CMAJ has two articles on MEDICAL NECESSITY. A problem since the 1980s when OHIP fined Doctors for referrals to specialists & investigations above the statistical norm for the area. The problem of MEDICAL NECESSITY was also brought before the Hon.Justice de Carteret CORY inquiry about the Ontario College of Physicians & Surgeons (CPSO) Medical Review Committee (MRC) that had no fixed policy about Medical Necessity. As a result the MRC was dissolved. The Chairmen were community GPs; e.g. Stanley.BAIN , Barnett GIBLON & Sandy SHULMAN. The MRC Inquiry was the result of a Legislative Assembly question by NDP MPP Lawyer Peter KORMOS. after the 2003 drowning suicide of the sole Welland Paediatrician Dr.Anthony HSU (57y) who was fined $108,000 by the MRC for not writing enough
Gentle
Dr. Hsu and the audit that haunted him
Christie
Blatchford -
Wednesday,
October 27, 2004
TORONTO -- For about 15 minutes yesterday
morning, the widow Irene Hsu sat directly across a boardroom table from retired
Supreme Court Justice Peter Cory and wept behind her big sunglasses.
Mrs. Hsu was there to tell the judge, who is
in charge of reforming Ontario's much-maligned system of auditing doctors, how
that system drove her husband, who drowned himself in April last year, to his
death.
"Justice Cory," she said in a voice
quivering with emotion, "my husband did nothing wrong. The only thing he
did was devote too much of himself to his patients" such that his
record-keeping suffered.
"He was punished for his abbreviated
notes," Mrs. Hsu cried, notes she said he kept to the brief essentials
because as a frenetic pediatrician in the doctor-starved city of Welland,
something had to give in his practice, and he chose his young patients over
paperwork. The body of 57-year-old Anthony Hsu, by all accounts a dedicated
doctor and gentle father of three, was pulled from Lake Ontario on April 10
last year, almost a week after he had gone missing.
Audited by the now-suspended Medical Review
Committee, which is an agency of the Ontario government administered by a committee
of the College of Physicians and Surgeons of Ontario, Dr. Hsu had cashed in his
RRSPs in order to repay $108,000 for services that were allegedly incompletely
detailed in his billings.
"He felt the audit had tainted his
name," Mrs. Hsu told Judge Cory through her tears.
According to Mrs. Hsu and others who have
appeared at the hearings in downtown Toronto, at the heart of her husband's and
many other physicians' alleged irregularities was one of the complex, vague
billing codes contained in the Schedule of Benefits.
This is the billing bible for doctors, so
impenetrable that Judge Cory yesterday said, of his own reading of it, "I
thought I might never surface again."
The judge flatly termed it "an awful
mishmash" and "the root of all evil," meaning that many of the
problems he has heard about here in two days stem from the incomprehensible
document that governs how physicians should bill for their services and how
they are paid.
Dr. Hsu, for instance, had billed for general
assessments, yet the MRC found that because his examination didn't include an
examination of all the body's "parts and systems," as required by the
Schedule of Benefits, he should have billed instead for less expensive
"intermediate assessments." Part of his repayment order was to make
up the difference between the two.
Another doctor, London pediatric
respirologist Brian Lyttle, was similarly ordered to repay the Ontario Health
Insurance Plan for his failure to conduct "rectal/gynecological
assessments" on his young patients as part of his general examinations.
But Dr. Lyttle appealed the MRC decision to
the Health Services Appeal Review Board, which found that the MRC's
interpretation was wrong and ordered Dr. Lyttle to be reimbursed in full.
As another pediatrician, Albert Cannitelli of
Woodbridge, yesterday told Judge Cory, referring to the Lyttle case, "You
bring your four-year-old child to me for a cough and I do a rectal exam"
and he would be hauled before the college's disciplinary committee for
professional misconduct.
In Dr. Cannitelli's case, he said, he was
flagged by OHIP because he saw more patients than the provincial average;
because his average cost per patient was slightly higher; and because, on three
particular days, he saw a very high number of patients and did a high number of
the troublesome general assessments.
Yet the explanations were there, he said, had
the MRC paid attention: His practice is heavily weighted to newborns and
youngsters under four, who require more first-time complete exams; he had
recently joined a much busier practice in Woodbridge, and on the three
particular days, his partner was off -- and Dr. Cannitelli had also seen his
patients.
Ironically, about the same time, he was
subject to a routine "peer review" and received an excellent rating. Yet,
almost four years after his MRC audit began, and without having actually
formally appeared before the committee yet, Dr. Cannitelli is facing a bill of
as much as $200,000, including a repayment order, interest and legal fees for
his own lawyer.
Even college president Barry Adams, registrar
Rocco Gerace, and Rachel Edney, the current chair of the embattled MRC -- all
of whom appeared before Judge Cory yesterday on behalf of the college -- agreed
that the audit system is perceived as unfair, secretive and unjust by many
doctors and has lost the confidence of the profession.
As the three were discussing a problem of
"perception," Judge Cory quickly added a clarification. "The
perception, and in some cases the reality," he said, "is that doctors
have been mistreated and abused" by the MRC.
Because the MRC is bound by confidentiality
rules, its members can't comment on specific cases, but outside the hearing
room, Dr. Edney yesterday disputed how the MRC has been painted here.
"I don't think the system is truly
unfair or unjust," she said, adding that contrary to claims by some
doctors, the MRC always gives written reasons for its decisions, and physicians
who are audited always know the allegations against them.
But she agreed the hearings aren't
transcribed and all three from the college agreed that audits -- about 100 of
the province's approximately 23,000 doctors are audited every year -- should be
finished within a year at most.
Though some doctors have told Judge Cory that
the college shouldn't be part of whatever new system he designs, and suggested
it be a more independent body, perhaps even headed by a judge, Dr. Adams said
repeatedly the college should and could continue to administer the audits.
Outside the hearing, Dr. Gerace said it was
the college itself which, about 18 months ago, began the push for reform behind
the scenes, but that it was also statutorily bound to continue participating
even as the system's flaws became apparent.
Listening to the day's evidence -- except for
Cesar Garcia Pan, who gave his submission behind closed doors and who, The
Globe and Mail has learned, told Judge Cory about the suicide of another doctor
who was under the MRC microscope at the time -- was Mrs. Hsu.
In her late husband's quarter-century in
medicine, she told the judge yesterday, he had only ever taken a week off every
year, working long hours and every second or third weekend because he was so
devoted to his young patients.
When her grandchildren ask where their
grandpa is, Mrs. Hsu said she tells them, "He's gone on a very long
holiday, and we will see him again one day."
--
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