What’s My Doctor Billing to See Me?

Good Cheap FastPeople ask, “What does my Family Doc bill when I go to see her?” This post tackles the most common fee code that family doctors use and how cuts relate to patient experience.

“Do I have pneumonia?”

Imagine you visit your doctor for a bad chest infection. She listens, asks about specific symptoms, rules out other problems with more questions, reviews your family history and performs a physical exam. She orders a CXR and blood work, reviews your allergies and medications, and writes a couple prescriptions. A few days later, she reviews your blood work and x-rays then has her staff call you with the results.

Your visit, tests and follow-up cost $33.70.  The fee code is called an Intermediate Assessment, A007, a cornerstone of family practice.  Of course, there are higher fee codes (e.g. Annual Physical). They’re billed far less often and require more office time.  A007 acts as a benchmark for work in family practice. The OHIP definition reads:

“An intermediate assessment (A007) is a primary care service that requires a more extensive examination than a minor assessment. It also requires a history of the presenting complaint(s), inquiry concerning and examination of the affected part(s), region(s), system(s) or mental and emotional disorder as needed to make a diagnosis, exclude a disease and or assess function. This is a family practice code but should also be billed by specialists practicing outside of their specialty and/or in a primary care practice setting.” 

A007

In 1999, A007 paid $25.65.  Fifteen years later, it pays $33.70. It increased 1.84% per year – less than inflation for the same time period (1.97%).

Overhead, Hours, Billings

A doctor’s office costs approximately $120-$140,000 per year in Southern Ontario. Most doctors take at least 4 weeks holidays. Therefore, overhead costs $2500 – $2900 per week worked.

A physician must spend 20-30% of her time with office work, not seeing patients. That means 1 day of reviewing labs, charts, and X-rays for every 4 days of time with patients.

Seeing patients generates fees. Reviewing labs and X-Rays does not.

A full time family doctor has 30 hours/week to see patients (7.5 hr x 4 days). Doctors must see 2.5 – 2.9 patients every hour, at $33.70 per patient, to cover overhead.

Most doctors can see 4-5 patients per hour if patients have one, straightforward complaint. With high overhead and 4 patients per hour, doctors earn $37.07/hr. At the other extreme, with low overhead and 5 patients per hour, doctors earn $84.25/hr.

How to increase billings and decrease expenses

Doctors increase efficiency in 4 ways.

  1. They work longer hours after their office is closed and staff have gone home.
  2. They take fewer holidays when the office is open. That is, they avoid paying for an office unless patients are in it.
  3. They decrease overhead expenses.
  4. They see patients faster.

The first two cause physician burn-out, the third causes staff burn-out and the last cuts time with patients.

Treadmill

Patients feel the biggest impact of fee cuts in less time available with their physicians. Doctors end up trying to shorten visits and book unique appointments for separate concerns.

Primary care reform changed the fee-for-service-treadmill with capitation – paying doctors one fee (e.g., $135) – to provide all care for 1 year no matter how many visits are required. Older patients carry a slightly higher fee and the young a much lower one. But now, some patients struggle to get in to see their doctors; especially if they require multiple visits.

Patient Impact of Fee Cuts

Fee cuts:

  1. Make the treadmill faster – less time with patients
  2. Increase patient visits – docs insist on 1 complaint per visit in fee for service
  3. Make it harder for patients to get an appointment in capitated models
  4. Encourage physicians to work longer and harder for the same earnings (more burn-out)

After overhead, many family doctors make just over $100,000 per year (every average requires some to fall below the mean). Patients feel legislated fee cuts when they access care. Regardless of how you define what qualifies as a high income, most professionals will try to maintain earnings by working more, running faster, or decreasing overhead (e.g., reduce unpaid services). Patients feel this. That’s more than enough reason to stop cuts.

photo credit: smartchinasourcing.com

 

 

What Else Did Winkler’s Report Say? OMA-MOH

winklerYou probably shouldn’t read all 7 pages of Justice Winkler’s report. Hoskins only needs two lines from the 2nd last paragraph. He shared a link to Winkler in his news release.  As far as the Minister of Health is concerned, the retired Chief Justice silenced debate with:

“In the circumstances, I would urge the OMA to reconsider its rejection of the Ministry’s Proposal. Similarly I would urge the Ministry to not resile [deviate] from its final offer.” 

Hoskins tweeted,

We had an umpire and he sided with us, not the OMA. It was a fair proposal. And a fair process.” And again“It was a fair offer. Our mutually agreed-upon conciliator (retired judge Winkler) told the OMA to accept it. They didn’t.”

It seemed that way to me too, at first. Winkler sided with government, the end. But after a few deep breaths, I tried to understand why such a highly regarded judge would “…urge the Ministry to not resile…” It didn’t make sense.

Winkler said a 3 year deal

“…would afford the Parties the time required to focus on…the systemic issues threatening the sustainability of Ontario’s publicly funded health system. If the Parties can take advantage of the opportunity that the Task Force provides to them, they will have provided an invaluable service to the citizens of our province.

What was Winkler talking about?

Winkler’s Report

Since Hoskins made the report public, we’d better discuss it.

A major section, almost 20%, tackles system change. Winkler dares to mention political kryptonite. He asks for review of our publicly funded healthcare system.

If we listen carefully, the 5 paragraphs on pages 6 and 7 may be an historic turning point.

1. Pressing Need

“At the start of the Conciliation it became obvious to me that there was a pressing need for a collaborative dialogue analysing the current system of financing of the delivery of physicians services.”

No surprise here. He believes that a “pressing need” exists to analyze the “current system of financing” MD services. So do many others.

2. Collision Course, Sustainable?

“Absent some rationalization, the system may not be sustainable. Thus, the consensus emerged that without systemic changes to the health care system, the Parties seemed to be on a collision course so that a PSA [Physician Services Agreement], at some point in the future, may not be achievable.”

Does a collision course without systemic changes sound a bit alarmist? Winkler worried that an agreement might be impossible between the parties “at some point in the future“.

3. Review MD Services and Transform the System

Winkler offers two places to start.

“I introduced two initiatives which were intended to be separate from the PSA: The Task Force on the Future of Physician Services in Ontario (the “Task Force”) and the Minister’s Roundtable on Health System Transformation (the “Minister’s Roundtable”).

Both the Task Force and the Minister’s Roundtable would include representatives of important stakeholders in the health care system, especially the public. The purpose of the Task Force would be to conduct a long-term study and analysis of the sustainability of Ontario’s healthcare system with the mandate of advising and making recommendations for systemic changes to the delivery and funding of physician services.

The Parties’ agreement to embark on these initiatives was an important development as it enabled them to focus their discussions on the pressing matters required to agree on the 2014 PSA, with the comfort that the broader systemic issues impacting the sustainability of health care in Ontario would be appropriately and collaboratively addressed in a larger forum. I tabled language that reflected the substance of the consensus reached in these two important areas.”

He says neither government nor physicians can fix the system by themselves. We need a 3rd party to recommend how to change the funding of physician services and broader system issues.

Did Winkler question the fundamentals of publicly funded healthcare? He seems to. He asked to review how physician services are funded. MD services currently rely on tax dollars 100%. Was he asking for a review of whether tax dollars were the best way to fund all physician services, or was he just asking to review how taxes are collected and disbursed?  Or did he mean something else entirely?

Ignore Winkler

Will we listen to what Winkler says in his report, or will we make it say only what we want to hear? Will we pick favourite lines and ignore the rest?

Clearly the government loved part of it. Hoskins dismissed the need for system change tweeting that, “We accepted his proposals. It is the year over year increases in billings that he said was unsustainable.” I guess I’d try to read it that way too, if I was in his position. But the judge did not say to cut fees and make plans for more. There’s massive growth in patient need for medical services with 140,000 new patients in Ontario each year. Hoskins’ reduction of the report to nothing but billing increases seems trite.

Will the government allow an objective examination of our system? Will they follow advice wherever it leads?

A task force would not suggest more of the same. If politicians insist on standing on Winkler’s report, we should ask them to stand on the whole thing. Support for cuts rests squarely on review of the system. You cannot have one without the other.

How do you read the report?

photo credit: globeandmail.com

Doctors’ Fees, Incentives & Greed

doctors feesAfter 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