Christmas came early for Ontario's
embattled physicians with the December 12 introduction
of the omnibus Bill 171, or Health System Improvement
Act, at Queen's Park. Physicians will rejoice in the
announcement of a new provincial public health agency,
better access to information for patients and improved
regulation of alternative therapies. But mostly they'll
love the bill's formal abolition of the despised Medical
Review Committee (MRC). The Act proposes a new, more
physician-friendly audit system based substantially
on the 2005 Cory Report, which condemned the MRC as
tantamount to a physician witch hunt.
DRACONIAN
MEASURE
The Kafkaesque MRC was suspended back in September 2004,
and during this two-year break from auditing, physician
billing tabs rose by about $700 million. Public and
media pressure — including investigative reports
from the Toronto Star, the Hamilton Spectator and
the Kitchener Record — had been mounting to
reintroduce some sort of oversight.
Retired Supreme Court of Canada
Justice Peter Cory, author of the report, never imagined
the government would leave things in limbo for such
a long time. "There's a need for an auditing system
in order to prevent the abuse of public money —
because that's what it is," he said from his Toronto
office. "But the vast majority of doctors are honest
and straightforward. And if the system of billing and
the billing items were clearer I'm sure there wouldn't
be that same problem."
Justice Cory's report found that
Ontario's old auditing system was not only strict, but
it was substantially different from that of other provinces.
The paperwork demands were so persnickety and officious
that they actually had a negative impact on patient
care. What's more, the audits were so disruptive and
loathed by physicians that they likely worsened the
exodus of doctors from the trillium province.
THE
BAD OLD DAYS
The MRC grew to be more aggressive in its scrutiny of
physician billing starting in the late 1990s and in
the early part of this decade it was clawing back about
$5 million annually from Ontario's doctors. The system's
de facto presumption of guilt meant that honest data
entry mistakes were treated as fraud. The MRC's practices
reached the flashpoint of public outrage with the harrying
of Welland pediatrician Dr Anthony Hsu. Dr Hsu took
his own life in 2003 after his name was publicly dragged
through the mud and his retirement savings vacuumed
out in order to pay back claims that didn't comply with
OHIP's opaque coding rules. The demise of this hard-working,
widely admired doctor showed that a system that ostensibly
was there to protect taxpayers against MD fraud, more
closely resembled a backdoor tax on physicians who had
the nerve to spend more time with patients than with
their chartered accountant.
Dalton McGuinty's Liberals vowed
to fix the medical audit system prior to getting elected.
On 24 June 2004 the Ontario legislature unanimously
voted to suspend the MRC until a new system was readied.
And the Liberals made good on their promise by appointing
retired judge and present York University Chancellor
Peter Cory to head a commission charged with creating
a better audit regime.
The former puisne judge got an
earful from Ontario's doctors. "There were public hearings
and a great many doctors came and explained their problems
with the audit system and there were organizations as
well, like the OMA and the College of Physicians and
Surgeons, and the various specialist organizations that
came to put forward their position with regard to what
was wrong with the system from their point of view,"
recalls Mr Cory. "And there were very good submissions
and recommendations."
The feeling was mutual: the Cory
Report was well-received by Ontario doctors, including
the OMA and The Coalition of Family Physicians (COFP).
The latter group's president, Dr Douglas Mark, was one
of the MRC's most outspoken critics and a passionate
advocate of the late Dr Hsu. He dubbed the Cory Report
"a civil rights proposal for Ontario doctors" and stated
he was "...delighted that his Honour appears to have
adopted all major recommendations requested by the COFP."
WHAT
MADE THE CUT
Now that Mr Cory's recommendations have made their way
into legislation the most immediate question is how
much of the report made it into the bill?
Plenty, says Ontario Ministry of
Health and Wellness spokesman A G Klei.
"Of the 118 recommendations in
the report, if the proposed legislation is enacted,
the vast majority will be implemented in whole or in
part," he says. "Of the recommendations not being implemented,
those relating to an Audit Board Inspection process
have been replaced with a records review by the Ministry.
The Ministry and the OMA have worked together in developing
the revised process."
The OMA released a lengthy commentary
on the heels of Bill 171. It finds the proposed changes
to the audit system by-and-large positive, but did have
some problems in a few areas: the rules on how the schedule
of benefits is interpreted; how doctors are compensated
when payment is wrongly withheld; and some unclear wording
in the section on withholding payments.
The commentary lauded Bill 171's
abolition of doctor's office inspectors, its call for
advance notice before audits and above all the creation
of a new Physician Audit Board, which will be made up
of 30 doctors from diverse branches of medicine plus
10 non-physicians.
OMA President Dr David Bach singled
out George Smitherman in his statement to the media
on 12 December. "The Minister deserves a tremendous
amount of credit and thanks for tackling this difficult
issue and for working with the OMA to find a resolution,"
he said. "The system that is proposed today is the result
of months of work between the OMA and the Ministry."
COULD
HISTORY REPEAT?
When asked if the new law was designed to prevent another
tragic case like Dr Hsu's, Mr Klei declined to comment
directly but hinted that clarifying the coding process
will help and that auditing will be more of a last resort.
"Mr Cory was asked to develop best
practices for the audit process, and his report did
not address specific cases," he said. "This system,
if implemented, would focus on educating and assisting
physicians to meet the OHIP billing requirements. In
the event that the educational interventions are not
successful, the physician may go to the new independent
Physician Review Board which will operate under the
Statutory Powers Procedure Act (SPPA)." The SPPA ensures
fairness in non-court tribunals like rental boards and
social assistance boards.
Mr Cory agrees that many audits
could be averted with better coding. "A lot might go
into education for the doctors on what's needed to understand
and proceed with the billing process," he suggested.
But will Ontario under Bill 171
be a kinder gentler place to practise medicine? Mr Klei
thinks so. "These amendments, if implemented, will focus
on educating physicians regarding the billing requirements
of OHIP; provide a more transparent system for auditing
physician payments and make use of a new independent
board — all of which are in support of restoring
physician confidence in the physician audit system,"
he says.
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