Ophthalmologists bill more than any other type of doctor in Ontario, but experts say there’s good reason.

Ministry of Health data obtained by the Star shows there is a disproportionately high number of eye doctors among the province’s top billers between the fiscal years 2011-12 and 2017-18. Three of the top 10 are ophthalmologists; nine of the top 20.

Of the 194 highest-billing doctors in the data, 54 are ophthalmologists who billed an average of $1.9 million per year. Billings don’t reflect take-home pay as doctors cover such overhead costs as office space, equipment and staff out of their totals.

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.

There are about 400 ophthalmologists in Ontario and, if you exclude the top 10, “you’ll find that the vast majority of ophthalmologists in the province, their billings are not as excessive as one would think,” said Dr. Sherif El-Defrawy, chair of the department of ophthalmology and vision sciences at the University of Toronto.

Still, ophthalmologists bill more per year than any other medical specialist, according to data from the Canadian Institute for Health Information.

In 2016-17, the average ophthalmologist in Ontario received $723,768 in gross billings. This is more than $80,000 higher on average than the second-ranked specialists, cardiovascular surgeons, who billed $639,432. The average doctor in Ontario billed $344,531.

“With a growing and aging population, there has been a significant increase in the need for ophthalmology services,” said Dr. Raj Rathee, chair of the Eye Physicians and Surgeons of Ontario, in a statement sent to the Star.

In the last decade, the population of Ontario has grown by about two million to reach 14.3 million while the number of ophthalmologists in the province has lagged behind, rising to 437 from 390, according to the Canadian Medical Association. That’s about 15 fewer doctors than needed to keep pace with the change in population. And as baby boomers age, there will be far more demand for procedures from ophthalmologists.

“The number of patient (appointments) over the past decade has increased by more than half a million. Ophthalmologists work on a fee-for-service payment model. Every billing submitted to OHIP represents a patient they examined, a test they interpreted or a procedure they performed,” Rathee said.

By way of comparison, Canada has proportionally about half the number of ophthalmologists as the United States, at 3.2 per 100,000 people north of the border and 5.9 south of it.

“What you’re seeing is a significant increase in demand for services with absolutely no change in human resources,” said El-Defrawy, who is also ophthalmologist-in-chief at the Kensington Health Eye Institute. “There is significantly more work done by fewer individuals who tend to work very hard and bill very, very high.”

As a result, ophthalmologists in Ontario are seeing more patients than ever before, requiring bigger clinics, more staff and longer hours.

“A high-demand ophthalmologist, such as the ones on the list (of top billers) can employ anywhere between 15 to 60 staff. These employees (which are paid for out of the physician’s gross OHIP billings) possess varying skill levels ranging from administrative to certified technicians,” Rathee said. “This highly efficient practice model ensures that the ophthalmologist is making the best use of their time, seeing many more patients than they could on their own.”

Read more from The Star’s Operation Transparency series:

They’re Ontario’s top-billing doctors, but for years their identities have been kept secret. Until now

Revealed: Ontario’s Top 10 highest-billing doctors

Oversight system for doctors’ OHIP billings slammed as ‘ineffective’

In the years they made the Top 100, the 54 top-billing ophthalmologists in Ontario each billed for an average of 13,194 patients — that’s more than 51 appointments per day worked. This volume of patients is made easier by advances in technology — but the equipment that makes this possible is very expensive.

“An ophthalmologist opening a new office will easily spend half a million dollars for one set of standard ophthalmic equipment which generally needs to be upgraded and/or replaced within five years,” Rathee said, adding these upfront costs do not include servicing and calibrating the precision instruments.

If five years sounds like a short life span for a $120,000 optical coherence tomography (OCT) machine, which creates images of the retina, it’s helpful to think of them like smartphones, El-Defrawy said.

“It’s not that your iPhone 2 isn’t working anymore. It’s just completely obsolete compared to the iPhone 8,” he said.

“If you look at an OCT machine — which we use daily — the technology over the last decade has improved immensely: The resolution is so much better, the measurements are so much more accurate.”

And these improvements mean patient outcomes are vastly improved. When removing cataracts a decade ago, 5 per cent of patients would still have to wear glasses after surgery, El-Defrawy said. With the new machinery, that number is now reduced to less than 1 per cent.

While these equipment costs can be shared among multiple ophthalmologists in a larger clinic, in a smaller community with only one ophthalmologist, they have to incur these costs alone. The average overhead costs for ophthalmologists is higher than all other specialties, at 42.5 per cent of billings, according to a 2012 paper in Healthcare Policy, a Canadian peer-reviewed journal.

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The overhead data in that paper was self-reported by doctors, which was necessary because no one tracks doctors’ overhead costs.

Advances in technology also mean there are new treatments for eye conditions that simply didn’t exist before, like intravitreal injections, which are used to treat blind spots and blurred vision caused by blood in the retina.

“We didn’t have a treatment for wet macular degeneration 20 years ago. Now we have a treatment that requires the patient to come into the office every month, be assessed, have diagnostic tests and then get treated,” El-Defrawy said.

“In the past, we saw these patients once a year, and we saw them just for an office visit,” he said.

The new treatment requires an office visit, an assessment and an injection, producing three separate billings, each falling under a different OHIP code.

“And now you’re billing those three codes every month,” he said.

Most of the 31,500 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.

The billing codes — how much OHIP pays a doctor for each test, consultation or procedure performed — are periodically revised to account for new technologies that speed things up. In the last six years, the OHIP fee schedule has been revised twice, reducing by 20 per cent the price ophthalmologists are allowed to bill on six basic procedures.

“Fees within the schedule are determined based on a variety of factors, which may include the scope and difficulty of the procedure and the skill, time and responsibility involved in performing the service,” said Ministry of Health spokesperson David Jensen.

But these revisions lag behind the reality on the ground, El-Defrawy said.

Ten years ago, an ophthalmologist would perform nine or 10 cataract surgeries in a day. Now, they can do 15, and some can even do up to 22, thanks to streamlined techniques and improved technology.

At the same time, the billing fee for cataract surgery has dropped by 25 per cent, from $534.45 to $397.75, so doctors can actually make less while doing more. But these reductions are subject to fierce debate.

“The fee schedule does need a bit of an overhaul,” El-Defrawy said. “The billing has been changed. But I don’t think it’s at the pace that may be as needed.”

Choosing Wisely, a global campaign by health professionals to reduce the number of unnecessary tests and procedures, asks doctors to submit lists of redundant treatments that “consume precious time and resources” but aren’t “supported by evidence.”

In Canada, more than 50 responses have been received from professional societies representing specialties ranging from oncology to dermatology. One of the few disciplines missing? Ophthalmologists.

Joel Baglole, media manager for the Ophthalmological Society of Canada, declined to comment.

One of an ongoing series of stories.