It’s a test fictional doctors on medical dramas like Grey’s Anatomy often dramatically order at the beginning of an episode: the ECG or EKG, short for electrocardiogram.
It saves lives — both onscreen and off. But when done unnecessarily it can cause patients harm, and waste money in a public system where there never seems to be enough to go around. And it’s not the only test or procedure that experts sometimes question.
A committee of the Ontario Medical Association (OMA), which represents the political and economic interests of 31,500 doctors in the province, and the Ministry of Health has been tasked with finding $460 million in savings by 2021 through eliminating or restricting inappropriate or overused physician services. Dubbed the “Appropriateness Working Group,” it was a condition of a February 2019 decision from an arbitration board that ended a more than four-year battle for a new contract for doctors.
The Star is looking at unnecessary health care, and some of the most commonly used tests and procedures among top billers, as part of Operation Transparency, a series aimed at pulling back the veil of secrecy on physicians who receive the most from the public purse.
It’s not that the ECG, which measures the electrical activity of the heart through electrodes, is inherently bad, but cardiologists have recommended not ordering it routinely for low-risk patients without symptoms. Medical experts from across specialties agree there are some tests and procedures that have little impact on patient outcomes when done under the wrong circumstances. They can cause false positives, which trigger more tests; or they can involve anesthesia, which always carries a small risk. Some, like chest X-rays, expose patients to low levels of radiation.
“There’s an increase in the realization of something called low-value care, meaning that there’s a lot of traditional health care that’s provided that doesn’t actually provide value to patients,” says Dr. Rick Glazier, a family physician and scientist at St. Michael’s Hospital’s Li Ka Shing Knowledge Institute.
Many of these procedures have been flagged through a campaign called Choosing Wisely Canada, part of a global movement to reduce unnecessary medical care. Specialist groups, from pediatricians to cardiologists, each came up with a list of three to five evidence-based recommendations on tests and treatments that are not always needed.
As noted in the new agreement between the OMA and the province, Choosing Wisely and the Canadian Institute of Health Information, an independent research organization, together estimate as much as 30 per cent of medical services in Canada are unnecessary and inappropriate.
OMA spokesperson Anne-Marie Flanagan said the Appropriateness Working Group “is currently finalizing its work.”
The Choosing Wisely campaign is not about saving money. The procedures and tests that specialist groups have flagged are instead meant to trigger conversations about what’s necessary and appropriate.
They range from not routinely screening women under 21 or over 69 with Pap smears (these age groups are at low risk of cervical cancer), to not recommending cough and cold remedies for children under 6 (research shows they are not effective when given to children that age and can cause serious side effects).
They also include such suggestions as: “Don’t obtain screening electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease,” and “Don’t routinely perform preoperative testing for patients undergoing low-risk surgeries,” such as chest X-rays.
Read more from the Star’s Operation Transparency series:
Patients routinely having a chest X-ray and electrocardiogram before very minor procedures was identified “quite a few years ago as a waste,” says Glazier.
“It didn’t identify higher-risk patients. It really didn’t change the care they received,” he adds.
There are more than 8,000 fee codes — for every procedure, test and consultation a physician can perform — contained in a public document called the Schedule of Benefits and Fees. Each fee code has its own unique number, price and description. They range from fee #E126, laser surgery for premature babies with an eye disease called Retinopathy of Prematurity ($1,245 for both eyes), on the high end, to fee #G005, a pregnancy test ($3.88), on the low end.
Fee codes are set through negotiations between the Ministry of Health and the OMA and are supposed to take into account how difficult a procedure is and how long it takes to perform.
Both the ECG and the chest X-ray are what Glazier calls “low-ticket items,” meaning the prices attached to fee codes associated with them are relatively low compared to some other procedures. The professional component of an ECG (#G313), billed by the doctor who reads it, for example, is just $4.45. The two-view chest X-ray (#X091), also billed by the doctor who reads the test, is $10.75.
But “when you multiply it by all the minor procedures, it turns out to be a lot of money,” he adds.
Most doctors in the province get at least some of their compensation under a fee-for-service model, one of three ways they can be paid from the Ontario Health Insurance Plan. (They can also earn additional money both privately and publicly.)
Seven years of Ministry of Health data obtained by the Star through freedom of information requests identifies 194 doctors whose annual OHIP billings — from a high of around $6.9 million to a low of $1.4 million — placed them in the Top 100 at least once between the fiscal years 2011-12 and 2017-18. (The amounts reflect their gross billings out of which they pay often hefty overhead costs for things like staff, equipment and rent.)
The data also shows the top procedures and tests for these top-billing doctors. This is not representative of the entire province and it doesn’t mean these tests were unnecessary as the data doesn’t reflect variables like patient age, risk factors or symptoms.
The Top 10 most billed fee codes for the 194 highest billers since 2011 include both the professional component of the two-view chest X-ray and the professional component of the ECG, as well as pain treatments and urine drug tests.
The chest X-ray, coming in at the eighth most billed fee code, was done about 790,000 times by top billers. The ECG is No. 9 at about 748,000 times.
The most billed fee code was for an ophthalmology followup visit, done about 1.8 million times since 2011 by top billers.
These services are reflective of the high number of ophthalmologists, cardiologists, radiologists and drug addiction and pain clinic doctors on the list of top billers. Readers can find top procedures by cost and quantity for individual top-billing doctors in the Star’s searchable database.
Ophthalmologists are one of the few specialist groups that didn’t provide a list of low-value services to the Choosing Wisely campaign. A spokesperson for the professional group representing Canadian ophthalmologists did not respond to a request from the Star for comment on why.
Dr. Sohail Gandhi, president of the OMA, said in an email that it’s difficult to come to conclusions about this data without knowing the details of each patient’s needs.
“But I agree that there are many tests being done routinely, such as preoperatively, that may not need to be. That is why the arbitrator put the Appropriateness Working Group in place,” he said.
“Many of these tests are ordered because of various health-care regulations. For example, patients admitted to nursing homes are required under the Long Term Care Act to have a chest X-ray done within three months of admission, even though Choosing Wisely might not say this was warranted.”
Ministry of Health spokesperson David Jensen wrote in an email that the ministry is working with the OMA to ensure resources are allocated in the best interest of patients.
“The ministry will not accept any proposals that do not protect patients’ quality of care. Ontarians will not lose access to the health-care services they need and depend on,” he added.
Billing under the fee-for-service model is more common with specialists and less so with family doctors, and made up more than half — $6.7 billion — of all physician billings in 2017-18. The more tests and procedures a doctor does, the more money they can bill.
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“This can create perverse incentives in the system that reward doing more,” says Ivy Bourgeault, professor in the Telfer School of Management and the Institute of Population Health at the University of Ottawa.
Despite guidelines from Choosing Wisely and scientific consensus on “low-value” procedures, doctors can still bill and be paid for tests and procedures they perform, she says.
The Schedule of Benefits and Fees tells doctors to refrain from ordering ECGs and chest X-rays as part of routine procedure before unrelated surgeries on low-risk patients.
But fee-for-service billing is done on the honour system. Oversight is “weak” even for serious fraud, according to a 2016 auditor general report.
There’s also a lack of feedback within the health-care system, unlike in some U.S. health-care companies, where physicians are asked to account for their billing, Bourgeault adds.
It also means that specialties that involve more procedures, like ophthalmology, cardiology and radiology, are better paid than those that involve more cognitive skills, like psychiatry and palliative care. The OMA is currently tackling these pay gaps within medicine with another working group.
Dr. Wendy Levinson, chair of Choosing Wisely Canada, agrees misaligned financial incentives might come into play in some circumstances.
“But the most important reason is that we’ve learned to do it this way,” she says. “To leave no stone unturned. That a good doctor is one who thinks of every possible rare disease and orders the tests to rule it out.”
The campaign encourages patients to ask their doctors four questions: Do I really need this test and treatment? What are the downsides? Are there simpler, safer options? What if I do nothing or I wait?
On top of exposing patients to radiation, antibiotic resistance or drug side effects, unnecessary tests can also lead to false positives and the “cascade of harm that comes from doing a test that in the beginning was never needed,” Levinson says.
For example, doing a chest X-ray on a low-risk non-smoker, just because it’s part of a standard procedure, could lead to CT scans and even a needle biopsy in the lung, exposing the patient to radiation, potential complications and months of anxiety.
But it will be tricky for the Appropriateness Working Group to come to a consensus as it’s more complex than just getting rid of a few tests that are always useless, says Dr. Sacha Bhatia, a cardiologist at Women’s College Hospital, who has done research on unnecessary tests.
“As a concept of pure cost savings, it becomes really difficult to wrap your arms around,” he says.
“You don’t want to delist or exclude people from ordering ECGs or chest X-rays, because what if they need them? It does require a bit of a nuanced approach.”
Bhatia was lead author on a 2018 study in the peer-reviewed journal JAMA Network Open that looked at about 2,400 primary care physicians and found just 441 ordered 40 per cent of tests considered unnecessary.
One way to cut back on unnecessary care is to take more time to talk to patients about the risks and benefits of tests, treatments and procedures, he says.
“And then, finally, I think one of the things we should be talking about is not just not doing stuff, but, what are alternatives?”
Giving patients recommendations about different evidence-based things they can try, such as “physiotherapy, different exercises, certain types of medications, or techniques that they could use to alleviate their symptoms is really important,” he says.
Most patients, Bhatia finds, are happy to avoid something that might require them to take time off from work or pay for parking at a hospital, if they understand why their doctor doesn’t think it’s necessary. “If you’re unsure, you should just talk to your doctor and ask questions,” he adds.
The Choosing Wisely campaign is also working at changing the culture, starting in medical school, to curb the attitude that ordering tests to rule out even the most remote possibilities is best.
But patients’ own expectations also come into play.
Doctors often want to please them and don’t have the time to explain why procedures are not necessary, says Choosing Wisely chair Levinson.
“I think we live in a culture where more is better. Bigger cars. Big houses,” she says.
“Choosing Wisely is really about the conversation and trying to help patients understand the key message that more is not always better.”
One of a series of stories.
May Warren is a breaking news reporter based in Toronto. Follow her on Twitter: @maywarren11