The Ontario Health Insurance Plan (OHIP) does not cover all health services that can be provided by a doctor. These “uninsured” services include telephone renewal of prescriptions, writing sick notes for work or school and transferring medical records.
Doctors can offer patients the option of paying for a set of uninsured services with a single “block fee.”
There is a lack of clarity about what a reasonable block fee is, how doctors communicate the existence of the fee to patients, and patients’ options regarding the block fee.
Case of Dr. Karen Dockrill
Karen Dockrill, a Whitby pediatrician, has been called before the Discipline Committee of the College of Physicians and Surgeons of Ontario for “an act of professional misconduct.” Dockrill charged an annual fee of $1,500 to access services through the Mom and Baby Depot, which she ran, for providing telephone support and education programs for families with new babies. The College of Physicians and Surgeons of Ontario (CPSO) alleges that Dockrill “charged a block or annual fee regardless of how many services were rendered to patients and charged a fee for an undertaking to be available to provide services to a patient, and also by refusing to accept new patients who did not pay the aforementioned fees”
Dockrill says that the fee charged was not a block fee, but rather “membership, because we were selling non-OHIP services delivered by a team of professionals” .
Doctors are permitted to charge patients for uninsured services. However the CPSO indicates that if doctors charge a block fee, they must also provide patients the option of paying for each service individually, and that the block fee “must not affect [patients’] ability to access health care services.” The charges against Dockrill came about after complaints that patients were not accepted into her practice unless they paid the membership fee. The Mom and Baby Depot has since closed.
Who decides what’s in and what’s out?
Not all services that doctors provide are paid for publicly. A joint committee of the Ontario Medical Association and the Ministry of Health and Long-Term Care, known as the Physician Services Committee, makes recommendations about which services are publicly funded. Colleen Flood, a health law professor at the University of Toronto, has criticized this process for excluding public participation and input.
Establishing policies around block fees
The CPSO policy on block fees and uninsured services says that “physicians must ensure that the fees charged for uninsured services are reasonable.” The policy suggests that doctors should refer to the Ontario Medical Association document Physicians Guide to Third Party & Other Uninsured Services for recommendations on how to set fees, and that doctors must let their patients know if they are charging more than the guide recommends. This guide provides information regarding what is a reasonable fee for individual uninsured services. However this guide, and other Ontario Medical Association material on uninsured services, does not make recommendations regarding what is a reasonable block fee. Moreover, these Ontario Medical Association documents are not easily available to the general public .
Danielle Martin, a family doctor at Women’s College Hospital in Toronto and chair of Canadian Doctors for Medicare says, “I don’t think most people have any idea what a reasonable fee is and what is reasonable is entirely dependent on context.” Martin says that “the problem with the word reasonable is that it depends on the nature of the service and the financial situation of the patient.”
Dockrill agrees that the current guidelines around block fees lack clarity. She notes that “professionals reading the guidelines are not understanding them, and certainly the public doesn’t understand either what all these different charges are for.” She suggests that “it all goes back to whether or not people understand what is covered by OHIP, and what is not”.
Kathryn Clarke of the CPSO says that “it is difficult to know how frequently block fees are being used in Ontario” and says that out of the 24,300 calls the CPSO received from the public in 2010, only about 3% of calls were related to block fees.” The small number of complaints may indicate that most Ontarians who pay block fees are happy to do so or believe that block fees are reasonable. However, it may also be a consequence of patients either not knowing their rights or being unwilling to complain about their doctor because they fear a backlash from their doctor. Block fees are not uncommon in Ontario – it was estimated that over 1000 doctors in Ontario asked their patients to pay a block fee in 2008.
Block fees and changing payment arrangements for doctors
Providing non-OHIP services individually or via block fees are ways of adding some private dollars into medical practices. Douglas Mark, a Toronto family doctor and President of the Coalition of Family Physicians & Specialists of Ontario says that “overall block fees help doctors provide more for all of our patients” allowing doctors to “make investments into their practices and helping them afford new equipment or new services and staff, to better serve patients”.
The way that Ontario doctors are paid is changing, with fewer paid solely on a ‘fee for service’ basis. Many doctors are now being paid a monthly fee for each patient they care for. The intent behind this approach is to encourage doctors to provide more comprehensive care. It is not clear whether services such as sick notes and telephone prescription renewals that are currently uninsured, are included within the monthly fee.
Martin says that “this is an area that is ripe for conversation between the Ontario Medical Association and the government in the next round of negotiations” and that “the intent of capitation is to move doctors away from a nickel and diming approach to medicine towards a more holistic approach of caring for people.”
Mark agrees that more guidance is needed around block fees. He argues that “there needs to be a process in place for doctors who are interested in setting up block fee systems to ask the College [of Physicians and Surgeons of Ontario] if everything looks all right”. Mark says that the current attitude of the CPSO is “frightening doctors away from being innovative” and hindering the provision of additional services to patients.
The comments section is closed.
I think we ought to see both sides of the coin in this case.
Block fees provide doctors additional incentive to work better. Doctors are, after all, only human, and such a fee would have a much stronger impact on their psychological being rather than their financial well-being. A doctor receiving even a small amount from a patient will be more compelled to help them out and deliver more services. I have no studies to support this but it seems like an intuitive conclusion.
The problem comes in the way these block fees may be graded, from very small to very large amounts. It may perhaps defeat the purpose of having such a fee at all, but I suggest that if we must have them, we must do it the right way and what seems to be lacking is a rigorous formality in the process. I suggest that doctors and patients be given input on what procedures out to have what block fees, and a mean amount be generated for each of a generic list of procedures. Such surveys could be administered by a doctor after examining their patients, and to the general public online. It seems like a project, but it needs to happen.
The problem with such an endeavor is that there will always be exceptions to the rules, and someone may not be well-off enough to even pay what some might consider a ‘reasonable’ fee. In such an event, a physician must make allowances.
The drawback on the outset of such a system is essentially that all it does is that it seems to be adding a little more to a doctors salary, and the Hawthorne-effect on physicians may diminish overtime, but it is necessary to acknowledge the benefits and freedom it gives doctors to be innovative and to be rewarded for going above-and-beyond regular protocol. It seems apparent that a doctor would want the best for their patients and not adopt the block fees system simply to charge them more, but rather to somehow enhance their treatment (with, granted, a perk for themselves).
I agree with CPSO’s somewhat-aggressive attitude, and it is necessarily aggressive, as it is an issue that needs to be dealt in it’s early stages. However, targeting doctors directly is not the solution, and rather a more systematic and democratic solution may be called for.
Allowing patients to pay for ‘uninsured’ services, that they they and their physician agree are beneficial, seems like a good idea. However, it does raise a number of important questions and issues that should be explored and considered in a open and rational way, with the aim of understanding how private activities might benefit the public system.
Considering that the public system has a limited funds and resources to provide medically necessary care, should Canadians who want and can afford a higher level of care be prevented from doing so? Might better prevention or early detection for some, lesson demands on the public system, freeing up resources for others?
If those who want and can afford this type of care access it through the US system what would be the impact? Could this affect economic development and health innovation in Canada?
Our public health care system is limited. Often people cannot access medically necessary care in a timely manner. Many Canadians do not have a family physician. Wait times for some procedures can be dangerously long. Considering this, does it make sense for publicly funded resources (i.e. physicians working in the public system, hospital laboratories, public clinics) to provide ‘private’ services? Does this create conflicts of interest? Does it lesson its capacity to provide medically necessary, publicly funded care? Would it be better if uninsured services were provided exclusively through the private system, such that there is clear separation of publicly funded and private activities?
I think there’s an important conversation to be had about how non-OHIP services should be addressed in the context of changing models of physician remuneration. On one hand, I can certainly understand the idea that under mixed funding models that involve a certain amount of capitation, that it is unclear whether things like telephone renewals are covered. I can also see why some would like to see these services covered. But on the other hand, many of those services are not listed for a reason – they are not considered medically necessary. A number of cosmetic procedures are also not covered – like skin tag removal. Drawing clear lines between all of the uninsured services could prove a little harder than one might think at first. It’s not obvious to me that the line isn’t already in the right place, in which case it seems pretty reasonable that if patients want to access non-necessary services, that they continue to do so out-of-pocket. However, I’m certainly open to having my mind changed if someone has a compelling argument to the contrary.
Block fees strike me as one of those practices that if employed properly can be of benefit to some patients, but that has significant potential for abuse. Above all, the fees must always remain optional – mandatory fees introduce a barrier to accessing primary care, which is simply unacceptable, from the perspective of both equity and public health. The use of block fees by organizations such as MedCan (http://www.medcan.com/) should also be investigated, as they seem – at least from the outside – to be used in order to create a two-tiered healthcare system. No doubt MedCan would claim, like Dr. Dockrill, that the fees are just going to non-OHIP covered services, but when they are charging that much to even let people in the door and their members can access specialists much faster than anyone can through the public system, it definitely looks to an outsider like it’s not completely above board.
This is an incredibly important issue and I’m happy to see Healthy Debate raising it. Another issue of concern linked to this is the use of block fees as an excuse to charge patients for services that are actually medically necessary. These fees have been seen as potential loopholes for introducing out-of-pocket payment in order to access all services a clinic provides, although on paper it is stated that the fee was used only for uninsured services.
Most block fees and special patient charges are created by physicians to generate more income often in monopoly or special situations such as local physician shortages. They do not lead to innovation or additional worthwhile patient services. The current OHIP fee schedule s generous and allows most physicians to have a solid income.