Canadian governments have moved decisively to cut waiting times for key medical procedures, resulting in shorter queues for patients who need a hip replacement or a cataract removed. But the ambitious strategy has also had the unintended consequence of enriching many doctors who specialize in cataract surgery.
A decade ago, just 10 doctors in Ontario billed taxpayers more than $1-million. That number swelled to 259 doctors who charged the Ontario Health Insurance Plan $1-million or more in the fiscal year ending March 31, 2009, including a disproportionately large number of ophthalmologists, according to information obtained under the Freedom of Information and Protection of Privacy Act.
One out of every five doctors in Ontario who made the list was an ophthalmologist, the documents show. In British Columbia, 10 of the dozen doctors whose billings exceeded $1.5-million last year were ophthalmologists.
Thousands of Canadians have reaped the benefits of former prime minister Paul Martin's pledge in 2004 to fix health care for a generation by injecting an additional $18-billion into the country's medicare system. But such a bold policy shift has bred tensions between the costs associated with tackling waiting times and sustaining a health-care system that, left unchecked, is poised to reach between 70 and 80 per cent of total program spending in Canada.
In Ontario, the growing ranks of the $1-million-plus club reveal that the McGuinty government has solved one problem and created another. Health-care experts say the fee structure for doctors has not kept pace with technological advances that have reduced cataract surgery time by more than half over the past two decades.
But the reality is the wait-time strategy never would have succeeded without incentives for doctors to perform more surgeries, said Brian McFarlane, chief executive officer of the Kensington Eye Institute in Toronto, the province's largest cataract surgery centre.
"They weren't going to work for nothing," Mr. McFarlane said in an interview on Wednesday.
As an incentive for specialists to work longer hours to reduce lengthy waiting times for patients, the Ontario government ended caps on billing that had been in place since the early 1990s. Revelations about the top OHIP billers come at an awkward time for Premier Dalton McGuinty. His Liberal government is calling on labour leaders to impose wage freezes for two years on nurses, doctors, teachers and other public-sector workers who bargain collectively.
Ontario Health Minister Deb Matthews said the government plans to honour the fee schedule for doctors under their current contract. But once the contract expires in March of 2012, she added, the government expects doctors to help the province find cost savings and reduce its $19.3-billion deficit.
"Clearly, it is very concerning that the number of doctors billing over a million has risen pretty substantially," Ms. Matthews said in an interview. "We have to do a lot better when it comes to getting the best value for our health-care dollars."
A similar pattern is evident in British Columbia, which publishes doctors' names and annual billings. Two ophthalmologists in the province topped the list last year with billings of just over $2-million. In all, 56 doctors in British Columbia had billings of $1-million or more.
The billings do not represent a doctor's take-home pay. On average, 40 per cent of billings pay for overhead expenses, such as office rent and salaries.
Health-care experts said the Ontario governments need to adjust the fee schedule for doctors to take into account technological advances in cataract surgery that allow ophthalmologists to substantially increase their volumes. Without change, there will be inequities in the system, with one group of specialists making much more money than others, said former Ontario deputy health minister Michael Decter.
Doctors bill an average of $178,000 a year, according to the Ontario Medical Association.
Shaun Singer, an ophthalmologist at the Kensington Eye Institute, said it takes 20 minutes on average to remove a cloudy lens from a patient's eye and replace it with a plastic one, but he has done a cataract surgery in as little as four minutes. The same operation took an hour when he began his career 26 years ago, he said.
Since that time, however, fees have gone up. Doctors bill OHIP $388.30 for extracting a cataract (the fee does not include consultations, diagnostic testing or follow-up visits), according to the Ministry of Health. In 1986, the fee was $340.70.
The Kensington clinic can take credit for making a big dent in the waiting list for cataract surgery. Since opening its doors in January, 2006, it has done 32,000 cataract surgeries. The clinic receives annual funding of about $5-million from the Ontario government, which covers operating costs for 6,700 surgeries, but it has the capacity to do 11,000 procedures a year, Mr. McFarlane said. He plans to ask the government for additional funding.
Jeff Turnbull, president of the Canadian Medical Association, said addressing scarce health-care resources is a top priority for him.
"I think there's a need for us to have alignment throughout our health-care system to ensure that the right type of activities are rewarded appropriately and that we don't have perverse incentives or disincentives," Dr. Turnbull said in an interview.