He's Ontario's highest billing doctor: Narendra Armogan, an eye specialist with a bustling Mississauga practice, has charged the Ontario Health Insurance Plan an average of about $6 million a year, the Toronto Star can finally reveal.

Armogan billed OHIP more than $42 million since 2011 for providing services and treatment to his patients, according to Ministry of Health data.

His name and those of other high-billing doctors can now be shared publicly for the first time following the Star's successful five-year quest to pull back the veil of secrecy on physicians who receive the most from the public purse.

Seven years of ministry data obtained by the Star identifies 194 doctors out of the 31,500 across the province whose annual billings — from a high of around $6.9 million to a low of $1.4 million — placed them in the Top 100 at least once between 2011 and 2018. Nearly half are ophthalmologists or radiologists.

By comparison, the average ophthalmologist gets about $724,000 and the average family doctor, about $307,000, according to the most recent figures from the Canadian Institute for Health Information, an independent research organization.

The billings are not the doctors' take-home pay and do not take into account the often hefty overhead costs physicians pay for expenses like equipment, staff salaries and rent. These costs come out of their billings.

In this story, the first of a series examining the data, the Star is seeking greater transparency on how health-care dollars are spent in the province.

Armogan, who was the top-billing doctor every year except in the 2016-17 fiscal year when he ranked third, did not agree to an interview. In one of a series of emails to the Star, the ophthalmologist said he does not concern himself "with the ranking of physician incomes."

"What matters to me is the care I give to my patients," wrote Armogan, who operates out of OCC Eyecare, with its main clinic located in an industrial area near Pearson Airport. "I save sight."

Armogan said in his email his overhead expenses "include at least 50,000-plus square feet, over 70 staff and probably more equipment than any other practice in Canada."

He added his patients' approval ratings consistently exceed 95 per cent.

"With an aging population and ever-increasing demand for health care, all physicians need to not only work harder, but smarter and this is what we do," he wrote.

"I put in long hours, am passionate about my work and constantly striving to improve. In collaboration with outstanding colleagues and caring support staff, we have built an eye-care practice that we believe provides top-quality, patient-centred care and does so in a way that allows us to reduce wait times."

Of the 194 top-billing doctors in the ministry data, Armogan is one of about 180 currently licensed to practise. Two doctors have died since appearing in the top ranking and 11 have either resigned or had their licence revoked. The name of one doctor, who is independently fighting to stay anonymous, remains secret.

Most of the top billers, including Armogan, have no record of cautions or discipline with the College of Physicians and Surgeons — the regulatory body for Ontario doctors. There are some with histories of overbilling or professional misconduct.

In 2017, the college ruled that Kitchener anesthesiologist Kulbir Billing could practise chronic pain management only under supervision for a year, disciplining him for professional misconduct related to improper record keeping, sterilization and overbilling of a pain treatment called nerve blocks.

That same year he billed OHIP almost $3.5 million, making him the eighth highest biller. In late May, while still being investigated by the CPSO, Billing resigned, agreeing to never again practise in Ontario.

Stefan Konasiewicz, a neurosurgeon working at five private pain clinics in Greater Toronto and Hamilton, ranked second in 2017-18 with a total of about $4.6 million in billings to OHIP. Last year, he was featured in the Star's Medical Disorder investigation, which revealed how doctors criss-crossed the U.S.-Canada border while keeping their medical histories secret. It found Konasiewicz had been sued for malpractice in the U.S. at least 12 times following surgical mishaps that left patients severely injured or dead. Patients in at least three of the lawsuits received settlements totalling $1.3 million (U.S.).

Konasiewicz also faced disciplinary sanctions in three states, before returning to Canada to practise. Those disciplinary sanctions — in Minnesota, Wisconsin and Texas — were all imposed in response to a 2010 Minnesota medical board decision on what it concluded was the "unprofessional and unethical" treatment of four patients.

Chatham ophthalmologist Christopher Anjema, who billed about $4.1 million to OHIP in 2017-18, has been a top biller every year in the data provided by the ministry, ranking as low as sixth and as high as second. He is also the subject of a current investigation by the CPSO, which is examining his standard of practice. In the meantime, he's agreed that when he performs cosmetic blepharoplasty (surgery sometimes referred to as eye lift or eyelid tuck), he will only do it under the guidance of a clinical supervisor acceptable to the college.

Konasiewicz, Billing and Anjema did not respond to repeated requests for comment through letters and phone calls from the Star.

In publishing data about these doctors, the Star is revealing how tax dollars are spent and pressing for greater accountability in a cash-strapped health system. Physician compensation costs Ontario about $12 billion annually, and amounts to about 8 per cent of the entire provincial budget.

"You want to make sure that people who contract with the government are behaving in a way that's ethical, that they're not double billing, they're not doing unnecessary work," said Christine Van Geyn, Ontario director of the Canadian Taxpayers Federation.

"The majority of them in every field are behaving ethically. But of course you want to catch the people who aren't."

Ontario's Sunshine List makes public the names and salaries of public employees earning $100,000 a year or more. It includes some doctors, such as those who work in community health centres and for boards of health. But the majority of physicians are not on the list.

Michael Decter, who served as deputy minister of health during Bob Rae's NDP government in the early 1990s and has advised various governments on health care over three decades, doesn't see why something similar shouldn't exist for physician billings above a certain threshold.

"There is no reason that the public shouldn't know where their tax dollars are going," he says.

"We publish tens of thousands of names of people who get paid by government. Doctors get paid overwhelmingly by government. I don't know why they'd be exempt."

In April, the Ministry of Health said it was starting discussions with the Ontario Medical Association (OMA), which represents the political and economic interests of the province's doctors, about making all physician billings publicly available. This has required a legislative act in other provinces, but ministry spokesperson Mark Nesbitt said it does not require one in Ontario.

Brian Golden, the Sandra Rotman Chair in Health Sector Strategy at the University of Toronto and the University Health Network, said releasing a Sunshine List for doctors would be more about public "intrigue" than public interest.

He also thinks it could cause in-demand doctors in smaller communities to cut back on hours "if we get to the point where we start to embarrass physicians" with posted billings.

"There are physicians who work extreme hours because they are the only provider in their community," Golden says.

"I don't think we want them to cut their provision of health care because of this."

Dr. Sohail Gandhi, who recently became president of the OMA, did not agree to an interview with the Star. He said in an email that physicians are not government employees but independent contractors with small businesses.

Most doctors in the province — including all those in the ministry's Top 100 — get at least some of their compensation under a fee-for-service model, one of three ways they can be paid from OHIP. (They can also earn additional money both privately and publicly.)

Billing under the fee-for-service model is more common with specialists and less so with family doctors, and made up more than half — $6.7 billion — of all physician billings in 2017-18.

Under this model, doctors bill OHIP for each service they provide using a unique fee code.

This is done on the honour system.

There are more than 8,000 fee codes — for every procedure, test and consultation a physician can perform — contained in a public document called the OHIP Schedule of Benefits and Fees. Each fee code has its own unique number, price and description. They range from fee #E126, laser surgery for premature babies with an eye disease called Retinopathy of Prematurity ($1,245 for both eyes), on the high end, to fee #G005, a pregnancy test ($3.88), on the low end.

Fee codes are set through negotiations between the Ministry of Health and the OMA, and are supposed to take into account how difficult a procedure is and how long it takes to perform.

"The billings submitted by physicians to OHIP aren't salaries," Gandhi wrote in his email, "rather they are gross billings out of which each physician must pay all the overhead costs necessary to run their practice and provide patients with the care they need."

Overhead costs can include everything from salaries of professional and administrative staff, to office space and supplies, medical equipment and ongoing training.

In a 2018 decision to release the OHIP billings to the Star (and later appealed to the Supreme Court), the Ontario Court of Appeal noted that billings are business information, not personal data, and "not a reliable indicator of the individual's actual personal finances or income."

For example, Dr. Ron Linden, CEO and medical director of the Judy Dan Research and Treatment Centre in North York, and among the top 100 billers since 2011, estimates his overhead expenses amount to more than $1 million a year, almost half of his 2017-18 billings.

His clinic uses hyperbaric chambers to treat wounds. The treatment, which can help save limbs, requires the use of expensive equipment, as well as several staff, said Linden in an interview.

Linden, who has a spotless record with the CPSO, said he doesn't think physicians' billings should be made public.

"The problem is that the public will misunderstand it or misread it," he said, adding he thinks physicians could also be targeted by "local criminals."

According to a 2012 article in Healthcare Policy, a Canadian peer-reviewed journal, doctors self-reported average overhead ranging from 12.5 per cent in emergency medicine to 42.5 per cent in ophthalmology.

But, according to Eye Physicians and Surgeons of Ontario executive director Marcia Kim, overhead costs can be as much as 50 per cent for ophthalmologists, who specialize in diagnosis and treatment of eye disorders, as their equipment needs to be replaced as often as every five years.

It's hard to tell exactly how much physicians are spending on overhead. The ministry doesn't track these costs, spokesperson David Jensen said, as physicians are independent contractors.

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That's not the only place where oversight is lacking.

A 2016 report by Ontario's Auditor General called oversight of the physician billing system "weak," and found serious issues, including that the ministry doesn't even bother to go after a lot of doctors with questionable billings because it's too resource-intensive.

An internal Ministry of Health audit dug into questionable billings of the 12 top billing doctors that same year. The audit flagged concerns involving seven doctors over "upcoding," charging OHIP using fee codes for more expensive procedures, or charging for services that weren't provided.

But little has been done to improve the situation since a followup report came out in December 2018.

Gandhi said the OMA sees the current system as "structurally appropriate," but agrees that the audit system could be improved "through proper resource allocation, bilateral work between the Ministry and the OMA, and a comprehensive implementation" of recommendations from a 2005 report by Justice Peter Cory on Ontario's medical audit system. It suggested, among other things, that a new and independent board be responsible for audits, and the Schedule of Benefits be revised and interpreted flexibly.

Gandhi declined to comment on individual billings. But he said physician billings reflect the needs of the growing and aging population.

"As the demand for health-care services continues to increase, Ontario's doctors are responding and delivering the care Ontarians need. Their priority is to respond to the needs of patients, meaning treating and caring for more patients, not less."

These growing demands put pressure on negotiations between the province and the OMA for a new contract. After a four-year battle that went to binding arbitration, doctors finally got a new fee agreement in February, effective to March 2021.

A three-member board of arbitration rejected the province's request for a hard cap to be placed on the total amount physicians can bill the province annually, and eliminated unilateral fee cuts for all doctors. But it did call for a working group to eliminate $460-million worth of "inappropriate" medical services. That group is currently finalizing its work, according to the OMA.

Another hot-button issue during negotiations was the big pay gaps in medicine.

A September 2018 report from the OMA acknowledges "income relativity disparities" between specialists such as radiologists, ophthalmologists, cardiologists — known as the "Big Three" — and others such as infectious disease specialists, neurosurgeons and geriatric physicians.

Two months later, specialists from eight highly paid disciplines, including the "Big Three," voted to break away from the OMA, unhappy with the way the organization had been representing them in contract deliberations with the province.

The "Big Three" also made up a large part of two smaller groups of doctors who, along with the OMA, tried to block the Star's legal bid to get details of the top billers.

The next phase of arbitration, which the OMA is currently in the midst of, will look into how the pool of money for doctors is divided, and the gaps between different specialties. This controversial process is known as achieving relativity.

The list of the Top 15 billing doctors from 2011 to 2018 includes six ophthalmologists, two radiologists and three cardiologists. Two OB-GYNs, one anesthesiologist, who was working in a private pain clinic, and one internal medicine specialist make up the rest of the group.

The "Big Three" specialties have historically been highly paid because ophthalmology and cardiology involve a high volume of services, and big ticket items like complicated eye surgeries. Radiology procedures have a lower average fee code price, but a very high volume of services, according to the 2016 Auditor General Report.

Radiologists — doctors who specialize in diagnosing and treating patients using medical imaging such as X-rays, CT scans, and MRIs — have overheads of 70 per cent or higher, according to a written statement from the Ontario Association of Radiologists, in response to questions from the Star.

"Almost 50 per cent of our services are delivered after hours on a 24/7/365 basis," the association wrote, adding compensation reflects additional training, which takes a minimum of 10 years after undergrad.

Overhead costs for cardiologists, who diagnose and treat diseases and conditions of the cardiovascular system, are also "significant," added Tim Holman, executive director of the Ontario Association of Cardiologists, in an email.

This imbalance between specialtiesplays a part in a serious gender pay gap in the field, says Ivy Bourgeault, professor in the Telfer School of Management and the Institute of Population Health at the University of Ottawa.

Thirty-nine per cent of physicians in Ontario are women, according to the most recent figures from CIHI. But only nine of the 194 overall top billers are women — less than 5 per cent.

The fee codes for procedures are the same regardless of the gender of the person billing, Bourgeault notes. But procedural, task-based specialties like ophthalmology and cardiology are in general better paid than more cognitive specialties such as pediatrics or geriatrics.

Women as residents are channelled into the more cognitive, lower-paid areas "either implicitly or explicitly," she said, calling for a review of the fee codes from a pay-equity perspective.

"The more highly remunerative specialties have fewer women in them and in the more poorly remunerated specialties you have more women."

Gandhi responded that pay equity is an "important issue."

"The reasons for this are not completely clear and investigation into causes is the first step in addressing it," he added.

These kinds of discussions about health care spending have traditionally been behind closed doors.

But Kathleen Finlay,CEO and founder of the Toronto-based patient advocacy group, the Center for Patient Protection, believes more transparency in billings would contribute to public debate about where health-care dollars are going.

"Transparency helps to build the trust the system must have if it's going to meet the needs of patients and families," she wrote in an email. "And, to be honest, if we don't get a better handle on where all our health-care dollars go — and everyone is able to measure that return — the system at some point will become unsustainable."

First of a continuing series.

With files from Jesse McLean, Jacques Gallant, Toronto Star Library, Star staff

May Warren is a breaking news reporter based in Toronto. Follow her on Twitter: @maywarren11

Theresa Boyle is a Toronto-based reporter covering health. Follow her on Twitter: @theresaboyle