The Value of Value-Based Healthcare: OHIP+ and Sexual and Reproductive Health
Shawn Mouro, RN, BScN, CCN(C), MN-LPNP(c)
Graduate Student, Arthur Labatt Family School of Nursing, University of Western Ontario
Since the inception of universal healthcare in Canada, financial barriers to accessing care have diminished while costs continue to rise exponentially, with one-tenth of Canadian gross domestic product spent on healthcare (Krahn et al., 2019; McCaughey et al., 2019). Within the Organisation for Economic Co-operation and Development (OECD), Canada ranks amongst the highest healthcare spenders and is “the only [member] with universal health insurance but no [universal] prescription pharmaceutical coverage” (Canadian Institute for Health Information, 2018; Katznelson et al., 2021, para. 1). As such, I find it unsurprising that Canada is attempting to shift from a pay-per-service model toward a value-based, outcome measures approach (McCaughey et al., 2019). In 2017, the provincial government announced a financial drug plan, called the Ontario Health Insurance Plan Plus (OHIP+), which would cover 5,000 prescription medications for Ontario children, adolescents, and young adults under the age of 25 (Pullen, 2018). However, in 2018, the Conservative government announced the elimination of coverage for those under the age of 25 who were privately insured (Gladysz, 2019).
In my opinion, OHIP+ had the potential to address value-based healthcare (VBHC), but I would still posit that potential is limited and questionable. Recent changes were made to strengthen and improve the provisions of OHIP+ to address positive patient outcomes and overall healthcare expenditures (Ashley, 2018). Instead of improving patient outcomes, I consider these changes an erosion of bodily autonomy and consent for adolescents and young adults at the hands of parental surveillance. Regardless of recent changes, OHIP+, as a whole, continues to have implications on the sexual and reproductive health of adolescents and young adults.
Ultimately, I firmly believe that OHIP+ reinforces hegemonic heteronormative and patriarchal discourse. I find that OHIP+ reinforces the viewing of sexual and reproductive health through a heteronormative lens and effectively upholds patriarchal discourse, supporting the notion that reproductive and sexual health is the sole responsibility of female bodies.
OHIP+ and VBHC: Compatible or Conflicting?
Value-based healthcare is becoming a leading approach in domestic and international healthcare systems in an attempt to control healthcare expenditures while maintaining positive patient outcomes (Canadian Foundation for Healthcare Improvement [CFHI], 2020). According to Porter (2010), value in healthcare expenditure is created through a relationship between patient outcome and cost. Building on this conceptualization, VBHC, is concerned with “linking how much money is spent on healthcare programs or services over a patient’s journey to the outcomes that matter most to patients – rather than focusing primarily on the number of services, or on specific processes or products” (CFHI, 2020, p. 5).
On the surface, the implementation of OHIP+ is congruent with VBHC, as it is concerned with positive patient outcomes while controlling for cost. Research demonstrates that out-of- pocket expenses either decrease or completely impede the use of necessary medications (Laba et al., 2020). Recent data reveals that 5.5% of the Canadian population forgo prescription medications, subsequently increasing the use of additional healthcare services. This means that more than one million Canadians sacrifice basic needs in order to pay for medication (Laba et al., 2020). OHIP+ effectively ensures that Canadians are able to attain positive outcomes from prescription medications without the worry of cost. These positive outcomes, in turn, will reduce the use of additional healthcare services positively impacting overall healthcare expenditures.
Changes made by the conservative government, however, threaten to displace the potential for OHIP+ to maintain a model of VBHC. Through deductibles, partial coverages, coverage limits, or noncoverage of certain medications, “insurers will often expose patients to out-of-pocket costs as a way to manage total expenditure” (Laba et al., 2020, p. 977). As I see it, the removal of individuals with private insurance from OHIP+ effectively exposes them to financial vulnerabilities. The latter creates potential to fuel the foregoing of prescription medications or basic needs while adding to the use of additional healthcare services and total healthcare expenditures. The perceived cost of including all Canadians into the OHIP+ plan has been cited as a long-term barrier to its implementation, though “universal public drug coverage would likely yield substantial savings to the private sector with comparatively little increase in costs to government” (Morgan et al., 2015, p. 491). Regardless of these recent changes, it seems clear that OHIP+ fundamentally fails to address reproductive and sexual health issues through a value-based lens.
OHIP+ and Sexual and Reproductive Health: What’s Really Being Said?
Bodily Autonomy and Parental Surveillance
The first issue I find with OHIP+ surrounds its recent changes to omit those covered by private insurance. If adolescents and young adults are under their parent’s private insurance plan, their bodily autonomy and medical privacy is dependent on parental surveillance. These changes grant parents the right to survey their child’s medical needs and choices even if they are legally obligated to make their own medical decisions and legally entitled to medical privacy (Ashley, 2018). Thus, “patients have less autonomy in the decision of their treatment plan, which may impact the attainment of desired health outcomes” (McCaughey, 2019, p. 50). This raises a number of issues; namely, impeded access to female contraception, the forced “outing” of transgender people when seeking hormone replacement therapy, and the potential for delayed treatment of sexually transmitted infections (STI) for fear of parental backlash (Ashley, 2018; Bueckert, 2019). As such, I am concerned that control over reproductive and sexual health will be ripped from those who should legally possess it, and instead, cloud the medical decision of adolescents and young adults through fear of parental blackmail, abuse, and coercion. This, subsequently, ensures a potential for an increase in unwanted pregnancies, further use of additional health services for untreated STIs, increased youth homelessness, substance use and abuse, and negative outcomes regarding adolescent and young adult mental health (Ashley, 2018; Bueckert, 2019).
It is these changes that I find impede OHIP+’s ability to function as a branch of VBHC. This is specifically evident in the potential for parental surveillance to limit access to female contraception increasing unwanted pregnancies as a negative patient outcome and an added cost to overall healthcare expenditures. Research shows that, in Canada, unwanted pregnancies in women aged 20-29 years, account for $175 million in direct costs. Of this, $143 million, or 82%, was due to contraceptive non-adherence (Black et al., 2015).
Sex and the Reproductive, Heteronormative Lens
More troubling yet is that through the implementation of OHIP+, the Canadian government continues to frame sex through a heteronormative, reproductive lens. By covering pharmaceutical female contraception, while negating the coverage of barrier-type, male-based contraception, such as condoms, it is clear to me that the focus is solely on sex as a reproductive act. OHIP+ encourages those engaged in sexually active, heterosexual relationships to unilaterally use female contraception over barrier-based methods because of cost. Although this will address the risk of unwanted pregnancies, it does not address the risk of STIs in both the heterosexual and homosexual populace. As I have reiterated before, OHIP+ continues to enforce a narrative, which unethically places the responsibility of sexual health on female bodies, as the cost-effective choice is the choice that regulates female physiology.
These concerns also threaten the Canadian government’s ability to enact VBHC. By focusing on legislation, such as OHIP+, that only covers pharmaceutical, female-based contraception, risks to patient outcomes and cost are evident. OHIP+ has the potential to drive STI rates, as its focus is on sex as a reproductive act, and therefore, the only variable that needs to be controlled is unwanted pregnancy. Furthermore, in the absence of legislation covering barrier-based contraception, OHIP+ encourages the use of female-based contraception which does not offer any form of protection against STIs.
We know, according to the Public Health Agency of Canada, that STI rates in Canada have continued to climb since the 1990s and disproportionally affect female adolescents and young adults (2019). This, again, throws into question the impact that parental surveillance may have on the potential for female adolescents and young adults to forego treatment for STIs if forced to seek care under their parent’s private insurance plans. This highlights, not only the possibility of negative patient outcomes but also “represent[s] an important burden on the healthcare system” at large (Public Health Agency of Canada, 2019, p. iv).
Female Contraception Protecting Patriarchal Discourse
When I think about and focus on sexual and reproductive health, legislation surrounding OHIP+ is unable to fully center both patient outcomes and, as an extension, cost when specifically exploring unwanted pregnancies and STIs. Furthermore, it is my stance that with legislation only focused on female contraception and no financial respite for barrier-based contraception, the government continues to support the narrative that reproductive and sexual health is, predominately, of female concern. Moreover, I find a troubling concern that OHIP+ supports the idea that unwanted pregnancy is the only risk worth addressing through a value-based lens. This supports the patriarchal discourse of female-only onus in pregnancy prevention. As Brown (2015) demonstrates, if unwanted pregnancy is observed as “the only risk of unprotected sex, then hormonal contraceptives…are methods that will protect against that risk, but are all methods that, firstly, require action from the woman and, secondly, will afford…[her no] protection against STIs” (p. 322). We know that women have disproportionately been affected by limited reproductive choice, STI rates, and the repercussions of unwanted pregnancies, ultimately, influencing broad socioeconomic implications, such as declines in education and employment, economic instability, and impaired family well-being (Sonfield et al., 2013). It is my continued opinion that these gendered health disparities continue to support a patriarchal narrative, whereby an absent male, in decisions surrounding sexual and reproductive health, is a rewarded male.
Conclusion
At its inception, the potential value of OHIP+, as a step towards VBHC, was evident. When focusing on reproductive and sexual health, the value of OHIP+ is thrown into question. Furthermore, more recent changes furthered the displacement of OHIP+ in its potential ability to address positive patient outcomes and overall healthcare expenditures. Regardless of its impact on VBHC, I find OHIP+ continues to highlight the Canadian government’s obsession with controlling the bodily autonomy of females to maintain hegemonic discourse surrounding patriarchy and heteronormativity. Surely, if the Canadian government is only willing to fund female contraception and ignore the need for male-based contraception, then, the onus, consequence, and accountability of sexual and reproductive health is placed squarely on the female body and on the construct of sex as an exclusive heteronormative and reproductive act. Fundamentally, if the Canadian government is truly concerned with VBHC, in regard to sexual and reproductive health, then it must be understood that “to reduce cost, the best approach is often to spend more on some services to reduce the need for others” (Porter, 2010, p. 2477).
References
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Photo by Lelia Adolphsen
