When the Ontario government rolled out its pharmacare-for-children program on Jan. 1, it was touted as a groundbreaking measure that would improve health care for all residents aged 24 and under.
But some parents say the new OHIP+ program, which gives the province’s 4 million children and youth free access to more than 4,400 approved medications, is creating more bureaucratic hurdles for kids with certain serious or chronic illnesses that require expensive treatments.
The OHIP+ program covers all prescription medications currently listed on the Ontario Drug Benefit Formulary. Additional medications eligible for funding through the Exceptional Access Program are now also covered for those under 25.
For those who have private insurance for health-care expenses, OHIP+ is now the “first payer” for approved medications. That means, even if both parents of a sick child have drug coverage through their workplace benefits plans, they first have to seek access to the medication through OHIP+. If the government doesn’t cover the cost of the drug, they can then seek reimbursement from their insurance providers.
For Joanne Witt, whose 11-month-old son, Hudson, was born five weeks early with a congenital heart defect, the new system has created “added work that really wasn’t necessary,” she said.
Before Jan. 1, the cost of Hudson’s critical medications was mostly being covered by Witt’s and her husband’s private insurance. After OHIP+ came into effect, Witt discovered that the government program does not cover the specific concentrations of two medications that her son requires.
Instead of simply filling the prescriptions and submitting the costs to her insurance company, Witt will now have to request drug coverage under the province’s Exceptional Access Program (EAP), which she didn’t have to use before. If the EAP rejects her request for coverage, she can then go back to her insurance provider.
“It’s an ongoing saga,” Witt, who lives in Dundas, Ont., told CTVNews.ca in a telephone interview.
Witt, whose son spent months at Toronto’s Hospital for Sick Children, said she has spoken with a number of other parents who are facing similar hurdles now that OHIP+ is in effect.
“I’m assuming for the general population, that yes, it’s very helpful to have penicillin and (other drugs) covered. But when your kids are on a great deal of medication for specialized and chronic conditions, it’s really just another hurdle we’re jumping and paperwork we’re filling out,” she said.
Witt said that she and her husband can afford to pay for their son’s medications if they end up facing a gap in drug coverage, but she knows that’s not the case for most parents.
The Ontario Ministry of Health said the government is working closely with the private insurance industry “to ensure that Ontarian children and youth receive the best patient care and experience, and that drug coverage is not interrupted due to the implementation of OHIP+.”
In an email to CTVNews.ca, the ministry also pointed to a “streamlined” form for drug approvals under the Exceptional Access Program, which is meant to reduce the amount of administrative work required to complete them and the time it takes to assess each case.
'A lot of bureaucracy'
Dr. Eric Benchimol, a pediatric gastroenterologist at Children’s Hospital of Eastern Ontario (CHEO) in Ottawa, said he’s worried that the extra layers of drug approvals involved with OHIP+ will ultimately affect patient care.
He said CHEO currently treats about 300 children with various forms of inflammatory bowel disease. About 60 per cent of those patients require expensive medications known as biologics, typically made from cells or their components.
Dr. Benchimol said his team began sending requests for drug approvals through OHIP+ well before Jan. 1, and the two nurses who are handling the cases are already overwhelmed by the amount of paperwork required and OHIP’s many requests for additional information about patients’ histories to justify the use of certain medications.
“A lot of work has gone into getting these patients pre-approved, a lot of bureaucracy, really,” Dr. Benchimol told CTVNews.ca in a phone interview.
He also said bureaucrats who are handling the drug coverage requests don’t always seem to understand the nature of pediatric inflammatory bowel disease and how it needs to be treated.
Dr. Benchimol gave the example of the drug infliximab, which is used to treat inflammation caused by Crohn’s disease and other disorders.
Infliximab is typically used every eight weeks as “maintenance therapy,” but some patients require more frequent administration of the drug. Dr. Benchimol said OHIP often questions requests for more frequent dosages or refuses to approve them in some cases.
Dr. Benchimol stressed that he is “completely, 100 per cent in favour of universal pharmacare,” but worries that “the implementation of OHIP+ has been rushed.”
He said the issues with OHIP+ can be fixed if the Ministry of Health and health-care professionals work together. The ministry needs to trust that doctors know which treatments work best for children with complex disorders, or hire specialists in pediatric disorders to review drug requests under OHIP+, he said.
The ministry said the EAP approval process “ensures that funding is provided in circumstances that are clinically effective” and that the government has worked with specialty clinician groups in an attempt to address “potential transition issues” before OHIP+ was implemented.
The ministry added that it invites further feedback on OHIP+ and “remains open and willing to continue to working with clinicians and specialty groups who provide care to children and youth.”
Consultations with insurance industry
Karen Voin, vice-president of the group benefits and anti-fraud division at Canadian Life and Health Insurance Association, said the insurance industry worked “very closely” with the Ontario government leading up to the implementation of OHIP+ to ensure that children and youth don’t experience any gaps in drug coverage as of Jan. 1.
The goal was to “minimize the impact on patients,” Voin said, but acknowledged that there may be some confusion in the early days of the OHIP+ program until all stakeholders are educated on how it works.
Voin said private insurers in Ontario have voluntarily agreed to a six-month “transition plan,” during which they will continue to consider coverage for certain types of prescription drugs as the requests move through the province’s EAP approval process.
Those drugs include certain antibiotics, blood thinners, and drugs with low EAP approval rates.
The Ontario Pharmacists Association (OPA) said it applauds the implementation of OHIP+, but acknowledged that pharmacists have encountered “coverage issues” when trying to fill certain prescriptions for young patients.
“The vast majority of these transitions are invisible to the general public,” OPA CEO Andrew Gall said in a statement to CTVNews.ca. “But while many of these transactions are relatively seamless, there will be some that may require some additional intervention.”
Gall said Ontarians can “rest assured that pharmacy professionals are doing everything they can to ensure there is little to no interruption to care, and this will often include, when possible, the advancing of a few doses free of charge until difficult coverage issues can be resolved.”
OHIP+: How it works
Ontario is the only province to provide medication coverage at no cost for children and youth.
All Ontario residents who have OHIP coverage and are between 0 and 24 years of age are automatically covered by OHIP+. The program covers the entire cost of more than 4,400 medications approved by the Ontario Drug Benefit program. The list of approved drugs includes antibiotics, asthma inhalers, epinephrine injectors, various antidepressants, and insulin.
For approved medications, parents or youth simply need to take a prescription and the patient’s Ontario health card to a pharmacy to get the drug at no cost. For those who have private insurance plans, OHIP+ is now the first payer for approved medications.
Drugs that are not covered by OHIP+ may be covered by the province’s Exceptional Access Program. Applications to the EAP must be filled out by a doctor or nurse practitioner on the patient’s behalf.
The Ontario Ministry of Health says that more than 220,000 young people had already taken advantage of the program in its first 11 days. A recent Conference Board of Canada report estimated that 1.2 million children and youth did not have any drug coverage before OHIP+.
Ontarians with questions about drug coverage can email OHIPplus@ontario.ca or call Ontario Public Drug Programs toll free at 1-866-811-9893.
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