Shawn Whatley, Author at shawn whatley md

Doctors’ Fees, Incentives & Greed

After the last post, readers wanted more discussion about doctors’ fees; how doctors bill for services they provide.

Are fee codes just a fancy way to track services?
How do fee codes get created?
Why does the government pay doctors?

Teams of bureaucrats and doctors create fee codes. The fee-code-committee learns about services that patients need. The committee works out a fee so that providers can offer the needed service.

Let’s consider a few examples.

I work in a tiny rural office. We still offer venipuncture (blood draws) for routine lab tests.

I bill $3.45 for a venipuncture in my office. My staff draws the blood. The fee was closer to $5 before it was cut in 2012.

If you’ve had a blood test, is the set up and time required only worth $3.54? After repeated cuts to this fee, most patients now have to drive into a lab for bloodwork. Some rural patients drive over an hour for tests. When government cuts fees for drawing blood below what it costs to hire a phlebotomist, then doctors are forced to stop providing office venipuncture.

Another example. We offer ECGs (electrocardiogram – checks your heart) in our rural office.

I get paid $4.45 to interpret the ECG plus $6.60 to cover the cost of the stickers to attach the leads, paper, machine purchase/maintenance. Staff performs the test.

At this point, a business minded person would question my sanity. There’s no way I can cover the costs of the test for $11.05. They’re right. When our machine dies, we will not be able to afford a replacement. In fact, we probably should stop doing them now.

Fees Meet Needs

Fee codes get made to meet service needs. Fees solve specific patient care access problems. Fees have to cover the costs required to offer the service or doctors – small business owners – cannot provide the service.

One final example. Consider driving to the hospital to examine a newborn baby.

It costs around $7-10 for gas + $20-$25 for parking + $?? for mileage = $30-$35 just to get to the hospital. The drive, baby exam and charting takes between 60-90 minutes if I rush. I bill OHIP $52.

I earn less than $20 per hour to provide this service. I still have to pay my staff, lease, licences, etc. in the order of 35-40% of my billings. As much as I love new babies – and I LOVE new babies! – I cannot afford to provide this service. This is one reason why so few family doctors spend their days providing care in hospitals now.

Fee codes direct patient services

Just like grocery store specials encourage shoppers to purchase certain vegetables, fees encourage doctors to perform certain services. Shoppers could purchase other veggie’s. Doctors could perform other services. Shoppers buy veggies on sale because it makes good sense, not because shoppers are greedy or selfish. Doctors are encouraged to provide services that the government values with an appropriate fee.

But what about patient need? What if there isn’t a fee, or the fee is too low, and patients still need the service?

Great question! Doctors still provide the service if they can. Just like we still provide venipuncture and ECGs in our office, doctors will still try to provide the services simply because patients need them. Then physicians will plead with the government for an appropriate fee for the service.

That’s what this fight with the government is all about. Hoskins slashed fees for new patients, after hours care, weekends, on-call and a trailer load of other important services. Patients need those services. Fee cuts harm patient care.

I hope this helped. I’d love to hear your thoughts about fees, incentives and greed. Please let your MPP know that Wynne’s fee cuts harm patient care. Thank you!

photo credit: newsfeed.time.com

Doctors’ Guilt About Income Harms Patients

Most docs love to work; they find patient care fulfilling. Many can’t believe they get paid for the privilege of helping patients.

Many of us would work for free.

Seriously.

Talk about money or income makes most doctors squirm. We have jobs we love and higher than average incomes. We forget the sacrifice of training.

Politicians and media know this. Like lion trainers with whips, journalists make doctors cower by whipping out a headline about incomes.

Personal Incomes, Patient Needs

Doctors conflate their personal incomes with patient services. They know patients wait, and that the province is short of money. Ergo, if only doctors took a cut in personal incomes, then patient services would improve. But they’re confused.

The schedule of benefits – the fees that physicians get paid – does not exist because government likes doctors. It does not exist to pad physicians’ incomes. The schedule is designed to drive physician behaviour towards meeting patient needs.

Fees Fix Care Problems

Unmet medical need creates demand for new fees or adjustment to old ones. A new fee drives physicians to change behaviour to meet the need defined in the fee code. If you cut a particular fee, physicians’ behaviours change to service other, equally pressing, medical concerns.

For example, attaching a bonus for Family Docs to accept unattached complex patients after discharge from hospital makes it easier for these patients to find Family Docs. Everything doctors do relates to helping patients. All things being equal, doctors will provide care that the government promotes with higher fees, regardless of physicians’ individual altruism.

The MOH-OMA negotiations are about patient needs and how best to meet them, not individual MD incomes.

Fees and Access

Economists teach that prices impact supply. When supply drops, prices increase. If the government fixes a low price, supply decreases.

For example, over the years government slashed fees for community doctors doing hospital work. Guess what? Almost no community doctors spend a significant part of their day doing hospital work anymore.

You can decrease price and in the short run people will still be able to access services. But very soon, supply and/or quality will decrease.

Doctors and Privilege

Privilege relates to more than just income. Society honours physicians, to varying degrees, with respect, deference and a degree of autonomy. Patients do not begrudge what their doctor earns when they are sick themselves.

Society does not privilege doctors only out of the goodness of its collective heart.

People know that if they want some of the strongest students to sacrifice their youth in medical training, society needs to value the sacrifice. Students must be attracted into training.

When governments and media attack doctors and slander them as greedy, when patients look on doctors as undeserving recipients of their tax dollars, and when politicians arbitrarily slash doctors’ fees, our best students change their minds.

For example, before primary care reform, dozens of residency positions in family medicine went unfilled. Students looked to any other field besides family medicine. Society communicated that it did not value primary care. Only after major funding reforms in the early 2000s did students return to family medicine residencies. Now residencies are all full, for now.

Patient Needs Before Doctors’ Guilt

Physicians must not focus on their own squeamishness about money. They need to focus only on patient needs.

Doctors must put their sympathies with patients ahead of government budgets. We need to focus on how to convince the government to fund solutions for patient care.

Physicians, please don’t let the media suck you in to thinking this is about your income. It’s not. It never was. It has always been, and must continue to be, about patient care.

photo credit: businessnewsdaily.com

Wynne Attacks Doctors, Punishes Patients

Ontario has a $300 billion debt (Ontario Debt Clock). Let’s ignore how we got there.

Everyone calls for system change. Everyone. Even Medicare zealots want change.

Wynne got a majority government. Let’s ignore how she got it (bought it?).

Wouldn’t this be a great opportunity for real change? Might this be a great time to solve problems with access, quality and service for patients?

Instead, Wynne and Hoskins use their majority government to attack doctors, again. Because they can.

Change Requires Different, Not More

We could buy a better system by changing the way we spend taxes. Dozens of people have written about it. High needs patients, system integration and acuity modifiers for older, sicker patients offer a few critical places to start.

Fee increases vs. Population increases

Doctors do NOT ask for higher fees. Doctor do NOT want more money for doing the same work. They offered 0% fee increases for two years. 0%! They just don’t want more cuts. They already agreed to cuts in 2012 and 2013.

Doctors want the government to pay for growth.

NOT growth in doctors’ fees. Growth in patient volumes. New babies need care. Immigrants and an aging population increase the volume of services required in Ontario. New doctors provide that care. Or current doctors work harder. Hoskins refuses to pay for it. He calls it a raise to pay doctors’ fees for seeing more patients.

When is a cut not a raise?

What would you call the following?

You ask your staff to work more for less pay. Is that a cut?
You pay hospitals the same to see more patients. Is that a cut?
What if you pay your staff 10% more to do 20% more work? Is that a cut?
What if you cut the budget, underfund growth and slash-or-cancel programs for new graduates, unattached patients, continuing education, hospital on-call and more? Is that a cut?

Democracy and Law

What kind of government creates a state monopoly, then makes it illegal for 35,000 professionals to work outside the monopoly, then slashes the fees it pays for services provided?

Is this democracy? Is it something else?

Wynne Attacks Doctors and Punishes Patients

Politicians attack who they can and coddle who they must. All that matters is immediate public sentiment. Do voters believe doctors have enough?

Who cares if doctors hire staff and pay overhead?
Who cares about student debt?
Who cares about 12 years of university?
Who cares if it takes decades to catch up to friends who chose a different career.
- You chose that career!
Who cares about job stress — everyone is stressed.
Doctors earn $250 thousand dollars after overhead!

Jealousy: wanting what other people have while being ignorant of the sacrifice required to get it.

Fees drive physician behaviour. Voters don’t see that. Even the most altruistic doctor spends less time with you as a patient if she can only bill OHIP $33 for the visit. What happens if you need 45 minutes? You get less service or cannot find a physician at all.

What Next?

Doctors will keep seeing patients. They will grumble, but life will go on.

Eventually one of the last two state healthcare monopolies — North Korea and Canada — will wake up and admit that government monopolies hurt patients. They harm patients because they run out of money and get sloppy with management. Every other country in the world has admitted it. Even Sweden believes state monopolies harm patients. Communist Cuba used to stand with us. Now it’s just us and North Korea.

Dark Times Call for Great Leaders

We look to great leaders for direction in tough times. Maybe Wynne and Hoskins might quote a hero:

“There is no such thing as an absolutely hopeless situation.”

Vladimir Lenin in reference to capitalism

photo credit: cp24.com