The provincial government plans to improve oversight of the Ontario Health Insurance Plan, Health Minister Christine Elliott says.

To be unveiled Wednesday as part of the fall economic statement, the OHIP overhaul would see proactive disclosure of physician billings and tougher audits, she told the Star in an exclusive interview Friday.

“It’s a lot of money that we are talking about and we owe it to the taxpayers of Ontario to ensure that those tax dollars are spent properly. We want to make sure that we have a system that is completely reliable and is going to be there for the people of Ontario whenever they need it,” she said.

The province spends $16 billion annually on OHIP. That amounts to 25 per cent of all health-care spending and about 10 per cent of the entire provincial budget.

From that, more than $12 billion goes into the physician services budget. The remainder pays for, among other things, out-of-country patient care, Telehealth, diagnostic clinics, and OHIP-funded dental surgeons and optometrists.

The new measures would see physician-identified OHIP payments posted online annually, much like the Sunshine List of public sector workers who make $100,000 and more. OHIP payments are not the equivalent of income as they do not take into account overhead expenses such as staff salaries and supplies.

Elliott said she expects that enabling legislation will be introduced imminently. If it is passed, billings could start to be posted in 2020-21.

“That is something the people of Ontario want to know about, they want to know where their health dollars are being spent and they want to make sure that they know who is receiving what. There is a lot of interest on the part of the public to have a health-care system that is open and transparent. Physicians’ billings are part of that,” she said.

The package of reforms is intended to give the government greater authority to prevent, investigate and direct recovery of unauthorized payments to doctors, according to a backgrounder on the changes.

Elliott said the changes will help ensure the sustainability of the system: “We want to make sure it is robust now and well into the future.”

Under the reforms, the province would no longer recognize the 320,000 old-style, red-and-white OHIP cards that are still in circulation, a move that could save more than $10 million annually. These cards have been in circulation for more than two decades, but in recent years have been replaced by photo ID health cards. Some of the old cards have fallen into the hands of people who are not eligible for OHIP coverage, Elliott noted.

In the new year, the government plans to send out letters to legitimate red-and-white cardholders, letting them know they have about six months to switch to the photo ID cards. If they don’t comply, they could end up being asked to pay out of pocket for care, Elliott warned.

“Eventually it may happen if people don’t make the switch, and if they do require hospitalization for example, the hospital bill will be in their personal names,” she said. “We are very serious about wanting people to switch to the new card.”

The government first announced the OHIP overhaul, including the commitment to billing transparency, in its April 11 budget.

The budget was tabled the same day the courts gave the green light for disclosure of billings, bringing to an end a successful five-year quest by the Star for public access to physician-identified OHIP data.

The Star filed a freedom-of-information request for doctor-identified billings in 2014, but the health ministry declined to release physician names, arguing that doing so would violate their personal privacy.

The Star successfully challenged that decision with the Information and Privacy Commissioner of Ontario, who ruled that physician-identified payments actually constitute business information, not personal information. The decision was significant because it marked a change in position for the privacy commission which, in previous cases, had deemed physician-identified billings to be personal.

Three physician groups, including the Ontario Medical Association (OMA, essentially the union for the 31,577 practising doctors it represents) attempted but failed to get the privacy commission’s decision quashed — first at the Ontario Divisional Court, then at the Court of Appeal for Ontario and finally at the Supreme Court of Canada. The Supreme Court announced in April it would not grant the doctors leave to appeal, bringing the legal challenges to an end.

After obtaining physician-identified claims information from the health ministry earlier this year, the Star posted online a database on the top 100 billers from 2011-12 to 2017-18. It is part of an ongoing series, titled Operation Transparency.

The doctors had argued in court that they were concerned the general public would assume billings and income were one in the same, not appreciating that doctors have overhead expenses, sometimes very large ones. They also argued that billings should be disclosed only through legislation, not a court order.

Throughout the court battles, the health ministry said it would abide by the final ruling. Following the Supreme Court’s decision, the government said it would work with the OMA in looking at proactive disclosure of billings.

The government backgrounder said the health ministry sought input from the OMA on the reforms and would continue to do so on the rollout. One area of particular importance is improved education.

“Education on OHIP billing, to help providers understand how to bill and how to correct billings, will continue to be improved upon as an important support for physicians and other providers in reducing payment errors or misunderstandings,” the backgrounder said.

Elliott explained that the oversight overhaul would start with education. Tougher audits would follow.

“We are starting with an education campaign to work with physicians because it was explained to us through the medical association that there is a lack of knowledge in some areas about what appropriate billing codes are. We want to work with Ontario’s doctors to ensure they are comfortable with the entire system,” she said.

“(Often) when mistakes are made, it is not done intentionally, so that is why we need the education process. But in other situations, we do need to be able to enforce the rules and make sure that the billings happen in the way they are supposed to,” she added.

Loading... Loading... Loading... Loading... Loading... Loading...

Additional OMA recommendations being incorporated into reforms include:

The establishment of a 1-800 support line for billing questions.

A commitment to complete audits within 12 months.

An assurance that in-person audits will be conducted or supported by practising physicians/peers within the same or similar specialty who have audit training.

The reforms would add more checks and balances to the process of issuing OHIP billing numbers, which enable doctors to bill the taxpayer-funded plan. Doctors who have committed fraud in any jurisdiction would not be issued an OHIP billing number. Currently, doctors can continue to bill OHIP even after being found guilty of OHIP fraud.

Similar enhanced oversight measures would apply to the almost 900 “independent health facilities” throughout the province, where doctors provide such services as diagnostic testing. These are mostly privately owned and operated, but OHIP-funded, clinics. To ensure greater accountability, there would be expanded grounds upon which operating licences could be suspended, revoked or refused.

Clinics would have to post online and on their premises the outcomes of inspections by the College of Physicians and Surgeons of Ontario (CPSO), the regulator of the medical profession. If problems were found that compromise patient safety, for example with infection control, the province would have new powers to shut the clinics down.

Other changes include:

Enhanced information sharing with the CPSO.

Merging of a number of appeal boards and committees that deal with OHIP payments and coverage. These include the Physician Payment Review Board, which adjudicates payment disputes. It has not been very active and is widely viewed as ineffectual. Also to be included in the merger is the Health Services Appeal and Review Board, which adjudicates disputes over OHIP coverage.

Increased efforts to ensure OHIP coverage is extended only to OHIP-eligible residents.

For years there have been calls for greater OHIP oversight.

Provincial Auditor Bonnie Lysyk called for this in her 2016 annual report in which she cited concerns about problematic OHIP claims made by top billers. She pointed out that the health ministry has had no inspector function since 2005 when the now-defunct Medical Review Committee was officially disbanded.

The Medical Review Committee conducted audits of physicians’ billings. It came under fire following the 2003 suicide drowning of a Welland pediatrician who was the subject of an audit. A subsequent review of the audit system, undertaken by former Supreme Court Justice Peter Cory, found it to be too rough on doctors.

The arbitration panel that resolved a protracted contract dispute between the government and OMA earlier this year also called for improved oversight. Panel chair William Kaplan wrote in the arbitration award report that there needs to be a “modernization and streamlining” of the process for auditing and recovering unauthorized payments for medically unnecessary services:

“That is a matter that is the immediate responsibility of government and it is one that needs to be promptly addressed.”