Extra fees for uninsured services

There are many problematic issues with this article, that it is hard to be concise:

1- Restaurants don't charge for expenses such as cutlery washing separately because they are already included in the bill. A bill they set themselves based on their analysis of their costs, and which they may change at any time as they see fit. MD's are basically stuck with our negotiated rates, which are not keeping up with inflation, and do not take into account regional variations in expenses, or many other factors. Charging for cutlery use, would be more like an MD office charging for use of latex gloves use, or cotton swabs - I have not heard of anyone doing this. On the other hand while restaurants do not 'explicitly' charge for cutlery, they certainly do for various extras, like cheese on a burger, or side order of something. Some of these may be pricy, such as a lobster tail on the side. Extra services and products are routinely charged in many businesses. Good luck getting 'free' parking at a restaurant in downtown Vancouver, and if it were 'free', how much would you like to bet your meal price got adjusted to compensate. Costs are never just magically 'absorbed'.

2- Not charging for 'no-show' visits? For medical reasons this is understandable (ex- patient went to e.r. instead of MD office as condition suddenly got worse). We use EMR, and started keeping track last year. 400 + no shows for 3 docs!!! (* this already excludes what we deemed valid reasons for no-show). Conservatively, that is about $4500 in billings per MD for the year. That no show fee, that is described as being 'a lot' for the patient, is starting to be 'a lot' for us too. More importantly - if that is typical of other offices, and multiplying this out by only half the 5500 family MDs in BC, that works out to about 730 000 visits, or about 3-4 visits for each of the ~ 200 000 unattached patients in BC. Anybody losing any sympathy for the no-show patients yet? There is no question the fee is a disincentive to missing appointments. We started posting missed appointments data (monthly counts) on a whiteboard in our reception area. The vast majority of patients have given expressed outrage over the severe degree to which other patients are missing appointments, and thereby delaying their own office visits, and given us overwhelming understanding and support

3- Charging for a fax prescription - actually the charge is for properly assessing the patient, which we routinely do in our office when we are asked to make a fax prescription. Sometimes a chart review is enough; sometimes we do a phone call with the patient to check on things. College of Physicians has been very clear about needing to have a complete and appropriate note in the chart. Compensation for this by MSP here is explicitly zero. Time spent on this - not zero.

4- "Many patients would say that physicians are being paid out of their taxes and should not be charging extra". Coverage of services is not determined by what patients 'say' is covered, but by our negotiated contract. It does not cover everything, so that creates costs that have to be covered somehow. I've had patients also 'say' that I should order certain tests that I think are inappropriate. Its abusive of the medical system if I order those tests for 'free' for the patient, and its abusive of us if we are expected to do a lot of other things for 'free' to the patient as well. Our 'free' time has value. Charging for non-essential, and uninsured services is both moral, and professional.

Conflict of Interest:

I charge for uninsured services exclusively for patients not in financial difficulty

The editorial, "Extra fees for uninsured services", seems to be a general attack on the profession that is uncalled for. Dr. Ladouceur is out of line in making assumptions and accusations that I view as unprofessional; certainly not something I would expect out of Canadian Family Physician.

I will not get into specific rebuttals at this point, but certainly this is a complex area that consumes much time, energy, and resources. An out of context left field editorial is not a place for a one-sided view of this subject matter.

My business is family medicine and like most others who share this profession, I work hard in this business of caring. Idealistic rhetoric with ignorance of day to day realities at a time when our governments continue to erode and devalue the work we do is not appreciated.

A Holier Than Thou sermon does not bode well here and an apology is requested.

Conflict of Interest:

None declared

When I read Roger Ladouceur's editorial, I felt a flush of resonance and strong emotion - because he's raised and issue dear to my heart, and which has dogged my clinical life for 4 decades.

Since beginning practice, I have struggled with charging individuals fees for so-called uninsured services, and have undercharged, or not charged at all, on the vast majority of occasions. I have never been able to look someone in the eye (or compelled my staff to do so) and tell them to pay a fixed sum for a service, knowing, for example, that their material life is dependent on a welfare cheque or other modest or even desperately meagre fixed income. Nor have I been able to charge a sum for a routine note that takes me 3 minutes to write, or a form for a student health clearance that requires only a signature, or any of a myriad of daily acts that occupy my professional days. I don't ever charge for sending records to other physicians because -- for heavens' sake! -- this is how continuity of care, that estimable prize of good clinical practice, is maintained.

In fact, when patients come in perplexed because they've received a bill for, say $30 to $50, from a physician they have seen 10 times and who has performed only perfunctory care for modest health issues, I encourage them to ignore it.

Subversive on my part?

I don't think so. I think it's realistic and honest. People in many jobs, especially on a fixed salary, do just as many routine tasks as we do, and the costs are folded into their overall wages. We physicians, handed fee-for-service earnings on a platter, have started to believe that every little thing we do is worth recompense.

Several commentators have said "medicine is a business", suggesting Dr. Ladouceur is naive. One even went so far as to claim that not charging reinforces patriarchy (quite a challenge for female practitioners, I suspect), as if absorbing the costs of uninsured services was somehow demeaning to patients. I would point out to her, and to many others, that charging extra for more and more things is a relatively new phenomenon, and more a reflection of a general corporatization of social mores (with a little help from Reaganomics and the World Bank's infamous policy of structural adjustment, where privatization is a god) than it is a reflection of our work.

In making comments like these, I fear we forget several critical aspects of what we do.

First, our earnings, for the most part, come not from our patients, but from the public purse. Most practitioners get most of their cash simply by filling in a form, or making a data entry, and behold! - the cheques are deposited in our accounts without fuss. We are paid from taxes paid by all citizens.

That means what we do is NOT A BUSINESS. That is a public service, delivered to us in this fashion because society has decided, in its collective (and increasingly eroded) wisdom, that what we do is essential enough to the well-being of others that we should receive automatic compensation for what we do. Lawyers don't get paid like that. Scientists in discipline after discipline don't get paid like that. Almost all of our patients don't get paid in that automatic, secure way.

Calling what we do a business, under those circumstances, is illogical and TRULY naive. If any practitioner feels otherwise, then read the business literature. It's all about profit, loss, layoffs, downsizing, efficiency, "trimming" the work force (i.e. firing or laying employees off) depending on market fluctuations, moving production overseas to cheaper and less regulated work environments etc.

Physicians, almost across the board, are insulated from all those business realities. But there's more. We can't be downsized (a few operative specialists can be in some measure, but only in part). We can live where we want, we can practice as much or as little as we want, we can focus our work on areas that interest us, we can organize our practices in the way we find most convenient.

And by and large, compared to Canadians in just about any other occupation, we cannot be fired for anything besides indecent, immoral or illegal behaviours. I would be the first to say that Colleges (the provincial ones that licence) can be a bit starchy in the way they deal with clinical outliers, especially those who branch out into non- pharmaceutical remedies, but that's another story.

Second, and derivative from the first point, we get these privileges because we call ourselves a self-regulated profession. SELF-REGULATED.

That means that what we do as doctors is assessed and judged and regulated, for the greatest part, by other doctors -- not by our patients, not by government regulators (they can control the fee schedule and infrastructure, but they don't assess our clinical behaviour). We guard this privilege of self-regulation with great fervor, unwilling to let anyone tell us how to actually practice. That's because we believe that the social contract that gives us this attribute is our right - but society acknowledge that RIGHT only if we exercise a parallel RESPONSIBILITY to act in the public good.

I have long contended that if we don't take seriously our responsibilities - and a few modest sacrifices - to act consistently in the direction of achieving a public good, then society will be inclined to withdraw our self-governing status, and turn what we do into just another job, with increasing restrictions, rules, and more of the standard employee vulnerabilities. Like other government employees, we will be told where to work, how to structure our clinical activities, what hours we can adopt, and if we will have to be let go because there are too many of us, and our services are not valuable enough to be affordable.

Finally, we can all charge for services that are uninsured, but who we charge for them is critical. Charging large and profitable enterprises like insurance companies, legal and other third party representatives whose fees are truly profit-oriented, or charging for a substantive effort (like a long letter in support of a patient's personal needs, sent to a social service agency) is and always has been acceptable. I am not a billing nihilist.

So....

Do I think we should charge for uninsured services? Yes, occasionally, and in concert with our fundamental principle of "primum, non nocere". Our actions in charging for services are not neutral, or without impact. To see what we do as being part of a "business model" is, however, in my opinion, to negate the principles under which we work, and at worst, represents simple opportunism.

Conflict of Interest:

None declared

The editorial in the May 2016 issue of Canadian Family Physician left me asking a lot of questions.

Who is Roger Ladouceur?

What planet does he live on?

Does he actually practice family medicine in a front-line setting?

Why does he presume to rebuke me: after 40 years as a provider of quality health care, 30 of those as a member of the CFPC, do I need to be told how to behave?

Let's keep this very simple: my income has been cut arbitrarily and unilaterally by the Ontario Ministry of Health and Long-Term Care--by 7%; my bill from Bell Canada just went up 10%. Now, please explain how medicine is NOT a business.

How can the CFPC permit such an offensive (and naive) article to appear in the publication that purports to serve Canadian family physicians?

Conflict of Interest:

None declared

I have charged extra fees for uninsured services over a period of 30 years in practice. My patients were advised of this policy at their introductory visit and given a copy of the fee schedule which was also posted in the office. I spent 60-90 minutes at the end of each practice day filling out forms and other patient related activities. I felt it was reasonable to be re-imbursed for the time spent on the forms.

My "motivation" to provide excellent patient care has not changed over time and I resent the comment that my "ideals" may have been replaced by "mercenary" concerns. Shaming family physicians is not and should not be the mandate of CFP.

Dr. Ladouceur's article has been published in the aftermath of an almost 7% cut in provincially funded fees to physicians in Ontario for patient services. Family physicians are struggling to run a business ( yes, a business!) in the face of these cuts as overhead costs increase annually. How do we balance this financial equation? Are we to bear the brunt of the loss as individuals running practices? Would I be interested in practising under these circumstances if I was a new family physician?

Perhaps the CFP Editorials should be peer reviewed by two external readers ( such as family physicians running a practice) in addition to the editorial staff, as would be expected of any other published article in the CFP. Now THAT would be a pulse on the business of family medicine in the trenches.

Conflict of Interest:

None declared

The CFP and Dr Ladouceur have a long history of bemoaning what has become of the "noble calling" of family medicine. They expect us to be selfless advocates for patients, and to ignore the fact that we have to run a small business, pay the rent, pay employees and try and maintain a worklife balance.

Newsflash to the CFP and other ivory tower doctors like Dr Ladouceur...medicine is a business. We are in the business of managing patients health, not selling widgets, but a business just the same. Your restaurant analogy is ridiculous and insulting.

It is the patients who lack respect for physicians, not the other way around. There is a significant percentage of patients who take doctors for granted. Because health care is "free", it has no value. They treat the providers as employees ("my taxes pay your salary !")

I unapologetically do charge patients for missed appointments. My time is valuable, and I provide patients with an explanatory letter with their invoice. I point out that their missed appointment could have been used by someone with more acute needs, if they had the simple courtesy of phoning ahead to cancel, instead of treating it like a dinner reservation, to borrow from Dr Ladouceur's stupid analogy.

I unapologetically charge patients for filling out forms. Again, these forms take my professional time to fill out, and I am entitled to be compensated for that. Should we advocate for few forms, or get the insurance companies to pay for them? Of course, but in the meantime, my overhead rolls on relentlessly.

Dr Ladouceur seems to long for a mythical golden age of dedicated selfless Marcus Welby type doctors who can do it all, and apparently for free. Medicine it too big and too complicated and messy for anyone to do it all.

The CCFP and Dr Ladouceur are out of touch with the real world of medicine. I am disgusted by this editorial.

Conflict of Interest:

None declared

Dr. Ladouceur's editorial is spot on. I write as a retired family physician with over forty years experience: it is not acceptable for physicians with six figure incomes to charge more than twice the minimum wage to patients for a sick note. Obviously physicians should be paid for what they do, but this is excessive as are many other fees which impose real hardship on some patients. I find it distressing to read the howls of protest from some colleagues who feel entitled to charge their patients excessive amounts. They would agree, 'To them that hath shall be given and to them that hath not shall be taken away even that which they hath.'

Conflict of Interest:

None declared

Dr. Ladouceur has described a practice that has become so common in medicine that it is rarely commented on -- charges for uninsured services related to healthcare, such as parking, sick notes, and other forms. Although a hardship for many, fees are now the norm. This is unfortunate, as research has made clear that fees create a barrier to healthcare, particularly for the most vulnerable. Although the services provided by a hospital or a family doctor may be covered by Medicare, the additional charges could deter those seeking care.

Family doctors are undoubtedly being asked to take on additional work, such as filling out forms, for which they are not compensated. Many doctors pay high fees for running their offices -- and they also likely waive fees for patients when asked. However, many patients likely suffer without asking -- or simply don't access care.

Medicare is publicly funded because healthcare is a collective benefit. When there are gaps in the system, the patient should not be made to fill them in with costs that may cause harm to their health. Instead, we can (1) advocate to do away with unnecessary requirements such as sick notes and some forms, and (2) seek ways to have uninsured services that are essential to patient health be included in our healthcare system.

Conflict of Interest:

None declared

I practice inner-city family medicine. A large proportion of my patients are low-income and the working poor. Not uncommonly, when a patient becomes ill, they lose a day (or more) of wages, and without paid sick days, risk losing even more income. For many of my patients barely making ends-meet, the double-burden of taking additional time off and having to pay for a sick note can be a financial burden to heavy to bear. It's not hard to see how the cost of a sick note and other seemingly minor charges can quickly add up to present a significant barrier to care. Dr. Ladouceur's editorial, while uncomfortable for many, myself included, is a welcome and thoughtful piece that challenges us all to think about the way we work.

Conflict of Interest:

None declared

In reading Dr Ladouceur's editorial, I sense that he is looking to highlight the extra billing that often creates a barrier to care for patients. Paying for expensive parking, sick notes, and the completion of forms can be financially out of reach for patients with limited financial means.

Some physicians who charge for uninsured services will forgo charging patients they know cannot afford the fee; however, many others are unaware of their patients' financial circumstances. Patients might not be comfortable telling their doctor that the $25 fee for a sick note required by their work will be the difference between them having food on the table or not.

An ideal system might remove the need for extra billing by banning the need for doctors' notes and explicitly covering the cost of medications dispensed in offices. Regardless, patients should not bear the brunt of an imperfect system.

I bill fee codes to OHIP where allowed and charge insurance companies for the forms they want me to fill out for them. Wherever possible, I do not charge individual patients as this creates two tiers of care and I'm not comfortable with that.

As doctors, we make a good living. There are overhead costs that need to be absorbed and those costs can be thought of as coming out of our fee codes. I would rather that physicians advocate for the elimination of needless services, such as sick notes, rather than attack a physician advocating for a level playing field for his patients.

Conflict of Interest:

None declared

As a youngish doctor of the often maligned generation, Dr. Ladouceur's articles often makes me feel like he is trying to shame us. The undertone always seems to be about altruism and how medicine is supposed to be a "calling" - a profession that accepts only those of the highest moral character.

At risk of making an unpopular statement, I would like to refute this outdated stance. I argue that raising the "altruism flag" is the war cry of the patriarch. It is the hat worn by people who believe that what they do is more important, meaningful, and therefore above what other people do. It's a short slide from there to believing that you yourself are above other people. Or that your decisions are always right because they are made in the name of "altruism".

There has been a lot of ugliness in medicine in the past that has resulted from this flawed thinking and patriarchal mindset. Not many people from my generation, neither doctor nor patient, believe in this model anymore. We don't believe that doctors are "above" other people in their moral standards. We believe that we are human too, with all of the same potential for weakness and moral failings under duress as anyone else. We are smart, hard working, dedicated and compassionate. But this does not equate to altruism. Compassion and altruism are not synonymous.

In the end, if you are no longer venerated with the respect enjoyed by doctors past, you are no different from any other working person who struggles to balance work and family life. And without the benefits of feeling revered and respected above others in society, you will begin to re-align your priorities. You will put your family and sometimes your own health and wellbeing first. You won't work well for free. And if you do work for free, you will eventually become resentful because it will make you feel that your work has even less value to people than you thought. But this is actually progress. It is the way things have evolved due to the knowledge revolution. What we know and do and how we do it is pretty amazing, but it's not so amazing that we should think that we are morally above others. We do it as much because it makes us feel good, pays the bills and has the added benefit of helping others most of the time. It is a privilege to practice medicine, but not in the sense that it carries the right to be exempt from criticism.

Conflict of Interest:

None declared

I found it amusing that the author began this article by using an odd analogy and then referencing policies surrounding "uninsured services" in quebec and ontario. To the first point, eating at a restaurant and being charged for cutlery is not an accurate analogy. You cannot eat your meal properly without cutlery and it is well established that these tools are part of the experience. None of the examples of fees (besides procedural ones) would prevent a patient from having a successful doctor visit. Additionally, I have yet to see a business balk at printing out an invoice for a customer before they agree to pay for the paper upon which it was printed. Laughable example.

The author is also complaining about having to pay for parking, oy. Well there is also the option for patients to take a taxi, or public transport, no-one is being forced to drive to the physicians office. Asking a family physician to pay for all patients who wish to park at their office, whether it in downtown toronto, vancouver or montreal is just preposterous. Or is he just targeting the ones who work at hospitals?

The uninsured services links the author casually points to is not evidence of wrongdoing, quite the opposite. It is a set of rules around which physicians MAY charge extra fees. The vast majority of physicians i know routinely undercharge their patients for fees they could be recovering. Yes, there are probably people out there who charge more than what is reasonable, just as there are those physicians who like to take pot shots at their fellow physicians for perceived injustices.

The author seems very upset that medicine seems to be a business and all about the money. Well let me educate you here, the government sees medicine as a business and a very unprofitable one at that. Family Physicians fees are not increasing with inflation, some specialists make obscene amounts of money for simple surgical procedures and yet we take the brunt of managing complex cases with little to no compensation for our time and energy. We are increasingly asked to do more with less resources yet the author feels this is completely acceptable.

A little tip here: allowing yourself to be trampled-on daily and not getting paid for your expertise does not equate to respect, that means you have no self-respect. Charge your patients what is reasonable and in turn you will respect yourself more, as will your patients.

Conflict of Interest:

None declared

While I get a chuckle of out Roger's rose-coloured view of the business of medicine (and make no mistake, it is most definitely a business), his public condescension toward colleagues seems to be ongoing[1,2], so I feel I must respond.

First, to his point about charging for missed appointments, in my experience most physicians advertise these penalties but rarely enforce them. If I missed a dentist appointment I would be charged, if I wasn't home to open the door for the plumber I would be charged, and a doctor's office is no different, in that it is time wasted for the business. If I had a patient who missed multiple appointments without a reasonable explanation, I would not hesitate to ask them for compensation for my time.

To be clear, I run a business trying to maximize profits, and yet I care deeply about each and every patient I see and work my hardest to do right by them. What Roger seems to miss is that these goals are not mutually exclusive. Just like most every other business, there is a market rate for my services. In recent years, government fee schedules have not kept up with the market rate for these services, and certainly have not kept up with changes in technology and innovative service delivery models, and so in talking with my colleagues we feel increasing pressure to fill this gap by billing for services that previously went uncompensated. My own professional interest is in innovation in service delivery in Family Medicine (for example, how many patients in Canada can freely send an email or text their physician?), and as fee schedule changes are inherently conservative, this type of innovation will necessarily come from user fees, with the hope of being included on the fee schedule once proven. My patients are free to shop around for a Family Physician, and all fees are published upfront and before service delivery. I refuse to be made to feel guilty for asking to be compensated appropriately for my services.

[1]: http://www.cfp.ca/content/61/12/1029.full [2]: http://www.cfp.ca/content/61/4/301.full

Conflict of Interest:

None declared

This article promotes the misconception that healthcare and all its associated costs are "free" and that we as physicians despite school debts and office overheads should work for free (or pay to work as government fees do not cover many healthcare costs..like warts on many body parts etc). I am disappointed that this is published in a journal that supposedly promotes family physicians.

Conflict of Interest:

I AM A FAMILY DOCTOR DEFAMED IN THIS ARTICLE FOR CHARGING FEES

I am appalled that my professional Journal would publish such a terrible article. Just as we Ontario doctors are fighting for our livelihoods and our patient's care in a sadly underfunded system, this MD is giving us lectures about charging fees not covered by OHIP. It is a terrible move on your part! As misguided as this gentleman is, the fault lays with the editor of this journal for publishing such drivel. I am a member of one of the largest online groups in Ontario actively fighting the government, in less than 24 hrs of me posting this article, 57 of your members have responded and it is NOT pretty, you owe us an apology. A few months ago I spent a whole day in court, supporting one of my patients to try to keep him out of jail. I did not bill anyone for this, I did it for free. His lawyer demanded $1600 from the client before continuing to argue the case, no way is he doing anything for free. So essentially this MD thinks that our time is worth nothing what an insult! we are furious!

Conflict of Interest:

None declared

Conflict of Interest:

None declared

Wow, what an unbelievably misinformed article and shows how ignorant the writer is of the reality of day to day medical practice. All of the "extra" costs in the system are precisely because health care has been so woefully underfunded that we have become to depend on these "extras" to make the system work. Many hospitals would in fact have to cut services even more if they were to lose the parking revenue. I am so tired of so called experts spouting their ill informed views.

The examples are poor. What the writer doesn't realize is the $48 steak he's eating at his restaurant has the charges for paper, ink, washing of cutlery, linens and dishes not to mention rent, wages, and insurance etc. built in. If the restaurant only received $5 for the steak, you can be sure there are going to be extra charges. That is the reality that doctors are facing today.

OHIP does not pay for forms. Forms take time to complete and are not otherwise reimbursed. Ask your lawyer what he would charge to complete the reams of documents we see every day.

In a free market system where we could set our own fees, we could include some optional extras for free depending on the fees we charged. But you'd be paying $48 for that steak!

Conflict of Interest:

None declared