Ontario patients will have a harder time accessing house calls, urine pregnancy tests at doctors’ offices and ear-wax removals as the provincial government and physicians try to cut back on medically unnecessary procedures that would have cost the public system an estimated $83-million this year.
Patients with uncomplicated hip and knee pain may also find it more difficult to get an MRI or CT scan as part of an effort to reserve joint scans for those who truly need them.
The provincial government and the Ontario Medical Association (OMA), which represents doctors, unveiled a list of 11 changes to the Ontario Health Insurance Plan (OHIP) Thursday that are supposed to save money and protect patients from the risks that can come with tests and treatments they don’t need.
The cost-cutting effort was ordered by arbitrator William Kaplan who ended a long-running contract dispute between the Ontario government and OMA.
In February, an arbitration panel directed the parties to set up an “appropriateness working group” that was supposed to find $100-million in savings for the remainder of this fiscal year – or $120-million on an annual basis – and another $360-million for the following year.
“We have based our recommendations on evidence, on best practice and on consultations with experts,” said Paul Tenenbein, a neuro-anesthesiologist at Toronto Western Hospital and a representative of OMA.
“We have a shared goal on this committee of improving the quality of our health-care system.”
Dr. Tenenbein co-chaired the working group with North York General Hospital chief executive officer Joshua Tepper, who represented the ministry.
The initial list does not include any changes to OHIP coverage for deep sedation during colonoscopies, psychotherapy or nerve-block injections for chronic pain.
Those were three of the more controversial ideas floated in a Ministry of Health proposal to the arbitration panel that was leaked to the media in the spring.
Travis Kann, a spokesman for Health Minister Christine Elliott, said that he couldn’t speak to the working group’s future deliberations, but that “the government will only accept proposals that protect or enhance patient care.”
Interim Ontario Liberal leader John Fraser said: “The working group has identified the low-hanging fruit. The bigger challenge is to come.”
Most of the changes unveiled Thursday would see OHIP decline to pay physicians for providing certain services unless there is an urgent medical need to deviate from the new normal.
For example, OHIP will continue to pay doctors to administer blood tests to determine pregnancy, but it will not insure urine dipstick tests unless “there is an immediate need to determine pregnancy to prevent imminent harm to the patient.”
Other changes to OHIP announced Thursday include:
- Avoiding unnecessary X-rays to diagnose sinus problems, for an estimated annual savings of $1.99-million;
- Halting the funding of loop recorders, which the appropriateness working group describes as “an older and outdated form of technology used to evaluate cardiac electrical activity in out-patients,” for a savings of $8.52-million;
- Ending a rule that forced patients to get a repeat referral from their family physician to see a specialist they had recently seen for the same problem, for a savings of $6.6-million;
- Limiting public insurance for ear-wax removals to cases in which the wax buildup causes hearing loss or can’t be treated with over-the-counter remedies, for a savings of $2.6-million;
- Ending unnecessary preoperative “history and physical” assessments prior to surgery; for a savings of $6.16-million;
- And scrapping premiums paid to physicians who perform house calls, unless the patients are frail and elderly or housebound, for a savings of $18.5-million.
Two of the other changes deal with how the health-care system treats patients with run-of-the-mill knee and hip pain, usually caused by osteoarthritis.
The government has set up a provincewide system of new musculoskeletal rapid-access clinics where specially trained physiotherapists, nurses and doctors will evaluate patients and separate those who need an MRI or CT scan – and possibly surgery – from those who don’t.
The new approach is supposed to cut down on inappropriate scans, exposing fewer patients to needless radiation and speeding up access for people who would actually benefit from an MRI, while also saving more than $12-million a year on scans.
The appropriateness working group also agreed to stop insuring knee arthroscopies for most patients with arthritis.
Recent studies have shown that the procedure – which involves inserting a tiny camera into the knee joint and using surgical tools to try to correct the problem – is no better at relieving arthritic knee pain in the long term than physiotherapy and standard pain management.
Ending unnecessary knee arthroscopies for arthritis sufferers is one of more than 350 recommendations made by Choosing Wisely Canada, an education campaign that works with professional medical societies and patients to decrease the use of unnecessary medical services that don’t add value and could cause harm.
Choosing Wisely Canada and the Canadian Institute for Health Information released a study in 2017 that found Canadians are undergoing more than a million tests and treatments every year that they probably do not need.
Wendy Levinson, a professor of medicine at the University of Toronto and the chair of Choosing Wisely Canada, acknowledged that it can sometimes be tricky to convince patients that they don’t need certain tests or treatments.
The campaign guides doctors through those difficult conversations.
“Patients want to feel like you’ve listened, heard their particular circumstance and helped them make a good, informed decision,” Dr. Levinson said.
“If we pay attention, listen carefully and reassure patients, the vast majority of them will say, ‘Fine, if you don’t think I need it, that’s okay.’”
The budget for paying doctors in Ontario is set at $13.6-billion for 2019-20 or slightly more than 21 per cent of the province’s $63.5-billion health budget.