Some 518 Ontario doctors received more than $1 million in fee-for-service payments from the Ontario Health Insurance Plan in 2017-18, a new Star database on physician billings shows.
They are among 30,167 physicians whose names, medical specialties and OHIP payments are contained in the searchable database, which can be found on thestar.com. In total, Ontario’s doctors received $7.3 billion in fee-for-service payments from the taxpayer-funded health insurance plan.
The Star’s database shows that of those who billed more than $1 million, 158 were diagnostic radiologists, 96 were ophthalmologists, and 64 were cardiologists. Of 61 family doctors and general practitioners on the list, many work in pain clinics.
Another 482 family doctors and general practitioners — many also practising pain medicine — billed between $500,000 and $1 million.
Fee-for-service payments are not the same as take-home pay, because doctors pay for their own overhead expenses — staff salaries, offices, equipment and supplies — out of their OHIP billings.
The database reveals big gaps in pay for different specialty groups. For example, ophthalmologists make on average $724,183 in fee-for-service payments while psychiatrists make $227,479.
It also reveals big gaps in pay with specialty groups. For example, the 90th percentile pay for diagnostic radiologists is $1,096,541 while the median pay is $622,281.
The database lists payments that doctors can claim for more than 7,000 publicly insured services contained in the OHIP schedule of benefits. Claims are made largely on the honour system.
Some Ontario physicians are not included in the database because they are not paid on a fee-for-service basis. For example, some specialists who work in emergency departments, academic health science centres, long-term care homes and on-call in hospitals are paid fixed rates. Many family doctors work in primary care group practices which can see them paid a set amount for each patient enrolled in their practices.
The Star is able to share this database following a five-year quest for public access to the billing records. After the province’s health ministry denied a freedom-of-information (FOI) request for data on top billers in 2014, the Star successfully appealed to the office of the Information and Privacy Commissioner.
Under a reinterpretation of Ontario’s Freedom of Information and Protection of Privacy Act, the commission found that doctors’ billings are business information. The ruling was subsequently upheld by the Ontario Divisional Court and Court of Appeal for Ontario.
In April’s budget, the provincial government announced it would make billings public, much as it does with the annual Sunshine List of civil servants who make more than $100,000. Enabling legislation expected before Christmas will also allow for tougher audits of OHIP claims.
Ontario Privacy Commissioner Brian Beamish says public disclosure of billings will help ensure accountability for spending of public funds.
“Taxpayers have a right to know how government is spending their money,” Beamish said. “The health sector is such a large portion of provincial spending and OHIP is such a large portion of that.”
Transparency of billings can help taxpayers determine if they are getting good value for money, he added.
By getting access to billing data, the Star was able to raise questions in a previous investigation about Chatham ophthalmologist Christopher Anjema, who received $4,094,230 in OHIP payments in 2017-18.
The data showed he billed for a rare procedure — involving reconstruction of the eyelid — at a frequency that an expert said is medically impossible. The College of Physicians and Surgeons of Ontario subsequently charged Anjema with professional misconduct, alleging he was incompetent in his care of patients and inappropriately billed OHIP. He is to appear before a disciplinary tribunal of the College of Physicians and Surgeons of Ontario. Earlier he resigned from his post as head of ophthalmology at the Chatham-Kent Health Alliance.
For decades, the province’s doctors have struggled with the issue of fairness in pay. Disparities in pay between different specialty groups — an issue known as “relativity” — have grown, in part because technology has allowed some to work faster and bill more.
Last year, an internal OMA report obtained by the Star showed that the highest billing specialties are overpaid to the tune of 52 per cent and the lowest billing ones are underpaid by about 30 per cent. It called for pay cuts to the highest paid specialties and top-ups to the lowest paid ones.
Cardiologist Dr. Sacha Bhatia, the chief medical innovation officer at Women’s College Hospital, said transparency can help not only in shedding light on pay disparities between specialties, but also within them. This “gap within the gap” can be significant, particularly among the highest paid specialties, he noted.
“Why does one radiologist make two times what another radiologist makes?” he asked. “Is it because some doctors are working harder than others, or is it because the practice style of certain doctors is different than others?
“And that leads to the really important question: what is the value we are getting for the money we are paying? If one doctor is making double what another makes, are we getting double the value?”
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Bhatia said there are specialists who make more than $1 million and earn every cent of it. He gave the example of a psychiatrist who sees a large volume of patients in an underserviced part of northern Ontario.
“You’re billing a lot, but you are providing critical services and keeping people out of hospital. God bless you, man,” he said.
“They’re working really hard, and, to be honest, we shouldn’t encourage that. We should give them help,” Bhatia added. “But we shouldn’t vilify them because they are making a lot of money working six, often seven days a week.”
Regarding pay gaps within a specialty, Bhatia said it’s helpful to look at the 90th percentile of total payments to doctors in that area. For example, 90 per cent of ophthalmologists were paid less than $1.37 million in 2017-18. The other 10 per cent received more — including the province’s top biller, who made $5.4 million.
“Sometimes there is a two or threefold difference within the specialty. How one explains that is difficult,” Bhatia said.
Bhatia said more research is needed to get a better understanding of pay gaps within specialties. “We know there is a lot of unexplained variation in billing, some of which adds value and some of which doesn’t, and we’ve never really looked at that before.”
High-value services are medically necessary and result in better patient outcomes, Bhatia explained, whereas low-value services — such as unnecessary diagnostic testing — are “potentially driven by economic incentives.”
“It gets down to the fundamental question, why is there such a wide gap between how much one doctor is paid and how much another is paid? To have a sustainable, high-functioning system, we need to ask the question, which we really haven’t asked until now.”
The OMA supports parts of the legislation that would see the government publish all forms of compensation to doctors annually (although it also opposes the bill’s provision for tougher audits).
But the OMA has not always been in favour of public disclosure. In 2014, when the Star filed an FOI for names and payments to top billers, the organization objected on the basis that such disclosure would be “misleading,” because the public might not understand that billings are not the same as salaries.
OMA president Dr. Sohail Gandhi declined to be interviewed for this story.
Beamish said he is pleased the government is moving ahead with proactive disclosure, and that “the FOI process was a catalyst for getting this done.”
Other jurisdictions already make publicly funded, physician-identified billings public, he said, referring to British Columbia, Manitoba, New Brunswick and the United States.
When there is greater transparency, potential problems can self-correct, he said, explaining that people are apt to be more careful in filing expenses that can be publicly viewed.
Dr. Rick Glazier, a scientist at ICES (the research institute formerly known as the Institute for Clinical Evaluative Sciences) who has studied physician compensation, is also pleased to see more transparency.
But he cautioned that total billings reveal only so much. They do not detail how hard doctors work, how many days a week they work, how many patients they see, what the value of their service is or what their take-home pay is, he noted.
“Transparency is important, but there can be nuance in interpretation and that can be challenging,” he said.
One in a series of stories.