Government & Medicine

Too little too late?

An independent commission fires up to look into the deeply unpopular practices of the MRC. But is Ontario ready to slaughter a cash cow?

By Joshua Karpati

Ontario's long and contentious dispute between over billing audits may finally be approaching endgame. On April 7 the provincial Liberals, prodded by months of negotiations with the Ontario Medical Association (OMA), announced the creation of a commission, headed by former Supreme Court Justice Peter Cory, to thoroughly evaluate the entire audit process. There's also strong momentum in the Ontario Legislature for a moratorium on billing scrutiny until the commission is set to report back, in about six months.

The audits, conducted by the Medical Review Committee (MRC), have long infuriated Ontario's doctors and remain controversial even after years of attempted reforms. Tensions escalated when frequency of audits was stepped up under Mike Harris's Tory regime, especially between 1996 and 1999. The whole thing gained public notoriety in April 2003 when Welland pediatrician Dr Anthony Hsu killed himself after the highly unpopular MRC forced him to repay over $100,000 in contested billings.

The OMA has been feeling the sting of criticism from disgruntled doctors across the province for a while. Many of them feel that the OMA wasn't making audit reform a priority. After a number of aborted initiatives, Dr Larry Erlick, president of the OMA, feels that the upcoming Cory commission is a major stride toward changing the perception of complacency. "We support a fair and transparent audit process," declares Dr Erlick. "An independent review of the process is long overdue. We have been calling for such a review for some years now."

In February, an OMA panel exhaustively examined billing audit practices across the country, and recommended bold changes in Ontario's system. Their 27 recommendations tackled many of the touchiest issues surrounding audits, and prompted Minister of Health George Smitherman to launch the new commission.

FROM ONE WHO KNOWS
Dr Farouk Dindar, a neurologist in Scarborough and founder of the pressure group Ontario Doctors for Fair Audits, has been one of the most vocal opponents of the billing audit system. He's in a position to know: he was audited himself in 1999 and remembers his experience as "emotionally very traumatic ? I even contemplated leaving Ontario," he says. Nevertheless he considers himself lucky, as he was one of the few who have avoided large repayment judgments. He feels that many doctors have been driven out of the province by the tactics of the MRC, and says that doctors feel persecuted by a process that is stacked against them, and amounts to little more than what he calls a "cash grab."

Many practices of the MRC truly rankle, says Dr Dindar, who thinks that their underlying philosophy is based on the assumption that a clinical practice can be judged merely by looking at what's included on the patient's charts. Once a doctor is targeted for an audit, a small sampling of his or her patient charts is examined by a single MRC member ? a fellow physician, though not necessarily from the same specialty ? to determine whether the doctor is overbilling. Findings are 'extrapolated' over a two-year period, which can result in demands for massive fee repayments, plus interest, to the government. This is what happened to Dr Hsu.

Even more galling, is that any appeal costs of the MRC judgment will be borne by the physician. This greatly discourages many doctors, who feel that they have been maligned and unfairly penalized, from contesting the verdict. They just pay up. In Dr Dindar's books, this amounts to "blackmail." Dr Dindar also feels that the audits worsened when computerized 'data mining' was introduced, which flagged any doctors whose billing profiles deviated from the average. "There is no check with clinicians in the same field, who may recognize legitimate explanations for billing patterns," he says.

Dr Erlick stresses that fee-schedule reform is one of the OMA's priorities. "The schedule of benefits became a legal document, not a guide," he says. "It was never meant to be a legal document." He feels that the system needs updating to better reflect the real world of medical practice.

But for Dr Douglas Mark, head of the Coalition of Family Physicians, all this initiative for reform is too little, too late. "We cannot keep injustice going on. It is a witch hunt, an unjust process," he says. On April 7, Dr Mark, accompanied by Dr Hsu's widow, organized a rally at the Ontario legislature to pressure MPs to impose an immediate moratorium on audits in the province.

Dr Dindar, for his part, is actually quite optimistic about the impact of the commission's upcoming review. "Any person who looks at the audit system from the outside, any reasonable, decent, human being will look at it and say, 'This process is grossly, fundamentally flawed'."