Health services valued at $83 million — ranging from outdated fertility tests to unnecessary earwax removal — are being delisted or restricted from OHIP coverage, the provincial government and a committee tasked with modernizing Ontario’s taxpayer-funded insurance plan have announced.

Coverage for a total of 11 services will be affected as part of a major update to the OHIP Schedule of Benefits aimed at freeing up money for higher-value physician services, increasing access to those services and cutting wait-lists, reporters were told at a technical briefing by the committee at the Bloor St. offices of the Ontario Medical Association on Thursday.

But the changes fall $37 million short of the $120 million in savings the committee, known as the “appropriateness working group,” had been mandated to make.

The working group was created in February following an order by an arbitration panel that resolved a contract dispute between the province and the OMA, which is essentially the doctors’ union.

The order gave the committee, led by two physicians, one from each organization, the mandate to “establish evidence-informed amendments to payments by eliminating or restricting inappropriate or overused physician services or physician payments.”

The working group was directed to “achieve a settlement,” with changes totalling $120 million, by May 1 this year. And it was ordered to reach a second settlement by Sept. 30 this year for an additional $360 million in changes to take effect next year.

If the committee cannot modernize the OHIP fee schedule as required, the arbitration board, chaired by veteran labour lawyer William Kaplan, will make the decisions, the order notes.

The committee’s co-chairs dodged questions about the dollar value of the changes, and reporters were directed to the health ministry for answers.

Travis Kann, director of communications for Health Minister Christine Elliott, confirmed both that the committee did, indeed, identify $120 million in savings, and that the government has so far accepted only $83 million worth of them.

“We have not rejected any of the proposals. We are currently accepting 11 that add up to $83 million,” he explained.

It is unclear what proposals the government has so far declined to accept.

It is also unclear who has the final say in making the changes — the government or the appropriateness working group.

The working group’s job is politically sensitive. Even though the OHIP updates it has identified are based on evidence, there will always be people who complain when coverage changes are made.

“We are not going to recommend changes that are not going to be in our patients’ best interests. We are not going to recommend changes that are going to decrease access to care,” said committee co-chair and OMA representative Dr. Paul Tenenbein.

“We have based our recommendations on evidence, on best practice, on consultations with experts, as well as a scan of the guidelines from other jurisdictions,” he added.

The arbitration process, which ended a four-plus year contact dispute, started in May 2018 under the previous Liberal government. Much of the discussions were devoted to addressing the issue of “appropriateness” of care.

As much as 30 per cent of medical services in Canada are thought to be unnecessary, according to Choosing Wisely Canada and the Canadian Institute of Health Information. Choosing Wisely Canada is part of an international education campaign aimed at having clinicians and patients talk about unnecessary tests, treatments and procedures.

The Star has highlighted problems with inappropriate care as part of a continuing series about physician compensation.

Asked why physicians have continued to provide the 11 delisted or restricted OHIP services even though evidence shows they are inappropriate, committee co-chair and provincial representative Dr. Joshua Tepper explained that medical knowledge and literature is constantly being updated and it can be difficult to keep up.

“Effective testing and treatment evolve as technology and knowledge improves,” said Tepper, who added that OHIP coverage should evolve in tandem. The changes will “ensure Ontarians have access to the most modern and effective tests and services.”

All money saved will remain in the physicians’ services budget of more than $12 billion and be used to fund higher-value services.

A senior government source earlier told The Star that nerve block injections for pain, psychotherapy and a form of very deep sedation for colonoscopies will continue to be covered by OHIP. Upon further questioning, the source said those services will not be touched “for now.”

During arbitration proceedings, government negotiators called for the three services to be reviewed for “appropriateness.”

The prospect that they may be restricted has led to some public opposition.

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The 11 OHIP coverage changes will take effect Oct. 1.

They include:

Eliminating unnecessary imaging of sinuses, for annual savings of $1.99 million: Imaging is not required to diagnose most sinus problems and x-rays of sinuses can needlessly expose patients to radiation. If imaging is required, CT scans and MRIs are more effective and will be prioritized. In 2017/18, 900 physicians ordered 120,252 images on 58,218 patients.

Reducing unnecessary CT and MRI imaging and surgical consultations for chronic hip and knee pain, for annual savings of $10 million: The latest research shows that such imaging is not useful unless a patient has a history or symptoms that point to serious causes for the pain. Such imaging does not influence the management of age-related joint degeneration.

Over the last two years, the province has created 60 “musculoskeletal rapid access clinics,” where specially trained physiotherapists, nurses or physicians can provide more appropriate treatments for such pain. This change will result in faster access to CT and MRI imaging for patients who need it and reduce exposure to needless radiation for others.

In 2017/18, 582,193 CT and MRI scans were done on hips and knees.

Updating criteria for outpatient cardiac monitoring and using more modern equipment, for annual savings of $23.27 million: In 2017/18, 605 physicians monitored the electrical activity of 46,000 patients’ hearts, using wearable devices known as loop recorders, an outdated form of technology that will no longer be funded. In the same year, 1,200 physicians billed OHIP for providing about one million cardiac holter monitoring services. There will be new technical requirements for these monitors which record heart rate and rhythm.

Decreasing how often patients must get referral letters from family doctors to see specialists, for savings of $6.6 million: Patients require such letters for initial visits, which specialists claim as “consultations” when billing OHIP. If specialists see the same patients again within a two-year period for the same problems, they should bill OHIP for “assessments,” which are valued at less than consultations. But sometimes, patients are asked to get new referral letters, allowing specialists to bill at the higher consultation rate.

In 2017/18, 146,000 patients received second full consultations by the same 9,200 specialists for the same problems within a two-year period.

Dropping coverage of post-coital testing of cervical mucous to diagnose infertility, for annual savings of $30,000: This test is outdated and no longer considered best practice. In 2017/18, about 1,500 patients were provided this test by 221 doctors.

Reducing coverage for removal of ear wax, for annual savings of $2.6 million: Many patients can use over-the-counter treatments to soften and remove earwax, without requiring medical intervention. Removal will be covered if it is causing hearing loss and over-the-counter treatment is unsuccessful or if immediate removal is needed to diagnose or treat other ear conditions. In 2017/18, almost 120,000 patients received ear wax removal services from 9,100 physicians.

Preventing unnecessary larynx (vocal cord) examinations, for annual savings of $0.67 million: Laryngoscopes are often performed at the same time that upper gastrointestinal tracts are examined even though there is no suspicion or evidence of vocal-cord problems. In 2017-18, 120 physicians performed these two examinations concurrently on almost 11,000 patients.

Reducing dipstick urine pregnancy tests, which provide less information than blood pregnancy tests, for an annual savings of $0.77 million: The two tests are often done together, creating unnecessary duplication. Dipstick tests will be insured only when there is an immediate need to determine pregnancy to prevent imminent harm to a patient. In 2017/18, almost 150,000 patients received urine pregnancy tests from about 6,100 physicians.

Eliminating nonmedically necessary preoperative assessments, for annual savings of $6.16 million: History and physical assessments are often requested by surgeons and performed by family doctors or specialists as an administrative requirement of hospitals, even though they are not necessary. Preoperative assessments are also carried out by surgeons and anesthesiologists, and these will continue to be covered. In 2017/18, preoperative assessments were performed by 1,200 physicians on 128,000 patients.

Reducing knee arthroscopy surgeries, for annual savings of $10 million: Research shows this kind of surgery is ineffective for many patients with arthritis. It would still be available for those with degenerative knee disease in specific circumstances such as when bone or cartilage is loose, causing significant functional problems that have persisted despite non-surgical treatments. Others could receive non-surgical treatment focused on pain management and physical therapy. In 2017/18, 20,500 patients received arthroscopic knee surgery from 405 doctors.

Eliminating special premiums for doctors who do house calls to patients who are not frail elderly or housebound and who can be seen in their doctor’s office, for annual savings of $18.5 million: Currently doctors are paid extra for all house calls, even to patients who are mobile. In 2017/18, home visits were made to 91,000 patients by 5,300 physicians.