By Sohail Gandhi Opinion Friday, July 19, 2019
There are over 5,000 individual OHIP billing codes, and each represents a specific service or procedure that a physician can provide to a patient. A physician will provide many different types of services on any given day, and depending on a patient's specific needs during a visit, the physician may provide several services to that one patient.
One patient visit doesn't necessarily mean one single code is billed, it's much more complex than that. Over the course of a year, this can add up to tens of thousands of unique billings for a high-demand physician. Using Ontario's 489 ophthalmologists as an example, last year they treated over one million individual patients for a total of almost three million visits. The average number of fee codes billed by an ophthalmologist last year was more than 13,800.
Number-crunching tens of thousands of lines of raw OHIP codes in a given year down into a handful of top-line figures may provide information about the total number of treatments and services that a physician provided. It may also tell you, say, the three most common codes that the physician billed. It does not, however, tell you about the patient, the care required, the conditions treated, or which health care provider provided what treatment.
Without critical context, numbers alone do not provide the full picture and may in fact create misleading, misinformed or meaningless impressions. Without access to patient records (which would obviously be a violation of patient privacy), there is no way to know their patients' individual conditions and complexities — or the physician's patient demographics as a whole. Were these patients referred to that particular specialist because they have advanced or rare illnesses? Some of these physicians are so in demand because they have a particular subspecialty and focus on certain types of cases. Based on their particular expertise and experience, each physician determines the services and treatments required for each patient according to that patient's needs.
Limited number-crunching also doesn't take into account other factors that can cause a dramatic change in a physician's practice from year to year — and which can result in equally dramatic changes to their billing patterns. For example, one physician at a clinic may take a primary role on a certain type of procedure. Advances and implementation of new technologies can lead to changes in the standard treatment, which in turn leads to changes in the types and frequency of codes billed.
And changes in technique based on evolving best medical evidence require a different billing code. Let's use another type of specialist as an example: an orthopedic surgeon scoping inside the knee of a patient experiencing pain might, based on best evidence, shift technique from addressing the lining of the knee to addressing the bone and cartilage. This would require a different fee code than the one they might have previously used.
What about the physician's practice model and clinic setup, and why is it important to know this when analyzing a physician's billing codes? Many high-demand physicians employ nurses, medical assistants and other staff to assist in providing required services for patients. Some high-demand specialists literally employ dozens of people. Each of these health-care providers operate to the top of their scope, which means that they perform services to the degree permitted under their regulatory authority and training — and permitted by OHIP. This team approach allows a physician to see many more patients in a day than they could ever do on their own.
The result of this team approach is that many fewer Ontario patients are waiting for diagnosis and treatment. This takes on a sense of urgency for physicians when one considers, for example, that there are currently more than 50,000 Ontarians on the waiting list just for cataract surgery. Most of us knows a family member, friend or colleague who's on "a list" for something, and the stress and worry related to a delay in diagnosis and treatment can be all-consuming.
Given all these considerations, it's easy to see how what on the surface seems to be transparent — let's just add up all the billing codes for each physician — can become muddied or less meaningful. This is why the OMA supports transparency with context.
It is also important to remember that OHIP has a review system in place to catch billing red flags and anomalies. Additionally, the College of Physicians and Surgeons of Ontario also has processes in place to ensure that doctors are delivering care ethically.
The OMA will never condone or support any physician found to have knowingly provided inappropriate care to a patient, or who has knowingly billed OHIP for services they didn't provide. However, drawing broad conclusions based on limited data can be misleading.
Dr. Sohail Gandhi, President of the Ontario Medical Association
Used with permission from The Hamilton Spectator, www.thespec.com Copyright The Hamilton Spectator. All rights reserved.