In a recent letter to some of his colleagues, Vancouver Island doctor Jesse Pewarchuk explained why he won't be helping any more gravely ill patients to end their lives, despite his fervent support for assisted death.
"It is my deep regret to inform you that I am no longer accepting referrals for Medical Assistance in Dying," the letter began. "Recent changes to the [Medical Services Plan] physician fee schedule have made MAID economically untenable and I unfortunately can no longer justify including it in my practice."
Dr. Pewarchuk, an internal medicine specialist in Victoria who has presided over 20 assisted deaths, took his name off the list of willing physicians last month after the body that sets doctors' pay in British Columbia approved new fees that he and some of his fellow providers say are so low they could chase away even the most committed physician supporters of assisted dying.
A year after the passage of Canada's medical-aid-in-dying law, concerns among doctors over how they are paid to administer assisted deaths – a new medical service that is unlike any other – are not limited to the West Coast. In Nova Scotia, nearly half of the billing claims submitted so far for medical-aid-in-dying are stuck in processing, with some physicians saying they have yet to be paid for any of their assisted-death cases. In two provinces, Ontario and Newfoundland and Labrador, there are still no specific billing codes for hastening the deaths of the seriously ill.
"The truth is, across the country, and most acutely in the Atlantic provinces and currently in British Columbia, it has become a crisis," said Stefanie Green, a Victoria doctor and the president of the Canadian Association of MAID Assessors and Providers (CAMAP).
"It's been a year that my members have been doing this work. It has been done in good faith with the [understanding] that health authorities and provinces will be doing their job and setting adequate fees for this work to go on. That hasn't happened in some locations."
Determining how doctors should be paid for assisted dying is a delicate question, one that is difficult to separate from larger conversations about physician compensation and patient access to assisted death.
"I know MAID is really stressful, but so is counselling a suicidal patient. So is doing bedside palliative-care planning," said Trina Larsen Soles, the president of Doctors of BC, the umbrella organization that represents physicians in the province. "The MAID fees are done in the same ways as the other ones and [if] we're going to argue about which part of our jobs are more stressful and whether all parts of our job are adequately compensated, that's a big discussion."
In B.C., the fight over assisted-dying fees has been simmering for months as officials worked behind the scenes to determine how doctors should be compensated for the two main components of the service: assessing patients to see if they meet the eligibility requirements of the new law and administering the lethal injections.
The chair of the Medical Services Commission, which manages B.C.'s public health-insurance plan, formally accepted the new fees on June 20. This came after the tariff committee, a joint fee-setting body that includes representatives from Doctors of BC, voted in favour of a MAID fee proposal crafted by the Society of General Practitioners of BC, which speaks for family doctors. Most MAID providers are family doctors.
The new rates will be reviewed in three to six months to see if they are discouraging otherwise willing physicians from helping patients to die, Dr. Larsen Soles added.
The local health authority that oversees Vancouver Island – which has one of the highest assisted-death rates in Canada – said two doctors have asked to be taken off the assisted-death provider list in the past three months, one citing the low fees, the other time constraints.
The overall list of physicians willing to provide aid in dying continued to climb, from 14 providers in March to 21 at the end of last month, according to a spokeswoman for Island Health.
Under the new fee schedule, B.C. physicians will now be paid $40 for every 15 minutes, up to a maximum of 90 minutes, to conduct the first of two eligibility assessments required by law. Each of the assessments has to be provided by a different clinician. That works out to $240, a significant increase from the $100.25 interim assessment fee that has been in place in B.C. since shortly after assisted death became legal.
For second assessments, the time is capped at 75 minutes.
In the case of providing an assisted death, the province has set a flat fee of $200, plus a home-visit fee of $113.15.
The new fee, which is an effective decrease from the interim rate, applies no matter how long a case takes and covers all aspects of the service: Prescribing the drugs, picking the drugs up from the pharmacy, spending time with patients and families explaining the procedure, obtaining final consent, administering the drugs and filing followup paperwork with the coroner's office.
By comparison, 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, $600 in New Brunswick, $499.80 in Quebec, $480 in Manitoba and $465.60 in Saskatchewan. If doctors in those same five provinces billed for two hours, they could still earn more than B.C.'s $313.15 in every province but Saskatchewan, though not by much.
In most circumstances, B.C. does not compensate doctors for travel, which has led four of the province's MAID providers to turn to a small charity, the Toronto-based Right to Die Society, for help.
Ruth von Fuchs, the society's president, said her organization has doled out $11,207.82 for four doctors to travel to help grievously ill patients end their lives in and around Vancouver Island.
Tanja Daws is one of those doctors. A Courtenay, B.C., family doctor who has presided over 23 assisted deaths, Dr. Daws said that after paying her office overhead, she is losing money providing medical aid in dying, especially when she travels.
In one instance, Dr. Daws tried to bill $440.15 for an assisted death on Quadra Island in March, which she documented as taking five hours and 37 minutes, including travel time. The Medical Services Plan rejected her claim nearly three months later in a June 19 letter that said Dr. Daws could only bill $157.71 for 75 minutes of work.
"I may have to close up shop, which will be absolutely horrific," Dr. Daws said.
Nova Scotia is the only province that has set permanent MAID fees lower than the new fees in British Columbia. The Atlantic province allows doctors to bill a maximum of two hours for providing an assisted death at a rate that tops out at $292.20.
Tim Holland, the president-elect of Doctors Nova Scotia, said most of the province's core group of seven MAID providers has yet to be paid in full for MAID assessments and provisions, largely because of a complicated billing issue that he believes the health authority is working to solve.
Dr. Holland said he has not been paid for any of the eight people he has helped to die. His bigger concern is that the delay in payments and the two-hour time limit are proving to be a "hindrance" to attracting more doctors, which in turn makes the services less readily available to patients who are suffering at the end of their lives.
"In my experience, it's never been less than two hours," Dr. Holland said of providing assisted deaths. "You're treating a family, not a patient."
Tracy Barron, a spokeswoman for the Nova Scotia Department of Health and Wellness, said by e-mail that of the 67 claims filed so far for assisted-death assessments and provisions, 35 have been paid and 32 are being assessed for payment.
"The new health-service codes were introduced in September, 2016. It's not unusual to have an adjustment period when new codes are introduced," she said, adding the department is working with physicians to understand any billing concerns.