Surgical staff operate on patient Paul Szasz in the Multi-Purpose Operating Room (MPOR) at Toronto General Hospital in Toronto, Ont., on Feb. 13, 2012.Kevin Van Paassen/The Globe and Mail
Faced with a $14.8-billion deficit and a stubbornly high health-care budget, the Ontario government is taking a heightened interest in the billings of emergency-department doctors.
A group representing the province's 2,000 emergency doctors is warning its members of a recent flurry of formal audits by the Ministry of Health questioning the details of billings for services. The Ontario Medical Association's emergency medicine division claims in a notice to its members that was obtained by The Globe and Mail that doctors are not being properly informed as to why their billings are being questioned or being given sufficient time to respond.
"It borders on harassment," said Myron Haluk, chairman of the OMA division.
The Ministry of Health conducts audits when it suspects a doctor of overbilling the publicly funded medicare system. Officials would not comment on the number of audits being conducted, saying only that they are typically triggered by complaints from the public and health-care employees or fees for services that are outside normal billing patterns.
Doctors who spoke on condition that they not be named said the ministry has been aware for some time that a minority of doctors have been submitting unusually high billings.
But, they said, ministry officials were more concerned with a bigger challenge – a chronic shortage of doctors in overcrowded emergency departments.
Health-care costs are forecast to reach $47.7-billion in fiscal 2012-13, consuming 44 cents out of every dollar in program spending. And fees paid to doctors are one of the biggest cost drivers of the system. Ontario's 25,000 doctors collected $11-billion in compensation last year, according to government figures. The government is in talks with doctors aimed at freezing that funding.
Dr. Haluk said he is personally aware of three doctors at one hospital who are being audited. The unnamed sources said they know of several other cases.
Last year "less than five" doctors were audited, according to a Ministry of Health official. That same year, the ministry asked 400 doctors to supply additional information about some of their billings and recovered $4-million from claims it rejected.
Health Minister Deb Matthews said the vast majority of doctors' billings are fair and honest, but some of them raise red flags. The audits ensure that the fees doctors bill medicare are appropriate.
"I think it's important that we do audits," Ms. Matthews said in an interview. "I think it's important that every dollar we spend actually goes to improving care for patients."
The recent crackdown is aimed at emergency doctors who work in high-volume emergency departments, said one doctor.
The reported audits come as the government tries to get more doctors to sign on to a new funding model that consists of a fixed hourly rate rather than the traditional fee-for-services.
Alan Drummond, an emergency doctor at the Perth and Smiths Falls District Hospital in Eastern Ontario, said he would not be surprised if the ministry is using the audits as a "pressure tactic" to get more doctors to make the switch.
Ms. Matthews said an increasing number of hospitals pay salaries to doctors in their emergency departments rather than letting them bill the provincial plan for every service, a trend that is helping the province wring more efficiencies out of the health-care system.
The government pays for services based on claims submitted by doctors to the Ontario Health Insurance Plan. A 2010 study commissioned by the government says that in a system where doctors bill OHIP for each service they provide to patients, there is no incentive for them to measure the cost-effectiveness of their treatment decisions against the potential benefits. Dr. Haluk says in the notice to emergency physicians that the government is not following a new audit program it introduced in 2007, in response to the province's widely criticized predecessor system.
In a 2005 report commissioned by the government, retired Supreme Court Justice Peter Cory said the audits took too long to complete and the hearing process left doctors feeling they were presumed guilty from the outset. The Cory Commission followed the 2003 suicide of a Welland, Ont., pediatrician named Anthony Hsu, whose family and friends said he was punished for spending too much time with patients and not enough time on his records. His widow told Judge Cory that the audit made her husband despondent.
Under the current audit system, the basis on which doctors are selected must be clear, the method of auditing them must be transparent, and the process must be fair in all respects.
But Dr. Haluk said one doctor was given less than 20 business days to produce multiple patient records and was threatened with further unspecified action if he failed to comply.
The ministry did not explain why it was auditing the doctor, Dr. Haluk says in the notice, and also "threatened to unilaterally recover money paid to the physician before his reply."
Ms. Matthews said she is not aware of complaints from any other groups within the Ontario Medical Association, and said the ministry follows a "very clear, step-by-step audit process."
Dr. Haluk said in the interview that this is the first time unfair audits by ministry officials have been brought to his attention since he became head of the OMA's emergency medicine division in 2007.
"They're within their rights to ask for patient charts, but not to act as judge and jury," he said.
Editor's note: The original headline with this story mischaracterized the billings in question, and has been changed.
Karen Howlett