Ontario wants to make it easier for patients to find a family doctor and to have access to same-day service. Those are laudable objectives and I strongly support them.
But based on my experience as both a physician and a consultant for primary care optimization, I see a major barrier to meeting these goals: the government doesn’t know enough about the services that doctors provide and the availability of doctors to their patients. As a result of the lack of information, the government can’t tell whether or not they can realistically expect family doctors to take on more patients, or how many patients truly have same-day service.
The problem begins with the information we use to measure physicians’ work. Canada’s provinces and territories rely on billing data, which includes surprisingly little information: doctor and patient identifiers, date, service fee and diagnosis. That’s not enough to get a clear picture of doctors’ work burden and patient services.
Worse, most provinces’ archaic billing systems have an additional failing: they only permit a single diagnosis for each encounter. That’s a major issue in primary care, where a visit might cover three distinct problems – for example, high blood pressure, knee pain and a urinary tract infection. Whichever diagnosis the doctor selects, the other two will go unrecorded, leading the databases to underestimate the work involved in all multi-problem encounters. Service fees such as those for smoking cessation counselling or after-hours premiums can help to more accurately capture doctors’ workload, but there are too few of these to make up for what’s missing.
Another way billing data fail to capture physician work effort is that it doesn’t include patient-doctor interactions that take place by phone and email because there are no fees payable for those exchanges. However, patients want to have the ability to phone and email their doctor and it can free up physicians’ time by reducing in-person appointments. That would allow doctors to provide additional patient services, which would help to meet government goals.
In other words, the government is using a system designed for billing purposes as a way to gather information, and the data systematically understates doctors’ activity. That can lead health system managers to believe that those of us presently working as family practitioners have more capacity to take on additional patients than we actually do.
When it comes to same-day or next-day appointments, my colleagues and I have always offered them. However, to demonstrate that we provide that level of service would require that the government be able to audit the date and time that every appointment slot gets filled. Though that’s something that’s technically feasible, the government has neither sought such information nor obligated physicians to use computer systems that can record and report appointment data.
Instead, health care researchers ask patients and doctors about appointment availability. While that seems sensible, it turns out that patients and doctors give different accounts: only 44% of patients surveyed for Health Quality Ontario’s annual “Measuring Up” report say they can get same or next day access, while Ontario doctors told Commonwealth Fund researchers that 66% of them provide such service.
Perhaps doctors are overstating their availability or maybe patients are failing to distinguish between access and convenience (see this excellent piece on that subject by one of my office colleagues). Regardless, it’s hard to plan solutions when the source information is so inconsistent.
Fortunately, most of the missing data on doctors’ work activity and availability can be addressed by feasible changes to government and physician office information systems:
- Allow billing claims to include multiple diagnoses with a single service fee, as well as the time of day of the service
- Create fee codes for phone and email encounters so that we can track all patient services
- Mandate appointment software that records when a slot is booked by a patient
If we take these steps, we’ll gain a far better understanding of the actual work that family doctors do, which in turn will inform us on how to match physician supply to patient demand. With that new knowledge in hand, we can move forward to successfully plan ways to assure that everyone has a family doctor and that their doctor is readily accessible.
The comments section is closed.
Excellent analysis. My understanding is that the OHIP computer system that handles billing has been outdated for many years and was a repeat item on the Auditor General reports. It is time for a major investment in the billing system and physicians should have a large role in its development for both accurate reflection of activity and for infomatics/research purposes
And that doesn’t include hospital work or administration
Jack, thank you for the information. We appreciate the care we receive at “City of Lakes.” We also miss seeing you since your move to southern Ontario.
This type of info is so helpful. As patients we want to support our physicians. We know that they are very highly qualified, and generous. But to do their best work, they need their “employer’s full support.
The provincial government needs voter support. Thank you for being involved in improving our health system. Sharing your goals and explaining the problems to more people may help us be more supportive.
It also does not account for nurse practitioner visits . I have 2 NPs that work full time and are paid from my pocket . They are not allowed to bill so all the visits they do ( in lieu of me ) are not recorded
Excellent blog. There is a major problem with assessing the quality of healthcare delivery. We don’t try to measure what might be one of the most important determinants of a patient centred outcome: The extent of continuity of care from a primary care physician (related to TT comment). Our assessors are substituting the convenience, commoditisation and bureaucracy of healthcare delivery for quality of care.
Minor technical point: sometimes we do want to book in patients a long time in advance eg. for routine chronic care, anti-coagulation monitoring, day 21 progesterone. You will need to remove these outliers from any assessment system
Have no interest in a family doctor as that means no second opinions and no informed consent. I was fired from my last family doctor for refusing pap tests when I presented with a migraine. I now go to a walk-in and have had the same doctors for over 15 years. Now they have added mammograms and FOBT to the pap tests as well which I also don’t want. This means I will have to wait until 74 before I can get any family doctor. If the walk-in closes I get no migraine care except in the ER or street drugs I guess. I can’t find any family doctor as nine out of ten will not take patients who are “non compliant”.
I’ve spoken to the privacy commissioner of both Cancer Care Ontario and Ontario and got nowhere. I was told if I didn’t want screening to lobby my MPP and get the law changed. The walk-in said it’s my choice but for some reason family doctors say it’s their way or the highway particularly to women. For some reason men are only harassed for one cancer test not three. I get treated with more respect in the walk-in, no problem with same day appointments either, why would I want to change. I also can get treated for three and four items at one time with no issues. I’ve had migraine, a skin rash, generalized anxiety and a Zostavax prescription all done in one appointment.
Vera , the issue is that if you are rosteted to a family doctor and refuse the screening tests – they get ‘fined” ie don’t get the payments that add upto their income . In effect you could be costing them more than you bring in financially . Would you want to go to work if you had to pay to be there ….so it’s not the doctors fault . Ask the family doctor to de enroll you but still keep you on as a patient then it won’t matter to him / her what tests get done or not get done as they will be paid like a walk in doctor . I simply deroster patients if their choices make them a loss making patirnt . It dosent change the care , it’s just basic business 101
I’m not sure what Vera’s concerns are, but what about a doctor who fails to send a patient for certain tests like a PSA by the time they are in their fifties and sixties? My cousin’s doctor totally neglected sending him for this test and it wasn’t until he showed signs of prostate cancer did he do it (which wasn’t until he was 64 years of age).
Doctors should also be aware to what professions or work their patients do in order to help them prevent certain diseases. My cousin drove cab for over 30 years and it doesn’t take more than a simple Internet search to know that cab drivers have some of the highest incidents of prostate cancer (most likely because they are sitting on their taint all day long).
There are also many cases where being “non-compliant” is the best course of action for the patient. It is one thing to go to a doctor and constantly or irrationally fail to follow orders, but it’s another thing where an informed patient knows their own bodies and doesn’t want to have a certain procedure done or take some pharmaceuticals he/she knows will do more harm than good. The risk involved taking some of these crazy drugs is often too high, too expensive or downright pointless.
“Allow billing claims to include multiple diagnoses with a single service fee, as well as the time of day of the service”
Hey, I’ve got this REALLY AMAZING idea!!! Why not pay the doctors for all of the work that they do. Doctors get paid for one code only not matter how many they deal with in a visit. If I deal with three problems in one visit, I should be paid for all three. This would make a perfect marriage between patient convenience (not having to come back for multiple visits) as well as the blunt reality that doctors run a small business and have to pay all of their overhead (staff, supplies, equipment etc). It would end the ‘one problem per visit issue’ immediately.
Right now, my overhead keeps rising and my fees keep falling. One problem per visit it will continue to be until this changes.
But, hey, let’s keep blaming those greedy doctors for not wanting to do free work. Let’s keep blaming docs who run far behind schedule because patients drop 5 problems into our lap while 10 patients per hour are booked. Or let’s blame the docs for not seeing us because they are scheduling 20-30 minutes per appointment to deal with all of the extra issues that come up in a visit.
Dr. Conte points just a tiny bit of the binds that physicians have been put into by governments that over promise and are unable to fund their promises.
Theresa points out the problem that she lives 2 hours from her family doctor clinic and begs for a system in which she can have a family physician in her own town. Is this a realistic wish? Not in the foreseeable future for so many Ontarians. There are currently 800,000 Ontarians without a family doctor at all. This was before the huge cuts to health care made by the Ontario government that is causing doctors to shut down their offices and practicess. Addiction clinics shut down immediately after the government imposed its last cuts in September. Even walk-in clinics are shutting down. This is the tip of the iceberg.
800,000 patients do not have a family doctor! The Ontario health care system is failing so many and now it is getting worse. Sad for Theresa and hundreds of thousands of others. There is no short term solution. Being sick is bad enough. Being sick without adequate access to health care… That is awful.
Please don’t shoot the messenger
Is there a rationale for the physician only being able to bill one code per visit? Perhaps the rationale is for physicians to not pad their bills? To control costs?
Physicians ought to be held accountable for being honest, but on the other hand this system does not allow a physician to bill accurately. Surely its in the best interest of both the consumer and the physician to address all pertinent issues in one visit. Draw a parallel with another professional that provides a service. Would we go to the dentist for a check up and a cleaning but expect the dentist to bill us for only one service. If I hire a plumber to remove my old sink and install a new sink would I expect to be billed for only one service?
There are all sorts of dishonest professionals. Lets build systems to monitor their honesty and review when necessary. If a physician has billing practices that are beyond a threshold for example then they can be audited. I believe that most professionals are honest and just want to make an honest dollar. A system that does not allow this motivates the professional to either opt out or become dis-honest just to make a living.
Unfortunately, the reality in an office with overhead running $100-200/hr, and each patient bringing in $33.70 regardless of the complexity or number of issues, is that doctors have to limit what they can deal with and book people back for separate issues. There is no phrase a doctor dreads more than, “Oh, and just one more thing……..”
It is frustrating to us too, and none of us like to do it for patients who are disabled or come a long distance. Perhaps most frustrating of all is that patients have no idea how OHIP works, and what is covered and what is not. Least of all, they are shocked when they learn that their coverage discourages the doctor from dealing with more than one issue.
Other provinces such as Manitoba do not have such an archaic system, but rather allow a doctor to be renumerated accordingly for one, two, or three problems; and other provinces such as Saskatchewan give a premium for an elderly patient because they presume (rightly) that these encounters inherently require more time, not just because the patients have multiple problems but because even things such as getting up on the exam table or taking off a sweater for a BP check can be slow and painstaking. In Ontario, it’s $33.70 despite how many problems or how complex the patient. I am always amazed how the government keeps making plans to “improve access”, “increase patient satisfaction”, and “get everyone rostered to a family doctor”, while at the same time, they ALSO keep planning to cut fees further, and add clawbacks and caps. Sort of like planning to provide Holt-Renfrew service at Wal-Mart prices!
Surgeons bill 85% of fee code if they do an extra procedure during primary procedure. Should be same for family doc 85% for second do maybe 50 for third. One problem one visit is problematic as patient with sore knee and indigestion may choose the knee and die of their MI next day. Patients can’t prioritize their problems.
I worked most of my life in the computer repair industry, having to travel in the worst weather Northern and Southern Ontario had to offer. Your complaints are no different than what the majority of workers in the service industry have to deal with. The big difference between us is that you get paid big bucks whether your patient lives or dies (or suffers for years from the management of their disease).
It has always been my contention that most doctors would starve to death if they were paid by results. The only heroes in that industry are those working at dealing with trauma in emerg. For the most part, it has always been my experience that physicians aren’t interested in a cure or alternate methods of dealing with illness. Nor do they want to listen to some of the root causes of disease in order to help their patients and get them to understand that things like erectile dysfunction, heart disease or whatever isn’t “normal” when you enter your fifties and sixties… Just because a majority of people experience these things doesn’t mean it’s normal. It just means older people are prone to get these illnesses, and that a reversal of those illnesses can be safely done without pharmaceuticals.
In the same way a mechanic cannot solve a car problem just by hearing about one symptom, so to does a doctor need to listen to multiple symptoms from his patients in order to alleviate their problems. A person who comes into a doctor’s office complaining about knee pain must also take into account poor dietary habits, obesity and lifestyle and work habits. Prescribing a drug to deal with inflammation doesn’t solve the problem in the long run.
As much as I’d like to be sympathetic towards doctors when it comes to their dealings with the government, I am convinced through my own terrible experience with the Ontario health “care” system that a good portion of doctors are motivated by their own greed and do little to assist patients with prevention and routinely throw pills or medical surgery at them when the real solutions are far less expensive and effective.
If a person is born with a fantastic memory and can find the funds to enter medical school, it won’t be long before they are earning top dollar. In order to get rich, a doctor doesn’t have to be compassionate, understanding or competent. They can send a patient down a path of destruction without much effort. I should know because that’s what almost happened to me. It is only due to my own research and reading about my conditions was I able avoid being lead by the nose of doctors who’s only concern was making a buck off of me. They can stick their Cymbalta and statin drugs where the sun doesn’t shine.
yes lots of us don’t have family doctors and have to go to outpatient for help. we have been in Mattawa for 6 yrs and my husband and I are very sick. To see our family doctor we have to drive 2 hours to Huntsville, and like you said for 1 thing we can’t afford the 4 hour return trip, we are both on diability and here in Mattawa everytime you go to outpatient its a different doctor. We have asked for help but to no avail Please change the system so we can all get a family doctor in our home town . Thank you for posting this its a person like you that will make a big difference in your patients health. thank you Theresa Townsend, Mattawa ,Ontario
This makes sense as I don’t always need to actually see my Dr. In person and if the Dr. wants to see me I can go for a visit. Most people are capable of making the decision to visit or not.
Thanks, Dr. Dermer, for identifying these issues. If only government did more asking and less telling, solutions would be easier to achieve.