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Disclosing Physician Billings Tells An Utterly Incomplete Story

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When it comes to disclosure of physician billings, everyone has an opinion: nurses, patient advocates, politicians, even journalists.

Proponents say disclosure creates transparency and social accountability. They point to the Sunshine List: Ontario's catalog of public sector salaries. Its intent: show fiscal responsibility with taxpayer money. The result: without context, the listings are meaningless and serve to increase cost rather than responsibility.

Liberal MPP salaries, for example, sit smugly on the Sunshine List. Yet somehow, the Liberal party's scandals pile up. OPP investigations pile up. And a party elected on a platform of transparency and accountability hides its books from the Financial Accountability Office.

I believe the public should know how taxes are spent. More importantly, the public should know their money is wisely spent. With physician billings, though, I think we're chasing the wrong number.

Billings do not reveal how comprehensive a physician's knowledge is, how skilled their hands are, how empathetic their manner is, how patient-centred their practice is.

Billings are a crude, misleading measure of value for money. As one data point in the frustratingly complicated mess that is physician payment, billings totally miss the mark. Billings are but one chapter in a 500-page novel; in isolation, they cannot and do not tell the story we need to hear. Billings do not capture patients served, hours worked, services rendered, training and education, debt load, professional overhead, professional fees and so on. Billings do not reveal how comprehensive a physician's knowledge is, how skilled their hands are, how empathetic their manner is, how patient-centred their practice is. Billings do not even convey physician income.

British Columbia's Blue Book exemplifies the misguided emphasis on physician billings. For an insider's perspective, I contacted front-line B.C. doctors over various online forums. Shockingly, many stated the billings listed are factually incorrect! Others felt disclosure undermined the doctor-patient relationship with some patients censuring physicians for being "overpaid." Some small-town physicians faced criticism from random strangers. A few even observed that disclosure bred jealousy among colleagues. This is why B.C.'s list is known as the Blue Book of Envy and Resentment. Ironically, one physician asked, "Surely there's a cost to running such a useless list. Is this money well-spent?"

Despite this, provincial governments are jumping on a bandwagon merrily heading nowhere. Instead of improving the status quo, Ontario is following suit.

Last week, Ontario's privacy commissioner allowed reporter Theresa Boyle access to the top 100 physician billings from 2008-2012. A surprising departure from decades of usual practice, his decision was questioned by the past privacy commissioner.

Publishing the top 100 billings is even more worthless than publishing all physician billings. This group represents 0.003 per cent of Ontario's physicians. By what logic does a subset of less than one per cent of a group typify the average? Might as well extrapolate average Ontario household income from the top 100.

Boyle's goal seems to be shock value. She could have requested the middle 100, or even a random 100. Instead, she targeted the high earners. Not surprisingly, Boyle's lurid headlines will distract and detract from a necessary conversation on fiscal responsibility, transparency and accountability.

Spotlighting these top earners will likely weaken public sympathy toward doctors in the contract dispute against the Liberals. So this inquisition into high billers smacks of political warmongering. Given the timing, I wonder: is this prelude to another fee cut? Distraction from the real danger of ballooning waitlists, dying patients and bureaucratic overload? Or an effort to shame and silence physicians?

Because physicians are paid per service rendered, the only way to rein in billings is to provide fewer services.

Disclosure without context punishes physicians rather than informing the public.

Chasing the wrong metric has unintended, sometimes devastating consequences. Case in point: U.K. heart surgeons forced to publish individual surgical mortality rates. The intent: transparency and accountability. The result: surgeons avoided operating on frail, complex patients.

Sicker patients going under the knife are more likely to die; they also reap greater benefit from an inherently risky surgery. Surgeons must inspire trust to do their job; publishing mortality rates without context eroded that trust. By trying to make their numbers "acceptable," everyone suffered. If they had been allowed to follow best practice rather than government policy, the surgeons would have served -- and saved --more patients.

"Sometimes the price of transparency is unacceptable."

I know some of Ontario's top-earning doctors; thousands of patients benefit from their intense work ethic, the factor driving their billings up. In any other profession, workers who demonstrate extraordinary productivity are recognized and admired. Here, they are vilified.

This high-biller debacle is a manufactured crisis. In 2005, the Ministry of Health demanded that specialists work more to reduce wait times as part of a provincial strategy. What will happen when specialists are criticized for working "too much?" Waitlists are reduced by helping patients -- not by penalizing doctors.

The unintended consequences of outing these physicians will be devastating -- for patients. Because physicians are paid per service rendered, the only way to rein in billings is to provide fewer services. What if the top-earners comply -- and cap their hours to become normal?

What if they don't inject a father's eyes for macular degeneration to prevent blindness?

What if they don't read the MRI for breast cancer in the 30-year-old mom of three?

What if they don't fix the broken hip in the 90-year-old woman suffering in pain and disability?

What if they don't manage the child with congenital heart disease?

Physicians serve individuals and communities -- that crucial element of the story is entirely missed by billings.

If, after all this, the public still has a compelling interest in billings, let's do one better. Rather than pretending, let's strive for actual transparency and accountability. Although it's more complicated, it's also more useful. List patients served, hours worked, services offered, overhead expenses, professional fees, debt load, total billing and taxable income -- for ALL physicians. Don't mislead the public by just publishing the top 100.

Unfortunately, I suspect our government will cop out and just publish billings. By marginalizing and maligning the hardest-working among physicians, Ontario's health care will regress to the 1990s when thousands of doctors were driven away by a short-sighted government's smear campaign.

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