that there are people with decision-making authority
in our health-care system making decisions without taking cost into
account," said Brian Cohen, a Toronto lawyer representing Suzanne Aucoin,
36, a former Catholic school chaplain who was diagnosed with colorectal
cancer in 1999. "Suzanne tried to save the taxpayers money," he said.
Ms. Aucoin's battle with the province's health-care bureaucracy began in
October, 2005, when her oncologist recommended she begin receiving weekly
infusions of a drug called Erbitux. The drug was approved by Health Canada,
but its maker, Bristol-Myers Squibb, had not made Erbitux commercially
available in Canada.
Ms. Aucoin's oncologist applied to OHIP for out-of-country coverage for the
drug. She was denied.
Ms. Aucoin appealed the rejection, but as the case wound its way through the
system she shopped around for an affordable Erbitux provider in the United
States, settling on a private doctor's clinic in West Seneca, N.Y., where
Erbitux infusions cost about $4,000 per treatment.
Ms. Aucoin spent $31,065 on two months of Erbitux at the West Seneca clinic
before Health Canada and Bristol-Myers Squibb reached a deal allowing her
access to the drug at the Hamilton Health Sciences Centre.
Because Erbitux was not technically available in Ontario, it was not covered
by OHIP. Ms. Aucoin spent $21,182 for three months of treatment in
Hamilton, or about $1,600 per treatment.
In March of this year, without explanation, OHIP reversed its original
rejection of Ms. Aucoin's request and agreed to begin paying for Erbitux at
the Roswell Park Cancer Institute in Buffalo, N.Y., at a cost of about
$8,000 per treatment.
Yesterday's ruling by Health Services Appeal and Review Board addressed Ms.
Aucoin's bid to recover the costs of the infusions she paid for in Hamilton
and West Seneca. The panel said the Hamilton portion of the appeal was
outside its jurisdiction - the board is limited to reviewing rejections for
out-of-country funding - but it turned down the West Seneca portion on odder
grounds, Mr. Cohen said.
OHIP's regulations require that out of-country treatments be delivered at a
"licensed facility." The West Seneca doctor's office did not qualify, the
panel ruled, because although the doctor who owns and operates the clinic is
licensed, the office itself is not. Nothing in New York state law requires
doctors' offices to be licensed separately, Mr. Cohen said. In the end,
that technicality allowed OHIP to pay $8,000 per treatment at the hospital,
but not $4,000 per treatment at a doctor's private clinic.
Ms. Aucoin said yesterday she is mulling taking her case to the courts.
"I'm obviously disappointed and frustrated with this process," she said.
"But I'm not surprised because things have not been easy for me."
OHIP WINS APPEAL, NOT PAYING FOR TREATMENT - WOMAN SPENT $52,000 ON DRUG
NOT
COVERED BY PROVINCE
Kelly Patrick, National Post (Page A6)
Friday, November 17, 2006
The panel that reviews Ontario Health Insurance Plan (OHIP) rejections
yesterday dismissed an appeal by a St. Catharines woman who had hoped to
recover more than $52,000 she paid out-of-pocket for intravenous cancer
treatment.
The ruling is particularly interesting, the woman's lawyer says, because it
exposes the folly of regulations that allow OHIP to pay for the treatment at
a Buffalo hospital, but not at a New York state private doctor's clinic -
even though the treatment costs twice as much at the hospital.
"What's galling here is that there are people with decision-making authority
in our health-care system making decisions without taking cost into
account," said Brian Cohen, a Toronto lawyer representing Suzanne Aucoin,
36, a former Catholic school chaplain who was diagnosed with colorectal
cancer in 1999. "Suzanne tried to save the taxpayers money," he said.
Ms. Aucoin's battle with the province's health-care bureaucracy began in
October, 2005, when her oncologist recommended she begin receiving weekly
infusions of a drug called Erbitux. The drug was approved by Health Canada,
but its maker, Bristol-Myers Squibb, had not made Erbitux commercially
available in Canada.
Ms. Aucoin's oncologist applied to OHIP for out-of-country coverage for the
drug. She was denied.
Ms. Aucoin appealed the rejection, but as the case wound its way through the
system she shopped around for an affordable Erbitux provider in the United
States, settling on a private doctor's clinic in West Seneca, N.Y., where
Erbitux infusions cost about $4,000 per treatment.
Ms. Aucoin spent $31,065 on two months of Erbitux at the West Seneca clinic
before Health Canada and Bristol-Myers Squibb reached a deal allowing her
access to the drug at the Hamilton Health Sciences Centre.
Because Erbitux was not technically available in Ontario, it was not covered
by OHIP. Ms. Aucoin spent $21,182 for three months of treatment in
Hamilton, or about $1,600 per treatment.
In March of this year, without explanation, OHIP reversed its original
rejection of Ms. Aucoin's request and agreed to begin paying for Erbitux at
the Roswell Park Cancer Institute in Buffalo, N.Y., at a cost of about
$8,000 per treatment.
Yesterday's ruling by Health Services Appeal and Review Board addressed Ms.
Aucoin's bid to recover the costs of the infusions she paid for in Hamilton
and West Seneca. The panel said the Hamilton portion of the appeal was
outside its jurisdiction - the board is limited to reviewing rejections for
out-of-country funding - but it turned down the West Seneca portion on odder
grounds, Mr. Cohen said.
OHIP's regulations require that out of-country treatments be delivered at a
"licensed facility." The West Seneca doctor's office did not qualify, the
panel ruled, because although the doctor who owns and operates the clinic is
licensed, the office itself is not. Nothing in New York state law requires
doctors' offices to be licensed separately, Mr. Cohen said. In the end,
that technicality allowed OHIP to pay $8,000 per treatment at the hospital,
but not $4,000 per treatment at a doctor's private clinic.
Ms. Aucoin said yesterday she is mulling taking her case to the courts.
"I'm obviously disappointed and frustrated with this process," she said.
"But I'm not surprised because things have not been easy for me."