Monthly Archives: April 2016

A few thoughts ahead of this weekend’s OMA Council

This weekend’s OMA Council is certainly well timed, with the backdrop of the daily drama between the OMA and Ministry of Health. Certainly passions are high among many of the physician delegates that will be attending, and I hope that the meeting proves productive in producing constructive ideas and policies moving forward.

A few thoughts…

  1. I know that there will be vocal criticism of the Navigator campaign throughout the weekend, that their advertisements have been disappointingly ineffective, and that actions by grassroots physicians have had more of an impact on any progress physicians have achieved with the public. Navigator and the OMA will counter that their research shows that the campaign has indeed been effective, and the criticism will counter that Navigator can’t be looked to for objective analysis of the success of their own work. Not surprisingly, very little common ground will be found on this topic, and many physicians will likely be frustrated by this impasse. My personal opinion is that although I am quite disappointed with what Navigator has produced, now is not the time to move in a completely different direction, given the fragility of the negotiations situation with the ministry. We don’t need to create the media distraction of having fired our hired PR team, as that will create its own PR nightmare, and will play into the ministry’s hands. Wait until we have an firm agreement with the ministry, and then a serious accounting needs to take place of the successes and failures of the OMA communications strategy since early 2015.
  2. Along the same lines, I hope we see an official, genuine acknowledgement from the OMA of the tremendous work that grassroots physicians have done in bringing attention to our cause over the past year. I think this affirmation would go a long way to heal some of the subtle rifts that are slowly creeping in between the OMA and certain factions of its membership.
  3. Most importantly, delegates need to be vocal about what they expect from any negotiations framework with the government. I think it’s paramount that we insist on a binding arbitration mechanism that is as iron-clad as our OMA lawyers can dream up. Any short of that just isn’t good enough. The ministry is proposing artificial deadlines to create a sense of urgency, but we have to be organizationally methodical with this. We’ve been waiting well over a year for a sensible deal, and we’re all willing to wait as long as it takes to do this right. This has been professionally and emotionally draining for many of us, and I don’t particularly want to re-experience this a few years from now. Any proposals need to be transparently shared with, and approved by, a majority of the OMA membership. Ontario physicians as a whole are unquestionably more engaged in policy issues now than they were in 2012, and I think that needs to be appreciated by the OMA in moving forward with this process. Secrecy and any sense of coercion won’t fly.
  4. Lastly, every section needs to have a serious discussion about where cost-savings can reasonably be found within their section (low-value services, accountability, etc.). I know that many of us have spent the past number of months defending ourselves against the financial lies from the ministry, but that shouldn’t stop honest intra-sectional discussions about sustainability measures. Self preservation from sections shouldn’t be tolerated by the OMA once we’re crafting our best offer in binding arbitration.

I’ll be at the OntarioMD booth all day on Sunday, so feel free to pop by and say hello. Enjoy what should be an interesting weekend.

Hoskins attacks high physician billers: My response

Let’s pretend for a second that Ontario Health Minister Eric Hoskins was genuine today during his press conference that he wants to be fair to Ontario physicians, but only wants to get high physician billers under control. Let’s pretend that the press conference wasn’t about vilifying an entire profession, creating an anti-MD media buzz, or creating a further rift in his relationship with Ontario physicians. Let’s pretend all of that is true. Humour me here.

He is starting from the premise that the 500 MDs who billed more than a million dollars are abusing our publicly-funded health system, and that the only thing stopping him from fixing the problem is the OMA.

A couple of major problems with this premise. The government is already unilaterally making fee code decisions, without the OMA’s consent. Back in October, they already unilaterally reduced the fee codes billed by the professions most commonly represented in the top 500 list, including radiology, cardiology, ophthalmology, and addictions medicine, in addition to a 1.5% cut to all physician services. The government is not a helpless pawn in this, they are already dictating their own agenda.

The other problem with his premise is one that is brought up most frequently, that large gross billings from one physician is very complex to evaluate. Is one physician billing for a larger group? (Which by the way, is being punished in a separate manner by the federal government with their recent changes to corporate tax brackets for physician groups/associations). Is the physician working in the community, and paying for their own expensive equipment and large staff?

What frustrates me personally when I hear these numbers thrown out is that they are always given without any context. If it turns out the physician billing 6.6 million dollars per year is only paying 4 million dollars in overhead, then absolutely we need to be looking at a definite change in the payment models. With all due respect to those physicians who are doing extremely well financially, my personal belief is that exorbitant net income (>1 million a year) would be beyond what a physician should be rewarded with. But without that additional information of the exact practice situations, the large figures thrown around are meaningless.

From my standpoint, there are 3 ways that a physician could potentially exploit a payment system, in a broad sense:

  1. Bill for tests that were never performed
  2. Bill for tests performed that may not have been absolutely clinically indicated or needed
  3. Bill for fee codes that are inflated relative to the expertise, time, and risk associated with performing the procedure.

Addressing #1 is easy. If Hoskins thinks that physicians are billing for procedures that they didn’t perform, he has an entire OHIP department dedicated to investigating fraud. Don’t blame physicians for this one. Go out and find the crooks if they’re out there.

I’ll put the question to Dr. Hoskins to address #2. Where does he feel physicians are potentially unnecessarily driving demand in the system? Self-referrals? I have my own views on where this is happening, but I want to hear publicly  what he feels can be done to address the very small number of bad apples who may be driving this. Don’t keep blaming the OMA. Tell us your ideas. I might even agree with him on a thing or two.

As for #3, I for one want to hear publicly from Dr. Hoskins what fee cuts he has proposed to the OMA, and his rationale for the cuts. We have data on what specialists bill for each fee in other provinces and countries, and can easily evaluate whether his cuts are reasonable, or would drive physicians out of the province, putting patient care in jeopardy.

So if Dr. Hoskins truly wants to “address” the high billers, the solutions may be attainable, but today’s press conference wasn’t about solutions. Today was grandstanding. It was an attempt to inflame the public, throwing an entire profession under the bus.

The only possible positive that may come out of today’s press conference is his suggestion that binding arbitration may be on the table. If he is serious about coming to an agreement on that, we may have a path forward.


Crowdsourcing resources for patients: Part 1

Being a family doctor is pretty tough in the information age. You’re expected to be an expert diagnostician, therapist, health systems expert, up to date on the latest evidence, and you need to know exactly what to provide your patient in their time of need.

It’s a bit overwhelming at times to try to keep up with everything.

We all have our favourite resources that we use. Whether it’s bibliotherapy for patients, online resources for patients, and our online clinical resources, there are great resources out there, but like everything in our chaotic lives, we’re at the mercy of what information we are lucky enough (and have enough time) to encounter. And what resources we remember for when we’ll truly need it.

So let’s try an experiment. Over three separate posts, I’m going to be crowdsourcing your favourite resources: one post each for bibliotherapy, patient online resources, and clinician online resources.

Let’s do bibliotherapy first. What are your favourite books to recommend to patients? For any subject matter: bibliotherapy for mental health issues, parenting books, nutrition resources, addictions, anything you can think of! The more the merrier! Give me your answers in the comments, and don’t be afraid to repeat a book that’s already been suggested, because I want to see which emerge as consensus favourites. The books should be evidence-based, so please don’t post your favourite book about a quack fad diet or some shill author pushing supplements.

I will do a follow-up post to summarize the responses. In my own office, I have a library that I’ve established where I loan out books to patients, and I’m certainly eager to add any interesting titles that you suggest. Another intriguing possibility that I see in this sort of list building is that we can collectively approach local libraries in our communities about having books deemed clinically useful by clinicians to be easily accessible to all patients/citizens.

Looking forward to the comments!

Cancer Survivor Follow-up in Primary Care

The following post is a summary of a talk that I gave at the OntarioMD Every Step Conference in London on April 7, 2016.

Most family physicians have noticed that more cancer follow-up is being increasingly downloaded to primary care, especially over the past 5-10 years. Personally, I welcome this change as it allows us to manage patients for which we are certainly capable. However, there are many challenges that need to be addressed with this new trend, especially taking into account the EMR environments that physicians are settling into.

All practices need a formalized process for each cancer that allows for accurate and appropriate follow-up of all affected patients. The transition for cancer patients between specialist care and primary care can often be a juggling act, and it is important to capture all relevant patients for tracking purposes. Management protocols need to meet current standard of care, and should be easily updated to reflect new evidence. Most importantly, any program must be seamlessly integrated into a busy practice, without adding additional clinical or administrative burden.

Unlike cancer screening programs, which require thousands of patients to make one potentially life-altering diagnosis, the “number needed to track” for cancer survivor follow-up is orders of magnitude lower. One patient lost to cancer follow-up can have tragic consequences, and can expose a physician to a medicolegal nightmare.

Most offices have very efficient programs in place using their EMR for monitoring diabetes, CHF, COPD, immunizations and cancer screening, but these are often absent for cancer survivor follow-up. This is partly related to remuneration for cancer screening and immunizations, as well as the allied health staff available to some physicians (not for me) for CHF, COPD, and diabetes management.

Here is a brief framework of how to begin developing a formalized cancer follow-up framework (should be adaptable to most EMRs):

1) Decide on what types of cancer you need to be following (start with bladder, breast, cervical and treated dysplasia, CLL, colorectal, esophageal, lung, lymphoma, melanoma, prostate, pituitary, renal, sarcoma, thyroid, uterine, and add others as appropriate for your practice). Create a standard method of labelling each cancer, whether you use free-form or drop down text, and decide where this text will go (eg. consistently use breast ca in the Problem List, rather than a mix of breast ca/ca breast/breast cancer/breast carcinoma, etc.). Ensure that every user is aware of these standards, and have a glossary of terms available at each clinical workstation.

2) Find the patients who have each cancer. This takes some creativity, as you have to brainstorm every possible way you may have entered each cancer in the past (eg. some of your colorectal cancer patients may have been entered as sigmoid ca, rectal ca, ca colon, etc.) Search for all of the patients with your expanded criteria, and re-label them with your new standards.

3) For each cancer, decide on the most appropriate means of follow-up. What do they require for follow-up for each cancer (eg. imaging, bloodwork, yearly check-up, etc.)? Decide for each cancer whether it would be more appropriate to use a passive reminder system that would show up on routine reports (eg. prostate cancer patients who have not had a PSA in the past year), or whether you want to do active searching for these patients at routine intervals (monthly, yearly, etc.). An example of an active search I use is for lymphoma patients to ensure they have had all of the relevant routine imaging and bloodwork, since I have so few lymphoma patients and want to make sure I am manually checking that my follow-up is accurate. Another question to ask yourselves is how often do you want to be reviewing the evidence to see whether the guidelines have changed for each cancer?

This same framework can be applied to track other pre-cancerous conditions including colon polyps (labelled as tubular adenoma, tubulovillous adenoma, villous adenoma, serrate adenoma, colon polyp, etc.), thyroid nodules, Barrett’s esophagus, as well as a host of other conditions.

A warning: don’t try to do all of this work tonight (as tempting as it may be…). Establish a plan for your office, and delegate tasks accordingly. Re-categorizing all of these patients, with evidence reviews, is often too much for one person, and the tasks can be divided amongst multiple docs or other team members. Set goals for a few months down the road for where you want your office to be, and continually re-establish new goals for cancer survivor quality improvement.

The Peer Leader program is a free program offered by OntarioMD that provides peer-to-peer network support for EMR optimization. Contact OntarioMD for details about being connected with a Peer Leader in your area.

Going through a year’s worth of junk faxes…

When my secretary goes through our incoming faxes each day, she is quite proficient at sorting through what is relevant, and what I would consider complete junk. She drags those junk documents into a specified folder on her desktop which I check periodically.

Recently, “periodically” became “Oh shoot, I haven’t checked that folder since last summer”.

Now typically I hate going through this folder of useless correspondence. There’s a reason I go months without checking it. None of these faxes ever provide me information that benefits my clinical, personal, or professional life.

But I found it surprisingly interesting to sift through hundreds of items of complete trash. Some patterns emerged. Some were concerning. Some were hilarious. Some just made me shake my head.

1) I don’t want to brag, but I was invited to join the exclusive group of “Leading Physicians of the World”. I couldn’t believe it! For a mere $950, they would feature my biography in their prestigious registry. Plus another $35 a month for registry maintenance. And they would give me a shiny certificate to hang on my wall! (They have yet to respond to my inquiry for whether I could get additional copies for my parents and grandparents.) Of course most of us with a sliver of common sense would see this as a complete scam, but I know of at least one local physician who hangs his certificate proudly in his office. I wish I were joking.

2) There are a shocking number of conferences/summits/presentations that focus on cardiovascular risk factor management, with the same presenters focusing on the same messages of looking at surrogate markers. I won’t name any names, but we all know who our provincial usual suspects are.

3) Along the same lines, it appears to be the same general topics that come up time and time again in industry-funded CME. Atrial fibrillation, overactive bladder, COPD/asthma, hypertension, diabetes, rosacea, and more recently LDL targets (think PDSK9 inhibitors) have been disproportionately represented in CME over the past year. Unrestricted financial grants still influence the content of CME, let’s not kid ourselves. If you are relying on industry-funded CME for the majority of your yearly CME, you are missing out on entire swaths of relevant aspects of medicine. Let this be my reminder to you to diversify your sources of CME.

4) I can’t help but be concerned about the proliferation of companies in Ontario that are advertising for putting holter monitors in family physicians’ offices. Essentially if the physician feels their patients require a holter monitor, they put it on the patient for the desired duration, then mail it to the company who will have a cardiologist read it. The family physician is paid a portion of the technical fee for their time, usually around $50.

There are two major problems with this arrangement. First, it is not outrageous to assert that a physician may be more likely to order a holter when it is easily accessible in their office. I won’t go as far as to claim that a physician would order the holter strictly for financial gain, but I am always uncomfortable when any health professional stands to benefit financially by a specific clinical decision that they make themselves.

Second, many of these companies only offer holter monitors for 72 hours or more. The total cost to OHIP for a 48-hour holter is $188.65, and a 72-hour holter is $265.60. So will a physician, who only requires a brief monitoring period for a patient, refer their patient to a local cardiologist who does 48-hour holter monitoring, or will they set up the 72-hour holter in their office and claim their fee? I would like to believe they would choose the former in the name of stewardship for our publicly-funded system, but we can’t be completely naive here.


So the bottom line? I can probably go another entire year without checking my junk fax folder. Evidently I didn’t miss a single important thing.