Charging patients for services: much confusion, little consensus
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.