Effective October 1, 2019, the Schedule of Benefits for Physician Services (the "Schedule") and Ontario Regulation 965 under the Public Hospitals Act ("Regulation 965") will be amended to reflect recommendations of the physician-led Appropriateness Working Group (the "AWG"). Our previous bulletin, "Physician Payment Discounts End Effective April 1, 2019: An Overview of the Arbitration Process and Other Key Outcomes" discussed the outcome of the arbitration between the Ontario Ministry of Health and Long-Term Care and the Ontario Medical Association ("OMA"). While a significant outcome of the arbitration was an end to payment discounts on physician fees, the decision also resulted in two new working groups: one on "appropriateness" and another on primary care.

On August 22, 2019, the AWG submitted its first 11 recommendations. The recommendations were accepted by the Minister of Health and the OMA and take effect on October 1, 2019. Among them are reduced fees for house calls, duplicative referrals and assessments from primary care providers.

Purpose of the AWG

A hard fee cap on physician billings was rejected in the arbitration decision. In so ruling, the arbitrator observed that it is within the government's power to delist inappropriate services from the Schedule. The purpose of the AWG is to recommend changes to the Schedule that will result in cost savings and shorter wait times by reducing unnecessary services and services that are no longer supported by best available evidence. The AWG has acknowledged that technology and knowledge evolve, and so should the Schedule.

When established by the arbitration decision, the AWG's goal was to find $100 million in savings in this government fiscal year (to March 31, 2020), and $360 million in savings in the next fiscal year. It is expected that more recommendations are to come.

The Recommendations

Using current standards and best practices, the AWG made 11 recommendations in two thematic areas: to improve patient care and to reduce medically unnecessary services. The following is a brief overview of the recommendations.

Improve patient care:

  • Use more accurate diagnostic imaging for sinus problems by removing the fee code for sinus x-rays.
  • Make patient referrals to new province-wide musculoskeletal rapid access clinics for chronic hip and knee pain for arthritic care. The intention is to create greater access to CT and MRI imaging for patients who need it. Physiotherapists, nurses and doctors at the new clinics will determine which patients require imaging.
  • Update the use of ambulatory cardiac monitoring devices with new minimum technical requirements for outpatients. Loop recorders, considered out dated technology, will no longer be funded.
  • Eliminate the requirement for a referral to see a specialist for the same problem within a two year period. "Consultations" (a thorough assessment rendered following a written request from a referring physician or nurse practitioner) rendered by the same consultant to the same patient for the same diagnosis will only eligible for payment as such once every 24 months when provided in the office, and every 12 months in the hospital or emergency department. Any additional examinations and assessments are payable using the appropriate assessment code.
  • Fund more effective infertility testing and offer alternative tests only based on physician judgment and patient circumstances.

Reduce medically unnecessary services:

  • Perform ear wax removal procedure only when medically necessary (when it is causing hearing loss or is needed to treat/diagnose other issues).
  • Only include larynx examinations with stomach examinations when there is evidence of a problem.
  • Only offer urine pregnancy tests when there is an immediate need. These tests are often given in addition to a blood test, which is more effective.
  • Reduce pre-operative assessments to those conducted by surgeons and anesthesiologists. Assessments by family doctors are not necessary.
  • Provide knee arthroscopies only for degenerative knee disease in special circumstances, otherwise offer non-operative therapies.
  • Fund physician premiums for house calls only for frail elderly and housebound patients. Physicians offering home visits to patients who do not meet the requirements of the premium may use the appropriate assessment fee code for the service provided.

The amendments to Regulation 965 will enact the recommendation to eliminate the requirement for a family physician to conduct a duplicative pre-operative history, physical and assessment, in conjunction with the associated de-listing from the Schedule. When a medically necessary consultation by a specialist is required prior to a dental or surgical procedure in a hospital, that service remains eligible. According to the Ontario Hospital Association ("OHA"), assessments from surgeons and anesthesiologists are consistent with current practice, and there is no longer any regulatory requirement for a stand-alone complete history, physical and assessment from a family doctor. The OHA recommends that hospitals review their existing policies.

Other Schedule Changes

In 2017, the OMA and Ministry of Health and Long-Term Care established a working group to review Team Care in Teaching Units. In addition to the recommendations of the AWG, the Schedule has been updated to rename this section the Supervision of Postgraduate Medical Trainees and to clarify when supervising physicians can bill for services performed by trainees.

New codes have also been created for the use of Rubidium for cardiac perfusion PET and the application of SPECT.

Specific fee codes for all of the changes can be found in the Ministry of Health's Info Bulletin #4726, available here.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.