For the first five months after assisted dying became legal in Canada, Victoria doctor Stefanie Green took no pay for helping patients to end their lives.
Neither did Tanja Daws, another Vancouver Island doctor who, like Dr. Green, was among the handful of British Columbian physicians who embraced the controversial new law at its outset this past summer, travelling to communities where no other doctors would assess patients for assisted-dying eligibility or administer lethal injections.
Both doctors refused to accept the interim rate at which British Columbia had decided to compensate doctors for providing medical-aid-in-dying (MAID) services, arguing the sums were so much lower than what they could earn doing routine office medicine that it would be difficult to keep accepting assisted-death referrals.
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In protest, Dr. Green and Dr. Daws billed at a higher rate – a rate B.C.'s Medical Services Plan kept rejecting – until the doctors relented and in November began to collect their back pay at the lower rate.
Both doctors and a third B.C. MAID provider, Jonathan Reggler, have decided to take their months-long dispute with the provincial government public because B.C. is now looking at preliminary research on a MAID fee that would be lower than the interim rate, and lower than the rates paid to MAID providers in several other provinces.
The fight in B.C. brings to the surface delicate questions about how Canadian doctors should be remunerated for a medical service that is unlike any other.
Assessing seriously ill patients and helping them to die is not as technically complex as brain or heart surgery, but neither is it as straightforward as diagnosing ear aches or performing checkups. Putting a dollar value on MAID is challenging, particularly at a time when provincial governments are trying to rein in what they spend on doctors. Supporters of assisted dying fear that if the permanent fees are set too low, eligible patients could struggle to find doctors willing to help them end their lives.
"If doctors and nurse practitioners aren't compensated fairly, this becomes a barrier to access," said Shanaaz Gokool, chief executive officer of the advocacy group Dying with Dignity Canada. "No one is going to get wealthy providing medical aid in dying, but everyone needs to be treated fairly – the person, the family members and the health-care providers."
In British Columbia, the government initially directed MAID providers to bill under existing fee codes for the two main components of the service: Assessing patients to see if they meet the criteria set out in the new federal law, and presiding over the death itself.
"In terms of emotion and responsibility, in terms of the sheer work involved and the time commitment, I don't think [providing assisted death] is ever routine or taken lightly," said Dr. Green, who has consulted on about 70 MAID cases and administered the lethal drugs to 26 people.
B.C.'s interim fee for a MAID assessment is a flat rate of $100.25, while the fee for MAID provision by family doctors is $125.74 per hour, up to a maximum of 3 1/2 hours.
The latter fee covers everything involved in helping a patient to die: prescribing the drugs, picking the drugs up from the pharmacy, spending time with patients and families explaining the procedure and obtaining final consent, administering the drugs and filing follow-up paperwork with the coroner's office, said Dr. Reggler, a family doctor based in Courtenay, a community on Vancouver Island.
Dr. Reggler, who has so far assessed 20 patients for MAID and helped eight die, said he could bill for two to three times more seeing patients in his office than he can for MAID – and those billings aren't net pay. Like most family doctors, he draws on his billings to pay rent, staff salaries and other overhead.
"Medically assisted death is something which, already, many physicians are anxious about," Dr. Reggler said. "They recognize that it involves very intense work, emotional work. They are not going to want to provide medically assisted deaths if they know that not only will they have to do work that is much more difficult than routine office work, but that they will be compensated very poorly for it."
Dr. Reggler, along with Dr. Daws and Dr. Green, was part of a group of eight MAID physicians who initially proposed higher fees to the government – the fees Drs. Daws and Green used in their protest billings – but which the government rejected while a working group hammered out permanent fees for MAID. (Dr. Reggler said he billed his MAID work under the interim codes.)
The working group on MAID fees was set up by the tariff committee, a joint fee-setting body made up of representatives from the province's Medical Services Plan and Doctors of BC, the umbrella organization that speaks for the province's physicians.
The tariff committee's MAID working group in turn asked the Society of General Practitioners of BC, which represents family doctors, to conduct research on possible permanent MAID fees – research that was presented orally at a meeting of the working group last Friday.
The numbers floated at the meeting included an increase for MAID assessments to $40 for every 15 minutes, up to 90 minutes. That works out to a maximum of $240, a significant bump from the interim flat fee of $100.25.
But for providing assisted death itself, the figure suggested was a $200 flat fee, plus a home-visit fee of $112.14 or a hospital-visit fee of $31.45, less than what doctors could bill under the interim fee structure if they spent three hours on a case.
Alan Ruddiman, the president of Doctors of BC, stressed in an e-mailed statement that the working group is only in the early stages of drafting a proposed fee schedule for MAID.
"This work is not yet complete," Dr. Ruddiman wrote. "Once the tariff committee receives the proposal from the working group it will seek agreement from both Doctors of BC and the Medical Services Plan (MSP)."
However, if the numbers floated last week are ultimately approved, B.C.'s fee for providing an assisted death could be among the country's lowest at a maximum of $312.14 for family doctors.
For the provision of an assisted death by a family doctor, Alberta pays $51.80 per 15 minutes; Quebec pays $41.65 for every 15 minutes; Manitoba pays $40 for every 15 minutes; and Saskatchewan pays $38.80 for every 15 minutes.
If a doctor spent three hours start-to-finish on an assisted death – excluding the formal eligibility assessment – he or she could bill $621.60 in Alberta, $499.80 in Quebec, $480 in Manitoba and $465.60 in Saskatchewan. If doctors in those same four provinces billed for two hours, they could still earn more than $312.14 in every province but Saskatchewan, though not by much.
Kristy Anderson, a spokeswoman for the B.C. Ministry of Health, said the ministry plans to review MAID fees once a formal proposal is presented to the tariff committee.