I’ve wanted to write about this topic for awhile, but first a lawsuit prohibited me and then I was just tired. But the current insanity over health care raging south of the border has got me going enough to finally share my experience with American style health care in Canada.
Under Ontario law, when you’re injured in a car crash, your auto insurance company is supposed to cover your medical expenses under accident benefits. The Financial Services Commission of Ontario regulates what they cover. The insurer decides when. That sounds like government is dictating private health insurance for those injured in car crashes. But that’s not the case. Every few years (as is happening now), insurance companies whine about how much injured people are costing them, and the government amends the Insurance Act to give them basically what they want. I was covered under the Act in force in 2000. It is quite different now; worse actually. And my coverage in 2000 was much worse than what I experienced in 1991 under the version of the Act in force then. But the basics are pretty much the same.
After I was injured, I saw my family doctor or GP under coverage of OHIP (Ontario Health Insurance). All I have to do to see my GP is call up, make an appointment, walk in to the office, show my OHIP card, wait, and then see him. I don’t need no permission from no bean counter first. Because I’d been injured in a car crash, I had to file a claim with my car insurer and I had to do that quickly else I’d forfeit any coverage. I also had to fill in a form, and then later my GP had to fill in a disability certificate. OHIP doesn’t cover form filling, so he sent a bill to the insurance company. So far no sweat, right, just some form filling. Canadian style health care was working; American style was a pain but got it done.
Now for treatment. First came physiotherapy. When OHIP covered physiotherapy, my GP simply had to refer my then-husband to the physiotherapist. At the physiotherapy clinic, he showed his OHIP card, and that was pretty much all the hoop jumping one had to do to get physiotherapy.
Under accident benefits, my GP had to refer me to physiotherapy. Then my physiotherapist had to fill in a treatment plan. Then I had to wait (like hell I did) to get permission from some little bean counter in the insurance office who had as much medical experience and knowledge as a cockroach before I was allowed to get physiotherapy. They of course took their sweet time. Me not waiting for them got them a bit pissed. But I was in pain; I knew if I waited my injury would become worse; and if I waited too long I would be in for a lifetime of chronic pain. Like hell I was going to subject myself to that just because some insurance company wanted to save themselves a few bucks.
The treatment plan not only specified the treatment and the why of it, but also how long it would take, in other words, some fortune telling. Some therapists feared the insurance companies and would only specify 4 weeks max, leading to endless filling in and waiting for permission. Other therapists filled them in according to my need. They all upped their fees for insurance clients because of the extra costs involved in filling in the forms and haggling with the insurance companies. Any therapist I saw had to fill in a treatment plan; that meant physiotherapists, acupuncturists, massage therapists, doctors for certain kinds of treatments, psychologists, basically anyone who treated me for injuries relating to the car crash. After much arguing, I think they said yes the first couple of months. After that the real fun started.
When they said their standard “no, you can’t have that treatment,” they would then send me either for a DAC (designated assessment centre) or IME (independent medical exam). The idea was that one’s own GP was in it for the money and couldn’t be trusted to direct your medical care in this area. I have no idea how my GP profited from my injuries. He does not get rich from seeing a chronically ill or injured person. But there you go. The bean counters know better. So off I trotted from April to December to about 15 of these things, every one of which cost the insurer hundreds to thousands of dollars, money that had absolutely nothing to do with my medical care. Some, to their surprise and mine, said I needed the treatments, and so they had to say yes to the treatment plans. Unfortunately, that only held until the plan expired and it was time to submit another one (I got to the point where I really wished some therapists would stop worrying about what the insurer would say, assume it would be no, then at least when it finally got turned to yes, I wouldn’t have to go through the whole thing again a month later). Most IMEs and DACs said no. (My ex went ballistic at one, after several months of seeing how they fudged the exam results in order to say I was fine.) I persevered.
There are rights to appeal these expected nos under the law, but each step takes more and more time. I cannot remember how I did it, how I got the bean counters — and there were several that first year as they left and were replaced — to cough up the money for my treatments despite the usual IME hogwash, other than I had to employ lawyers and spend an awful lot of time on it. I remember at one point, they just stopped paying, I ran out of my own money to tide me over till they finally did pay, and I had to give up treatment for several months. By the time we came to an agreement, I was in agony. But they didn’t care. You see, the insurer doesn’t care if I get better or not, it doesn’t select and pay its IMEs to say yes; they expect these doctors and assessment centres to play the game and find a reason to say no. As time went on, these reasons became more and more ridiculous, even defamatory. Instead of spending my energy and time on getting better, getting back to work, I was spending it on fighting these guys to get the help I needed. Although they claimed that they under accident benefits would work with me to get proper medical care, they in fact did the opposite. They did not even hire a case manager — a person I would have greatly benefitted from medically and they financially — to manage my increasingly complex case.
The starkest difference between American style and Canadian style health care came when I saw occupational therapists. The insurer sent an occupational therapist to my house to assess my needs. Total joke. She sat at my kitchen table transcribing my answers longhand to her questions, then said this is what the insurance company would give me and so that’s what she’d recommend. She didn’t watch me function, assess my work situation, or inspect anything from heights of bathroom sinks to the kind of mop I had as she should have done. In contrast, under OHIP, the occupational therapist observed me in action, conducted several tests, assessed my needs, and then made recommendations and carried out treatment accordingly.
But that’s American style health care.
The insurance company is in it to make money, not to spend money on a claimant’s health care if they can help it. And anyone who thinks differently has been too much into the weed.
The best commentary on these two approaches to health care came when my physiatrist was trying to decide which rehab centre to send me to. One was covered by OHIP but entailed a 4-month wait. The other would be covered by my insurer, I’d be seen right away, but then I’d have to deal with bean counters to get the insurance company to pay. He felt I didn’t need that added stress, that waiting 4 months would be less harmful to my long- and short-term health than fighting bean counters on this most-important part of my medical care.
Going to OHIP-covered Toronto Rehabilitation Institute was the least stressful part of my overall treatment plan because I didn’t have to deal with the insurance company and their IMEs, DACs, and constant slagging of me just so I could get some care.
Right now, I’m applying for case management under OHIP. I couldn’t do that earlier because I was covered under private auto insurance who were required to pay for it. They refused to do so, and I was, quite frankly, fucked. I should have had this 9 years ago. I wonder if it’s too late, and I wonder if the insurance company had worked with me — instead of against me — how much healthier I would be today.
While the Americans slowly melt down into a stew of insane rumours and fear-mongering, I am thankful for Canadian medicare. I am thankful I only have to show my OHIP card when going to see my doctor or specialist. I am thankful I don’t need any bean counter’s permission to see a specialist. I am thankful I don’t have to waste my own time and time in the doctor’s office filling in forms to get permission from some insurance company just to get some care. I am thankful I don’t have to haggle for care. I am thankful that my GP, working with me, directs my care, not some profit-minded insurance company. I am thankful that when my heart goes wonky, I can go to the ER, show my OHIP card, and not worry at all about how I’m going to pay for this unplanned visit, not worry about what my insurance company will say; my only worry is my heart.
In the end, that is really the only thing I want to worry about when going to see my doctor: my health.
(This was first posted on my main blog, but I felt it was important enough to copy over here.)