[BeaverFever]

saturn_656 saturn_656:

BeaverFever BeaverFever:

$1:

OHIP isn't in practice an insurance provider, despite it's name.

It is exactly an insurance provider. Why would you think otherwise?

If OHIP operated as an insurance company, universal health care would cease to exist. Be happy they don't.

Insurance companies (public or private) rate clients on risk, and charge them accordingly.

OHIP can't.

They do. The client is the provincial government. The risk pool is the population of Ontario, which is a defined risk pool, fully measured and weighted by both public-sector and private-sector underwriters and actuaries. The charge is the amount of funds that the province has to make available to cover the expected cost of claims based on the risk pool

Insurance companies can decline to serve (and terminate coverage of) clients that entail too much risk.

OHIP can't.

The need to terminate coverage of high-risk claimants is a private-sector insurance practise, because they have a limited risk pool (their current customer base) that they have to manage. Public sector insurers don't need to worry about individual claims because they have the broadest possible risk pool (i.e. the entirety of the general public, both healthy and unhealthy), where individual outcomes matter less. In a limited risk pool, insurers are always to some degree uncertain of how represetative their customers are of the general risk data and compared to a universal plan, relatively large amounts of private sector customers are signing up because they are already ill or believe they will become ill. For example, it is easy to know what the mortaility rate of the population of Ontario is - it is a published figure - and they can then insure against that since know how with reasonable accuracy how many Ontarians are going to die and how many will remain healhty. It is much harder for a private insurer to know how represetnative their current customer base is - Many of whom will have signed up for private coverage precisely because they're high-ris - as compared to the general population data (known as "credibility"). A plan that is 100% credible means that the population is likely to have the same rates of death, disability, etc. as the applicable published rates.

Also note that in OHIP coverage is indeed terminated/denied to high-risk claimiants, defined as those who have been residing outside of Ontario longer than a specified period, and new arrivals to the Pronvice, since they may not be representative of the Ontario population risk pool. Also, people seeking treatment outside of the province may be declined for coverage for that treatment as it may entail risk (due to prices, procedures and practises that are outside of provincial control)



If you fall behind in payments (for OHIP it would be taxes) to your insurance company they can (and will) terminate your coverage.

OHIP can't.

Note that you have another layer of apples-and-oranges here because the appropriate private sector comparison would be an employer-sponsored or union-sponsored plan where the sponsor is reponsible for paying the premiums instead of the insured person. True that if your employer or Union doesn't pay your premiums, EVENTUALLY the insurer would terminate coverage but typically that is after many many months of non-payment and non-response. It's an academic point because, like an employer, if the province stopped making funds available for OHIP coverage, by default there would be no ability for OHIP to make payment.

Also note that many (most) large employers in Canada and the US don't even contract with an insurer to provide coverage - they pay the claims directly under what is known as self-insuring. Still even in these cases, there is an insurance policy, risk pool rating, etc same a regular insurer, the only difference being that instead of funding benefits through premiums paid to an insurance company, the employer deposits the funding in a special account earmarked for paying benefits claims. A third party (typically an established insurance company) is authorized to review the claims and pay the benefits from the employer's bank account. This would be most similar to the OHIP program, except that an employer's plan member population is usually not large enough to be fully "credible".

Insurance companies offer multiple insurance products to their clients with varying levels of cost and coverage.


OHIP doesn't.

Irrelevant - not the definition of 'insurer' They don't have to. They choose to. And surely some only offer a standard product.

If you are not satisfied with your insurance company, you can cancel your coverage (and cease paying them).

Can't do that with OHIP.

Irrelevant - not the definition of 'insurer'

OHIP isn't an insurance provider, it's a social program.

ALL Insurance is at heart a social program - all members are required to pay in, but only the sick receive payouts based on need - the very definition of risk pooling, which is the defining trait of insurance.

You're wrong on almost every point. What you're describing is a private insurer, but public insurance is a type of insurance.

[bootlegga]

I have to admit, this is a hard topic to discuss, and while I don't live in Ontario, I've been personally affected by something very similar.

My daughter was recently diagnosed with an unknown immune response disorder and prescribed GCSF (also used by cancer patients to boost immune systems after chemo). It doesn't cost near as much as the drug in question here, but without insurance, the cost would have been about $1600/month ($19,000 per year). We could have managed that cost (barely), but it would have severely impacted the lives of everyone in our family. Fortunately, our benefits covered most of the cost and we only have to pay $250/month ($3000/year).

So, I can totally understand where the Fletcher family is coming from.

Having said that, I don't know that any insurer anywhere in the world would commit to spending $100k/annually for one patient's medications. Given how demographics are changing things, this is probably going to happen more often in the next couple decades as Boomers age and die.

I'm not an ethicist, but the obvious question is how much is enough? Or too much?

Honestly, I don't have an answer, but as a society, we should sort it out before it potentially becomes a crisis.

[BeaverFever]

Just to clarify - the issue in the OP is that Ms. Fletcher is going to die from her disease in the near future regardless of whether or not she gets this medication...it will only extend her life temporarily but is prohibitively expensive. As such, her case doesn't conform with the cost-benefit assumptions for this drug.

It's hard to put a price on a human life, how much is another day, week, year of a person's life worth? Most peopole would say "priceless" but in the real world, doctors and insurers and hospitals -public or private - have to make that decision every day because resources are finite and they necessarily must make policies around it.