3 Nov 2012

MEDICAL NECESSITY: in Ontario NEVER DEFINED

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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