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.

 

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2 thoughts on “Hoskins attacks high physician billers: My response

  1. Andrew Roman

    This discussion the Minister started is senseless without comparing earnings with value created. It is like asking whether anyone should be allowed to sell a house for more than $1 million. Surely that depends on the location and size and amenities of the house, and not on some arbitrary number provided without context.

    I would not care if a physician is netting (after overhead) more than $1 million Canadian dollars a year, as that is an arbitrary number. Many lawyers, consultants and business executives with less capital investment and business risk earn that. Why not physicians?

    What does matter is the value of the services provided to patients for that money. A physician who works long hours and does highly skilled work could create better value for the health care system at $1 million than another who nets only $500 and sees half the number of patients, but performs simpler work with less effort.

    Don’t let yourself get dragged into political debates about arbitrary numbers without any measure of the value of the service provided by the physicians who earn these numbers. How much should a physician be allowed to earn? If the money is earned honestly, it doesn’t matter. There is no right number.

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  2. JK

    Great article, as always, Dr. Elia. Spot on analysis — if there is true fraud happening, it’s up to OHIP and the MOHLTC to root that out. I bet the OMA would even be supportive of such efforts!

    However, I don’t think I agree with you that there should be a ceiling imposed on physician income. If the six-million-dollar physician (let’s call them Dr. Steve Austin) is truly providing $6M worth of service, even with “only” $4M in overhead, then I say more power to Dr. Austin for finding ways to provide quality, efficient service to a large number of patients. This should be seen (by the gov’t, OMA, and other physicians) as a good thing — efficient, quality care should be the joint goal of all stakeholders, whether that $6M in service is delivered by one provider/group or divided among 10 different ones.

    Again, if billings (or billings by others billing less than Dr. Austin) are fraudulent, then the ministry should be rooting out these practices and punishing the offenders. But that’s why OHIP has an enforcement arm, and it’s up to them to use it.

    If Hoskins/MOH are concerned that billings exceed the arbitrary amount budgeted by the government, then they can propose solutions in negotiations. If they truly want budget certainty, they can propose, for example, putting physicians on salary as employees, with negotiated responsibility (e.g. patient numbers/clinic house), benefits, pensions, etc. However, I wouldn’t be surprised if 1) many MDs leave such a system for friendlier pastures and 2) numbers of orphan patients and waitlists for specialists skyrocket. The gov’t knows this, so they don’t propose it, since that would be politically much less palatable to the public than the current system.

    Ultimately, it serves the MOH and the Minister’s agenda to engage in “salary porn” as a way to deliver a shocking message in an attempt to convince the public of the righteousness of his side. But, as you say, it completely, 100% misses the point.

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