Gastroenteritis and Stomach Cancer Diagnosis: A Case Study

Symptoms and Medical Treatment

David Smith developed gastroenteritis while on holidays in Barbados in March 2017. Heexperienced gastrointestinal pain on the second day of his holiday. By the fifth day, his symptomshad worsened. He was unable to eat and decided he should seek medical attention. As a result,he attended a hospital and received treatment on March 22 and 23, 2018 including blood testsand an ultrasound. The Barbadian physician was concerned with the results of the ultrasoundand recommended that Mr. Smith follow up with his family doctor when he returned to Canada.When he returned from his holiday, he followed up with his family physician, Dr. Alicia Jones, inOntario. He reported that this was the first time he had experienced these symptoms andprovided Dr. Jones with the ultrasound report provided to him by the physician in Barbardos. Dr.Jones decided to refer Mr. Smith to a medical oncologist noting that he would likely get anappointment within the next three weeks to a month. Mr. Smith was concerned with the delayand complained that it took too long for him to obtain appointments with the necessaryoncologyspecialists.Dissatisfied with the delay in treatment, Mr. Smith contacted a physician Dr. Greenberg atMemorial Sloan Kettering in New York who indicated that he could see him the next week (April12, 2017) for an assessment. Mr. Smith travelled the following week and met with Dr. Greenbergon April 12, 2017. Dr. Greenberg diagnosed Mr. Smith with Stage 3 stomach cancer. She advised Mr. Smith that they could treat him right away: a surgeon would resect the cancer and she wouldfollow up with chemotherapy. She noted that that their oncology program includedcomplementary therapies such as acupuncture and massage. Mr. Smith returned to Canadawhere he met with Dr. Jones and requested that she complete a Prior Approval Form for Out-ofCountry Coverage for: (1) the surgery; (2) the follow up chemo provided by Dr. Greenberg; and(3) the complementary therapies. Dr. Jones encouraged Mr. Smith to see the Ontario oncologistbefore deciding to undergo treatment in the United States.On May 1, 2017, Mr. Smith saw Dr. Cho, an oncology specializing in the treatment ofgastrointestinal cancer, including stomach cancer. Dr. Cho confirmed the diagnosis of Stage 3stomach cancer. She advised that Mr. Smith would have to meet with a surgeon and followingsurgery would receive chemotherapy. She reported that the first opening for an Ontario surgeonis June 1, 2017. Mr. Smith told Dr. Cho that he could undergo surgery almost immediately in New York. He advised her that he was very anxious about the wait and asked Dr. Cho to completeaPriorApproval Form for Out-of-Country Coverage. She agreed that the wait would be stressfulbut indicated that he should ask Dr. Jones to complete the form as she was better placed to doso as his primary care physician.Mr. Smith returned to see Dr. Jones who agreed to complete the form. On the form, Dr. Joneswrote that in her opinion the surgery and chemotherapy performed by Dr.Greenberg weregenerally accepted in Ontario for a patient in the same circumstances as Mr. Smith and thatequivalent services were performed in Ontario. She also wrote that Mr. Smith would sufferserious psychological harm if he was forced to wait for the procedure.Mr. Smith submits the Prior Approval for Out-of-Country Care Form to the General Manager ofOHIP together with a claim for reimbursement for the two physician visits, blood test andultrasound in Barbados. He includes detailed receipts for the physician visits, blood test andultrasound.

Examine ALL stakeholders involved. As the General Manager of OHIP, advise whether you willgrant Mr. Smith’s claims for out-of-country care and reimbursement for the medical servicesinBarbados.D