Response to Government’s Proposed Additional Fee Cuts

September 22, 2015
Honourable Dr. Eric Hoskins
Minister, Ministry of Health and Long-­‐Term Care
Hepburn Block, 10th Floor
80 Grosvenor Street
Toronto, Ontario M7A 2C4
Dear Dr. Hoskins:

Re: Government’s Proposed Additional Fee Cuts
The Ontario Association of Radiologists (OAR), on behalf of the province’s 1,000 radiologists are gravely concerned and disappointed in the province’s recent unilateral move to cut an additional $235 million dollars from an already stressed health care system.  According to an OMA analysis, radiology is facing a $60M fee reduction or 25% of the  total  reduction. The fact that Radiologists  have  been  hit inordinately  by this latest  cut sends  a confusing message as to what the government  and the Ministry expect from the medical specialists doing the brunt of the medical imaging diagnoses for Ontario’s more than 13 million patients.

In  my  20  years  of  medical  practice,  I  cannot  recall  a  time  when  there  was  more  confusion  about  what  the government  is expecting  from  doctors  and  the  least  opportunity  to engage  with  the  Minister  and  Ministry  to collaborate  to find solutions.   All we hear are unilateral  statements  about more cuts and dramatically  different ways to make them happen even though it is obvious to us in the field that these changes, made without any consultation,  will have a harmful effect on patient care and safety, and undermine  physicians’  ability to provide Ontarians with the highest standard of quality health care services.

In January you announced across-­‐the-­‐board cuts.  Now in September, you are targeting an inordinate share of the $235M  cut  on  targeted  groups  of  physicians  like  our  specialty  with  no  clarity  as  to  what  you  are  seeking  to accomplish on a patient care level.  This significant shift in direction is reckless and prone to seismic impacts on the delivery of diagnostic imaging services.

It’s not clear how the government  is expecting  us to modify  our practices  to meet these  major  cuts while still responding   to  growth   in  patient   demand   for  medical   services   of  all  kinds.     Where   are  the  channels   of communication  for expert physician groups like the OAR to advise you? In less than 10 days time, the unilateral cuts  will  be  in  effect  before  physicians  understand  how  it  will  impact  their  practices  and  can  provide  the government  with an opportunity  to rectify some of the unintended  consequences  to patient care delivery.    We cannot believe that the government’s  intent is to reduce the level of patient care in Ontario, but that is precisely what you risk with these cuts.

The following is a synopsis of some of the top line issues that should be of mutual concern:

Impact on Patient Care Services

  • All diagnostic ultrasound and nuclear medicine fees will be reduced by 20%.   
  • MSK ultrasound fees have now been reduced by 63% and scrotal ultrasound by 74%, well over the 20% reduction for other ultrasound codes.
  • The unintended impact on patients is that these services will largely either cease to exist as of October 1st, or  be  greatly  reduced  with  long  wait  lists  and  undiagnosed  patients  because  the  service  is  no  longer viable.   
  • That  means  that  the  more  than  700,000  MSK  ultrasounds  performed  annually  (2011/12  -­‐  OHIP  data) will be significantly impacted thereby directly affecting patients.
  • Another estimated 100,000 scrotal ultrasounds may not be performed, or significantly delayed
  • These exams may be referred to other diagnostic imaging modalities with significantly greater costs to the health  care  system,   the  possible   use  of  ionizing   radiation,   and  clogging   other  diagnostic   imaging equipment resulting in longer wait lists.
  • MOH  officials  apparently  believe  there  is no value  in having  a Radiologist  present  to intervene  and to supervise  the  patient  examination  even  though  that  is  an  integral  part  of  the  quality  management process.  It is hard to imagine how you would convince Ontario patients that the quality of their care has been protected or improved.
  • The  government   is  specifically  discouraging   interaction  and  quality  assurance  in  some  of  the  most challenging situations, such as complex oncology cases and breast imaging.
  • Radiologist interaction with referring physicians will be discouraged and having a local presence in smaller communities and hospitals will be much less attractive.

Impact on Funding the Cost of Delivering Diagnostic Imaging Services (Technical Fees)

  • Technical  fees  are  the  overhead  OHIP  funding  that  covers  the  cost  of  the  medical  equipment,  the specialized technical support staff, medical supplies and space for diagnostic services.  Radiology accounts for about 70% of all technical fee expenditures in both public hospitals and IHFs.
  • The January, and now the September,  across-­‐the-­‐board fee cuts totaling 4.45% are directly affecting the amount of funding available to cover the overhead cost of delivering medical imaging services to patients in all practice settings.
  • There have been no fee increases to DI technical funding in over 25 years.
  • The  results  of  the  almost  5%  technical  fee  cut  will  translate  into  decisions  to  not  replace  older  DI equipment due to the lack funding and a laying off of highly trained diagnostic technologists as the impact of these cuts work their way into the delivery of patient care services.
  • This means a decreased number of DI scanners with greater diagnostic capability will be purchased and a reduced availability of diagnostic technical staff who are let go or not hired.
  • As physicians,  we will see the impact directly as will referring  physicians  who will be waiting longer for basic  diagnostic  examination  results.    In  most  cases,  the  reductions  in  service  will  not  be  obvious  to patients  at  first,  but  will  become  increasingly   clear  as  waits  increase,  or  services  are  reduced  or terminated.

Undermining MOH’s Own Quality Care Agenda

  • Successive  physician  fee cuts are at cross-­‐purposes  to important  initiatives  sponsored  by MOH and the Ontario government and undermine the quality assurance and quality management agenda in health care
  • Many  of these  initiatives  related  to DI and radiologists  are at the forefront  working  with  the MOH  to ensure their adoption and implementation
  • A large slate of DI quality assurance issues are at peril including, but not limited to, province-­‐wide DI peer review, CPSO-­‐CCO Quality Management Program initiatives including mammography, OBSP, CPSO IHF assessments, imaging accreditation programs (mammography, BMD), HARP Act modernization, etc.

Inconsistency In Dealing with Physician Funding Cuts

  • At this point we have no idea of what the total impact on radiologists will be due to the lack of available information, but it is likely that Radiologists, who are less than 4% of the physician community, are going to bear up to 20% of the total $235M cut to physician funding.  This needlessly exposes you to future criticism when unavoidable service impacts occur.
  • More than a week has passed since the news of these cuts was announced yet there is an unprecedented paucity of information available to the OMA and to individual physicians or sections of medicine
  • In  January  2015,  the  Ontario  government  announced  an  across-­‐the  board  cut  affecting  all  doctors  in Ontario yet the September 2015 announcement is a more punitive hybrid of a 4.45% across-­‐the-­‐board decrease  combined  with  a major  fee cut that  singles  out a small  number  of medical  specialists  and  a blanket cut for those hard working physicians earning higher than average incomes.
  • This means that radiologists and a few other specialties will face decreases of up to 10%.
  • Some practices will be significantly impacted such that they will be forced to change the mix of diagnostic services they offer.   Those kinds of changes will create unintended  consequences  that will affect patient care delivery.
  • There is no equivalent 20% reduction to the emergency physician ultrasound code (H100).
  • A call to the OMA as recently as yesterday,  confirms that they are in the dark as to the implication  and planned implementation of these new cuts.

Inequity of the Impact on Ontario Radiologists

  • The impact of the 20% cut of ultrasound and nuclear medicine fees alone is estimated to be in the order of a fee reduction of $28M to Ontario radiologists.
  • There are approximately  5,000 fee codes in the OHIP Schedule of Benefits.  The new 20% fee cut affects approximately 190 fee codes of which 165 are procedures done by Radiologists and other imaging physicians.   It is not clear why a small sub-­‐set of the physician population is being treated so harshly with little apparent consideration to the deleterious impacts it will have on those physicians diagnosing cancer, stroke, heart disease and other leading causes of mortality and serious illness.
  • There is a mixed and inaccurate message in this new fee cut.  Clearly the government is concerned about the fiscal impact of the increased utiilisation of medical services yet you have stated publicly there is no reduction of access to medical services for the public and that further cuts to physicians can happen with no consequences to patient care.
  • Radiologists do not refer patients to themselves.   Within the medical profession, radiologists are bearing the cost of DI examinations ordered by other doctors.  Radiologists are paying for the increase of these additional services without any fiscal responsibility being tied to the doctors who order them.
  • Over   the   past   decade,   more   non-­‐physician   health   professionals    (nurse   practitioners,    midwives, chiropractors, physiotherapists, etc.) have been authorized and encouraged by MOH to order diagnostic imaging  exams.   What started  out as being a limited  array of x-­‐ray  or ultrasound  codes has now been expanded to more or all DI modalities and/or a much broader spectrum of fee codes that are charged to the  physician  pool. The  volume  of  non-­‐physician  referrals  is increasing. It  is  patently  unfair  that radiologists are now on the hook for the ordering practices and behaviour of non-­‐physicians as well.

As an organization committed to the highest quality patient care for Ontarians and the advocates for Ontario radiologists,  we  respectfully  request  immediate  clarification  of  the  issues  raised  and  for  you  to  consult  us directly so that appropriate action can be taken to reverse decisions that will lead to a serious erosion of patient care.  I am available to meet you to discuss what we believe is a more proactive approach.


Mark Prieditis, MD, FRCPC President