2012 Agreement for Ontario Doctors

New changes to doctor's fees

On May 7, 2012, the government updated and rebalanced doctor's fees to reflect current medical practices and new technologies; and to avoid double-payments.

Read more about these changes:

3D Stereotaxis in Brain and Spine Surgery

What does OHIP cover?

OHIP covers all diagnostic tests that are considered to be medically necessary and listed in the Schedule of Benefits for Physician Services.

Changes to Feesfor 3D Stereotaxis

On May 7, 2012,the government announced changes to feesfor 3D stereotaxis in brain and spine surgery.

What has changed and why?

  • Two fees for this service have been reduced. The fee for intracranial stereotaxis went from $1,020 to $510 and the fee for spinal stereotaxis went from $1,076.75 to $538.40.
  • These fees have been changed because the process takes much less time to set up.
  • When stereotaxis was first introduced in the 1970s it was very complicated to perform and took up to three hours for the surgeon and staff to set up the computer and make a map of the brain or spine. Advances in computer and imaging technology mean that it now only takes about 1 ½ hours to set up this test.

Will patients continue to be covered by OHIP for 3D stereotaxis for brain and spine surgery?

  • Yes.

What are the savings from this change in the first year (2012/13)?

  • A total of $1.8 million is projected to be saved as a result of this fee change.

When is this fee change effective?

  • This fee changeis effective on April 1, 2012.

For More Information

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Anaesthesiology

What does OHIP cover?

OHIP covers anaesthesiology services that are medically necessary, and are listed in the OHIP Schedule of Benefits for Physician Services.

Changes to OHIP Anaesthesiology-Related Fees and Services

On May 7, 2012, the government announced changes to several fees related to anaesthesiology, including:

1. Anaesthesia for Intravitreal Injections for the Eye

What is it?

Intravitreal injections are primarily used to treat a medical condition called wet macular degeneration by ophthalmologists. The procedure involves the injection of a drug into the eye.

Typically, patients need a local anaesthetic before the injection of the drug into their eye. A local anaesthetic is one that removes sensation in one area of the body.

Age-related macular degeneration is a medical condition which usually affects older adults and results in a loss of vision in the center of the visual field, the macula, because of damage to the retina of the eye. It occurs in “dry” and “wet” forms. It is a major cause of blindness and visual loss of vision in adults aged 50 or older.

What has changed and why?

  • Giving a local anaesthetic is part of an ophthalmologist's practice and they are trained to do this. An anaesthesiologist is not needed to perform this service.
  • The fee for anaesthesia will be restricted to anaesthesia, other than local anaesthesia, such as sedation to calm the patient, or a general anaesthetic where the patient is not awake for the procedure.
  • Because of technological advances in equipment and as the procedure has become more common, the time it takes to do an intravitreal injection has been reduced to approximately 15 minutes.

Will patients continue to be covered by OHIP for anaesthesia used for intravitreal injections?

  • Yes. The fee for an intravitreal injection includes payment to give a local anaesthetic.
  • In cases where a patient needs to be sedated or have a general anaesthetic performed by an anaesthesiologist for the injection, those services will continue to be funded by OHIP.

What are the savings from this change in the first year (2012/13)?

A total of $0.3 million is projected to be saved as a result of this fee change.

2. Anaesthesia for Conscious Sedation

What is it?

Conscious sedation is an anaesthetic which makes a patient able to tolerate a procedure that may be uncomfortable or unpleasant. The patient is still conscious while the procedure is done.

Conscious sedation is used in procedures such as colonoscopy, sigmoidoscopy, cystoscopy, and cataract removal. In some cases, a patient needs extra sedation on top of a local anaesthetic, usually if they are nervous or uncomfortable. Conscious sedation involves inserting an intravenous (IV) line to inject medication.

What has changed and why?

  • Before the changes to these fees, there was a combined fee for conscious sedation that included a flat fee of $60.00 as well as a fee of $15.00 per 15 minute time blocks. For example, for 30 minutes of sedation, $90.00 could be billed. Anaesthesiologists may no longer bill for the $15.00 time block fee so the full fee for anaesthesia for conscious sedation would be $60.00.
  • Giving an anaesthetic for conscious sedation is not as complex as giving a general anaesthetic where the patient must be watched and monitored carefully throughout the full procedure. With conscious sedation, anaesthesiologists are able to monitor more than one patient after they give the injection.
  • For complex cataracts where a patient may need to have deeper sedation or general anaesthesia, an additional fee can be paid to the anaesthesiologist. For a case lasting 30 minutes, the fee would be six base units plus two time units at $15.01/unit which is $120.08. Extra units are also payable for patients who are sicker or older. For example, two extra units for ASA III patients (very complex cases) and three extra units for patients over 80.

Will patients continue to be covered by OHIP for anaesthesia for conscious sedation?

  • Yes.

What are the savings from this fee change in the first year (2012/13)?

A total of $11 million is projected to be saved as a result of this fee change.

3. Anaesthesia Premiums

What is it?

For some patients, extra payment premiums can be paid for anaesthestic depending on the medical stability of the patient.

What has changed and why?

  • The premium for giving an anaesthetic to patients who are at a slightly higher risk than most patients has been reduced from four units ($60.04) to two units ($30.02).
  • This fee was over-valued for the service delivered.
  • Patients who are more medically stable do not generally need the same work effort for anaesthesia during surgery as sicker patients.
  • Less healthy patients may need more effort to begin the anaesthetic, need to be monitored more closely, and need help during the surgery to correct oxygen levels, balance fluids, etc.. For example, a patient who might be considered more medically unstable could be a person involved in major trauma with multiple injuries including fractures and abdominal and chest injuries.

Will anaesthesiologists continue to receive extra premiums for patients depending on the medical stability of the patient?

  • Yes. The premium payable will depend on the medical stability of the patient.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $8.3 million is projected to be saved as a result of this fee change.

4. Nerve Block Fees

What is it?

Nerve blocks are the injection of a local anaesthetic to manage pain. They can also be used to find or diagnose which nerves are causing pain.

What has changed and why?

  • Four over-valued fees for nerve blocks will be reduced.
  • These fees are over-valued when given without an image or picture to guide the injection, so the nerve block goes to the right spot.
  • The specific fees that are changing include:
    • G228 Paravertebral nerve block – changed from $54.65 to $34.10
    • G123 Additional paravertebral blocks (to a maximum of 4) – changed from $27.45 to $17.10
    • G227 Other cranial nerve block – changed from $84.00 to $54.65
    • G238 – Transverse scapular nerve block – changed from $55.10 to $34.10
  • These blocks are typically done “blind”which means using anatomical landmarks, (location in the body), to determine where to make the injection without using some type of picture as a guide, such as fluoroscopy or ultrasound. The fees have been reduced to the level of fees for similar nerve blocks that are similar in complexity.
  • The Schedule of Benefits for Physician Services was revised in September 2011 to add new fee codes for many nerve blocks that would be given with the help of a picture or image.

Will patients continue to be covered for nerve block fees?

  • Yes. Nerve block fees will continue to be paid for by OHIP for patients who need them.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $13 million is projected to be saved as a result of this fee change.

5. Acute Pain Consultation with an Epidural

What is it?

Acute pain management happens in a non-emergency situation when one physician asks another physician to see a hospital patient about pain management and consult about pain control. Control of pain is very important and patients should have access as quickly as possible.

What has changed and why?

  • The fee for introducing an epidural to a patient in labour is $90.06. While the epidural is in place, the physician can claim extra fees of up to $180.12.
  • Some physicians were also claiming a consultation fee of $47.50. Physicians are now no longer able to claim this fee for an acute pain consultation with an epidural for labour pain.
  • When an epidural is performed, the anaesthesiologist is paid for both assessing the patient and doing the procedure. Claiming a consultation in addition to the procedure service is a duplication of payment.

Will patients continue to be covered by OHIP for epidurals?

  • Yes.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $0.5 million is projected to be saved as a result of this fee change.

6. After-Hours Procedural Premiums

What is it?

After-hours procedural premiums are extra payments given when services are provided to a patient between 5:00 p.m. and 7:00 a.m. or on weekends. These premiums increase payments by 20 to 75 per cent, depending on when they are provided.

What has changed and why?

  • Physicians who provide services in the evening, on weekends or after midnight will continue to receive an additional premium. The amount of the after-hours procedural premium is being reduced by 10 points – so for example, if the premium was 50 per cent, it will be reduced to 40 per cent.
  • There have been significant improvements in payments for consultations, assessments and visits over the last eight years, especially when physicians need to make special after-hours visits to the hospital. These payments are over and above the after-hours procedural premiums. The following fee example is for an appendectomy done by a general surgeon:
    • The general surgeon would be paid separate fees for a consultation, special visit to the ER, surgery, and after-hours premium
    • Total fee during the day: $503.30
    • Total fee in the evening: $657.94
    • Total fee after midnight: $785.09
    • In this example, it is likely that the general surgeon would be on-call for evening and after-midnight procedures and would also be entitled to Hospital On-Call Coverage payments, which on average pay $472.00 per day.

Will patients continue to be covered by OHIP for surgery after-hours?

  • Yes. Procedures performed in the evening, after midnight, and on weekends, will continue to be covered under OHIP.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $13 million is projected to be saved as a result of this fee change. These savings are from all physicians.

7. Intensive or Coronary Care Unit Premium

What is it?

Intensive or coronary care is care provided to patients in a hospital who are being cared for in an Intensive Care Unit or Coronary Care Unit.

What has changed and why?

  • A premium fee was being paid to a physician, who was not the Intensive Care Unit physician, who visited an Intensive Care Unit or a Coronary Care Unit.
  • This premium fee of $9.10 will no longer be paid.
  • Patients in an Intensive Care Unit/Coronary Care Unit are treated by an intensive care specialist who is paid a daily fee.
  • If a different physician visits the patient, they are paid a visit fee and may also be paid an additional amount for the time to properly attire to enter the care unit.
  • This extra premium fee will not be paid in addition to the visit fee in the Intensive Care Unit as this is a requirement for attending any patient in the hospital.

Will patients continue to have access to intensive and coronary care?

  • Yes.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $3.4 million is projected to be saved as a result of this fee change. These savings are from all physicians.

When are these fee changes effective?

  • These fee changes are effective April 1, 2012.

About Anaesthesiology Fees

  • The average gross payments to anaesthesiologists are $436,450.00 per year, as of 2011/12.
  • These gross payments have increased by 59 per cent since 2003/04.

For More Information

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Annual Limits for Sleep Studies

What does OHIP cover?

OHIP covers sleep studies for diagnosis and to assess treatment where the study is considered to be medically necessary.

Changes to Conditions for Annual Limits for Sleep Studies

On May 7, 2012,the government announced changes to clarify the terms and conditions annual limits for sleep studies.

What has changed and why?

  • Before the change on May 7, 2012, if a sleep study test was recommended by a physician practicing sleep medicine and the patient had already reached the limit of the number of studies allowed per year, the physician could apply to OHIP to have another sleep study before the test is done. If approved, the test would be covered by OHIP.
  • The fee schedule will be revised to clearly state where repeat sleep studies can be billed and where it would be faster for a physician to get approval for the next study from OHIP.
  • This change will reduce the amount of paperwork or administrative work that physicians have to do so that they can order a sleep test for a patient who has already reached the limit.

Will patients continue to be covered by OHIP for sleep studies?

  • Yes. Patients will continue to be covered by OHIP for sleep studies that are medically necessary.

What are the savings from this change in the first year (12/13)?

A total of $0.5 million is projected to be saved as a result of this fee change.

When is this fee change effective?

  • This fee change is effective on April 1, 2012.

Supporting Evidence and For More Information

College of Physicians and Surgeons Clinical Practice Parameters and Facility Standards
http://www.cpso.on.ca/policies/guidelines/default.aspx?id=1978

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Assessments with Selected Surgical Services

What does OHIP cover?

OHIP covers all physician assessments that are considered to be medically necessary and are listed in the Schedule of Benefits for Physician Services.

Changes to Fees for Assessments with Selected Surgical Services

On May 7, 2012,the government announced changes to fees paid to physicians for assessments with selected surgical services.

What has changed and why?

  • If a decision is made that a patient needs a surgical procedure and the procedure occurs on a later date, the payment for the physician assessment of the patient on the day of surgery will be reduced.
  • This change is being made because the assessment fee was over-valued. An assessment done on the day of surgery does not take as much time as it would if the surgery takes place at a later date when the patient's condition may have changed.
  • For example:
    • A patient goes to a plastic surgeon for a consultation and the surgeon decides to remove a cancerous mole on the patient's face.
    • For the first consultation with the patient, the plastic surgeon is paid $81.10.The fee for a consultation includes a full assessment of the patient's condition by the specialist and a written report to the patient's family doctor.
    • If the patient has the surgery to remove the mole on the same day as the consultation, the surgeon is paid $92.15 to do that service.
    • If the surgery is done on a different day, the surgeon can bill a lower assessment fee of $26.55, as the more detailed patient review and decision regarding the procedure has already occurred. The physician is still paid the same $92.15 fee to do the surgery.
  • Some jurisdictions do not allow any payment for an assessment in addition to the procedure if the original assessment/consultation occurred prior to the date of the procedure.

Will patients continue to be covered by OHIP for assessments with selected surgical services?

  • Yes. OHIP will continue to provide coverage for patient assessments.

What are the savings from this change in the first year (12/13)?

A total of $5.5million is projected to be saved as a result of this fee change.

When is this fee change effective?

  • This fee change is effective on April 1, 2012.

For More Information

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Cardiology

What does OHIP cover?

OHIP covers cardiology services which are medically necessary, and listed in the OHIP Schedule of Benefits for Physician Services.

Changes to OHIP Cardiology-Related Fees and Services

On May 7, 2012, the government announced changes to several fees related to cardiology, including:

1. Cardiac Loop Recording

What is it?

Cardiac loop recording is a tool used by cardiologists to measure a patient's heart rhythm over a time period (typically 14 days) to find infrequent rhythm changes in the heart. This tool can help a cardiologist to diagnose a heart condition.

Cardiologists are paid a professional fee to interpret cardiac loop recording results, and a technical fee to cover the cost to buy and maintain equipment and supplies.

What has changed and why?

  • The cost of cardiac loop recording equipment has gone down over the past 10 years.
  • There were two separate cardiac loop recording technical fees ($167.20 and $113.55) that could be billed.
  • These two fees have been combined into one new fee of $168.45.

Will patients continue to be covered by OHIP for cardiac loop recording tests?

  • Yes.

What are the savings from this change in the first year (2012/13)?

A total of $6.7 million is projected to be saved as a result of this fee change.

2. Inserting Cardiac Catheters

What is it?

To catheterize a heart, a cardiologist needs to insert an access tube into a blood vessel in the arm or leg and then insert the cardiac catheter tube into the access tube through the blood vessels and into the heart.

What has changed and why?

  • In many cases, an additional fee was claimed for insertion of an access tube.
  • Cardiologists will no longer be able to bill two separate fee codes for the same service.
  • For example, the fee for an angiogram that includes angioplasty (a procedure that includes the use of a cardiac catheter to open a diseased coronary artery) is $888.18. A physician will no longer be able to bill a separate fee of $121.40 to insert a catheter.

Will patients continue to be covered by OHIP for inserting cardiac catheters?

  • Yes. Cardiac catheterization will continue to be an OHIP insured service and paid through one fee code which covers the whole service.

What are the savings from this fee change in the first year (2012/13)?

A total of $14.6 million is projected to be saved as a result of this fee change.

3. Electrocardiograms

What is it?

An electrocardiogram is a tool used to diagnose heart disease such as atrial fibrillation, fluttering of the heart.

What has changed and why?

  • The fee for an electrocardiogram has been reduced by 50 per cent from $9.90 to $4.95.
  • Since this tool was introduced in the 1960s there have been significant advances in technology.
  • One example of how this technology has advanced is the use of computerized measurements to interpret results. It now takes significantly less time to interpret results; and the number of electrocardiograms that can be processed in a time period has increased.
  • There has been a 26 per cent increase in electrocardiogram services per physician, per day, between 2006 and 2011.
  • In addition to the fee for an electrocardiogram, a cardiologist bills also bills $157.00 for a consultation or $38.05 for a follow up visit, if it is needed.

Will patients continue to be covered by OHIP for electrocardiograms?

  • Yes. Electrocardiograms will continue to be an OHIP insured service.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $21 million is projected to be saved as a result of this fee change.

4. Pre-Operative Echocardiograms

What is it?

An echocardiogram is an ultrasound of the heart used to measure and assess the function and anatomy of the heart. Echocardiograms are most often used before cardiac surgery.

What has changed and why?

  • Payment for echocardiograms before non-cardiac elective surgery is now restricted to tests approved by the Ministry of Health and Long-Term Care.
  • If a physician or surgeon feels that a patient needs this test prior to elective non-cardiac surgery to prepare specifically for the surgery, the physician can apply to the Ministry of Health and Long-Term Care for approval prior to the test. If approved, the test is covered by OHIP.
  • Evidence from the British Medical Journal in June 2011 found that echocardiograms before surgery do not improve health outcomes for a patient for elective non-cardiac surgery. In some cases, these tests may even be harmful for patients, especially those who are having low-risk surgeries like cataract surgery, and who have no symptoms requiring such a test.

Will patients continue to be covered for echocardiograms by OHIP?

  • Yes. Medically necessary echocardiograms that are ordered before elective non-cardiac surgery will continue to be insured by OHIP.
  • If a physician or surgeon feels that a patient needs this test prior to elective non-cardiac surgery to prepare specifically for the surgery, the physician can apply to the Ministry of Health and Long-Term Care for approval prior to the test. If approved, the test is covered by OHIP.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $20 million is projected to be saved as a result of this fee change.

5. Intensive or Coronary Care Unit Premium

What is it?

Intensive or coronary care is care provided to patients in a hospital who are being care for in an Intensive Care Unit or Coronary Care Unit.

What has changed and why?

  • A premium fee was being paid to a physician, who was not the Intensive Care Unit physician, who visited an Intensive Care Unit or a Coronary Care Unit.
  • This premium fee of $9.10 will no longer be paid.
  • Patients in an Intensive Care Unit/Coronary Care Unit are treated by an intensive care specialist, who is paid a daily fee.
  • If a different physician visits the patient, they are paid a visit fee, and may also be paid an additional amount for the time to properly attire, to enter the care unit.
  • This extra premium fee will not be paid in addition to the visit fee in the Intensive Care Unit, as this is a requirement for attending any patient in the hospital.

Will patients continue to have access to intensive and coronary care?

  • Yes.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $3.4 million is projected to be saved as a result of this fee change. These savings are from all physicians.

6. Oximetry

What is it?

An oximetry test measures the oxygen available in the blood and is a common way to test the function of the lungs at rest, and during exercise.

What has changed and why?

  • Payment for oximetry is included in the fee for echocardiography or cardiac monitoring. The additional fee will no longer be paid.
  • This change is being made to eliminate duplicate payment for the service.
  • An oximetry test is a specific diagnostic test that is needed to measure pulmonary or lung function. However, oximetry is being billed for monitoring during some procedures such as cardiac stress testing where this monitoring is included in the procedure fee.
  • Oximetry fees are for the diagnosis and management of pulmonary disease, and not for monitoring.

Will patients continue to be covered for oximetry testing by OHIP?

  • Yes.

What are the savings from this fee change in the first year (2012/13)?

A total of $1.2 million is projected to be saved as a result of this fee change.

When are these fee changes effective?

  • These fee changes are effective April 1, 2012.

About Cardiology Fees

  • The average gross payments to cardiologists are approximately $585,348.00 per year, as of 2011/12.
  • These gross payments have increased by 57 per cent since 2003/04.

Supporting Evidence and For More Information

Cardiac Loop Recording
Long-Term Continuous Electrocardiographic Recording: Recording Techniques
http://www.ncbi.nlm.nih.gov/pubmed/3529907

Electrocardiogram
Screening Asymptomatic Adults With Resting or Exercise Electrocardiography: A Review of the Evidence for the U.S. Preventive Services Task Force
http://www.ncbi.nlm.nih.gov/pubmed/21930855

Evidence Fails to Support ECG Screening for Those Without Heart Disease Symptoms
http://jama.jamanetwork.com/iedetect.aspx

Pre-Operative Echocardiograms
Association of echocardiography before major elective non-cardiac surgery with postoperative survival and length of hospital stay: population based cohort study
http://www.bmj.com/content/342/bmj.d3695 (British Medical Journal)

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services - Effective April 1, 2012
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

CT/MRI for lower back pain

What does OHIP cover?

OHIP covers all medically necessary services for the diagnosis and care of low back pain that are listed in the OHIP Schedule of Benefits for Physician Services.

Changes to Fees for CT/MRI Tests

On May 7, 2012, the government announced changes to several fees related to the use of CT/MRI tests for the care of low back pain.

What has changed and why?

  • Language has been added to the Schedule of Benefits to clarify that CT/MRI tests for low back pain should not be routinely ordered unless a specific disease or condition is suspected or known, such as an infection, tumour, osteoporosis, ankylosing spondylitis (a type of arthritis of the joints between the spinal bones), fracture, inflammatory process, radicular syndrome or cauda equine syndrome (pressure on the spinal nerves).
  • In most cases, patients do not have symptoms of these suspected conditions and need other care to prevent long-term chronic back pain.
  • This change is based on the latest available medical evidence and on advice from medical experts. Many expert groups have recommended this change including the Alberta Guideline for the Evidence-Informed Primary Care Management of Low Back Pain (2009), and the American Academy of Family Physicians (Choosing Wisely campaign).
  • A physician ordering a CT/MRI will need to show that the test is medically necessary by recording the reason for the test based on the patient's signs and symptoms. The outcome of the test does not determine whether the test was necessary. For example, if a physician orders a CT scan for a patient with back pain that radiates into the right leg, but the CT scan does not help to diagnose a specific cause, the test would be insured even though the result is inconclusive or negative.
  • For a patient with low back pain, it is important to develop a treatment plan to reduce the pain and help the patient increase their movement. This will reduce the chances of developing long-term chronic pain.
  • Treatment for lower back pain includes a variety methods that control pain and improve mobility.

Will patients continue to be covered by OHIP for CT/MRI for low back pain?

  • Yes. OHIP will continue to insure CT/MRI tests for low back pain when these tests are medically necessary.
  • X-rays, CT or MRI scans should not be ordered routinely or given for low back pain unless a specific disease is suspected or known.

What are the savings from this change in the first year (2012/13)?

A total of $10 million is projected to be saved as a result of this fee change.

When is this fee change effective?

  • This fee change is effective April 1, 2012.

Supporting Evidence and For More Information

Alberta Guideline for the Evidence-Informed Primary Care Management of Low Back Pain (2009)
http://www.topalbertadoctors.org/cpgs.php?sid=63&cpg_cats=85

American Academy of Family Physicians (Choosing Wisely)
http://consumerhealthchoices.org/wp-content/uploads/2012/05/ChoosingWiselyBackPainAAFP.pdf

Investigation of Acute Lower Back Pain in Ontario: Are Guidelines Being Followed? (2004) ICES Investigative Report
http://www.ices.on.ca/file/ACFF.pdf

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

OHIP InfoBulletin #4563
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4563.pdf

Frequently asked questions

Diagnostic Radiology

What does OHIP cover?

OHIP covers all diagnostic radiology services which are considered to be medically necessary and are listed in the Schedule of Benefits for Physician Services.

Changes to OHIP Diagnostic Radiology-Related Fees and Services

On May 7, 2012, the government announced changes to several fees related to diagnostic radiology including:

1. Interpretation Fees

What is it?

Diagnostic radiologists interpret or read images taken by diagnostic tests like X-rays, CT scans, ultrasounds, and MRI scans.

What has changed and why?

  • Approximately 250 fees are payable for interpreting diagnostic radiology tests. These fees will be reduced by five per cent in 2012/13.
  • This change is being made because investments in new equipment, technology, and computerization have allowed radiologists to interpret images much faster and more accurately.
  • Digital diagnostic imaging systems have been introduced throughout Ontario. Digital images, including X-rays, ultrasounds, MRI, and CT scans, help radiologists to interpret more accurately, and share patient images electronically.
  • Canada Health Infoway estimated there has been a 25 to 30 per cent productivity gain due to these technological advances.

Will patients continue to be covered by OHIP for diagnostic interpretation of images by diagnostic radiologists?

  • Yes.

What are the savings from this change in the first year (2012/13)?

A total of $30 million is projected to be saved as a result of this fee change.

2. Three-Dimensional (3D) Interpretation of Diagnostic Imaging

What is it?

To diagnose different conditions, radiologists combine a two-dimensional (2D) image or picture from a CT or MRI scan to make three-dimensional (3D) images. 3D images allow radiologists to develop a faster, more exact understanding of a patient's illness or condition.

What has changed and why?

  • The fee to read 3D diagnostic images has been reduced from $65.40 to $32.70.
  • The fee to interpret 2D images such as CT and MRI scans has not changed.
  • The base fee for most MRI tests is $73.35 plus $36.70 for extra views. Base fees for CT tests range from $43.25 to $235.30.
  • Technology has made 3D diagnostic imaging easier and faster for physicians to do.
  • Investments in new equipment, technology, and computerization have allowed radiologists to interpret images much faster and more accurately. In the past, 2D images would have to be examined side-by-side. With 3D imaging, the radiologist can work with and change the image faster, and interpret the findings more accurately.
  • Canada Health Infoway estimated there has been a 25 to 30 per cent productivity gain due to these improvements in technology.
  • Physicians have been able to increase the number of CT and MRI services that they can do in one day by over 50 per cent.

Will patients continue to be covered by OHIP for diagnostic image tests include 3D interpretation of them?

  • Yes.

What are the savings from this fee change in the first year (2012/13)?

A total of $13 million is projected to be saved as a result of this fee change.

3. CT/MRI Tests for Low Back Pain

What is it?

Chronic low back pain can happen to many people in their lifetime and can be the result of a number of different issues, such as injury or aging.

CT and MRI tests are diagnostic tests that are performed by diagnostic radiologists and are used to find the cause of low back pain.

What has changed and why?

  • OHIP will no longer cover CT and MRI tests for low back pain unless a specific disease or condition is suspected or known to support the medical necessity of the test, such as an infection, tumour, osteoporosis, ankylosing spondylitis, (a type of arthritis of the joints between the spinal bones), fracture, inflammatory process, radicular syndrome or cauda equine syndrome, (pressure on the spinal nerves).
  • In most cases, patients do not have symptoms of these suspected conditions and need other care to prevent long-term chronic back pain.
  • This change is based on the latest available medical evidence and advice from medical experts. Many expert groups have recommended this change including the Alberta Guideline for the Evidence-Informed Primary Care Management of Low Back Pain (2009), and the American Academy of Family Physicians (Choosing Wisely campaign).
  • A physician ordering a CT or MRI test will need to show that it is medically necessary by recording the reason for the test based on the patient's symptoms. The outcome of the test does not determine whether the test was necessary. For example, if a physician orders a CT scan for a patient with back pain that radiates into the right leg, but the CT scan does not help to diagnose a specific cause, the test would be insured even though the result is inconclusive or “negative”.
  • For a patient with low back pain, it is important to develop a treatment plan to reduce the pain and help the patient increase their movement. This will reduce the chances of developing long-term chronic pain.
  • Treatment for low back pain can include a variety of types of care such as exercises, physiotherapy, massage, painkillers or anti-inflammatories.

Will patients continue to be covered by OHIP for CT and MRI tests for low back pain?

  • Yes. OHIP will continue to insure X-rays and CT and MRI tests for low back pain when these tests are medically necessary.
  • X-rays, CT or MRI tests should not be routinely ordered or given for low back pain unless a specific disease is suspected or known.

What are the savings from this change in the first year (2012/13)?

A total of $10 million is projected to be saved as a result of this fee change.

4. Vascular Ultrasound Services

What is it?

A vascular ultrasound is a diagnostic test that looks at blood flow in the body to help to find the cause of illness.

What has changed and why?

  • Vascular ultrasound services were reviewed. Fees will no longer be paid for specific older, vascular ultrasound services. More current ultrasound services, which can give more accurate results, are recommended in their place.
  • These changes promote the use of newer and higher quality vascular ultrasound tests. This change is based on current best medical practice and has been made to reflect recent changes in technology and patient care.
  • The number of vascular ultrasound services has grown 100 per cent since 2004. By no longer paying for out-dated tests, this change encourages physicians to provide access to the best tests and therefore provide the best quality of care.

Will patients continue to be covered for vascular ultrasound services by OHIP?

  • Yes. These changes promote the use of newer and higher quality vascular ultrasound tests.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $5 million is projected to be saved as a result of this fee change.

When are these fee changes effective?

  • These fee changes are effective April 1, 2012.

About Diagnostic Radiology Fees

  • The average gross payments to diagnostic radiologists are approximately $668,819.00 per year, as of 2011/12.
  • These billings have increased by 68 per cent since 2003/04.

Supporting Evidence and For More Information

Diagnostic Services in Ontario: Descriptive Analysis and Jurisdictional Review – ICES
http://www.ices.on.ca/file/diagnostic_services_ontario_oct16.pdf

Vascular Ultrasound
Guidelines for Noninvasive Vascular Laboratory Testing: A Report from the American Society of Echocardiography and the Society of Vascular Medicine and Biology
http://www.asefiles.org/VascularGuidelines.pdf

CT/MRI for Low Back Pain
Alberta Guideline for the Evidence-Informed Primary Care Management of Low Back Pain (2009)
http://www.topalbertadoctors.org/cpgs.php?sid=63&cpg_cats=85

American Academy of Family Physicians
http://consumerhealthchoices.org/wp-content/uploads/2012/05/ChoosingWiselyBackPainAAFP.pdf

Investigation of Acute Lower Back Pain in Ontario: Are Guidelines Being Followed? (2004) ICES Investigative Report
http://www.ices.on.ca/file/ACFF.pdf

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Electrocardiogram and Pulmonary Function Tests in the Annual Health Test

Changes to Fees for Electrocardiogram and Pulmonary Function Tests in the Annual Health Test

On May 7, 2012,the government announced changes to fees for electrocardiograms and pulmonary function tests when they are part of a routine annual health visit.

What has changed and why?

  • Physicians will no longer be paid a separate fee for routine screening using an electrocardiogram and/or a pulmonary function test when these tests are given during a routine annual health visit, unless there are symptoms of heart or lung disease.
  • Routine screening of patients for heart or lung disease using an electrocardiogram and/or a pulmonary function test when there are no signs of these diseases is not recommended by expert groups including the American Academy of Family Physicians.
  • The US Preventive Services Task Force also does not recommend the use of ‘spirometry' (the most common pulmonary function test that measures how much the lung can hold) to screen adults for chronic obstructive pulmonary diseases such as chronic bronchitis.

Will patients continue to be covered by OHIP for electrocardiogram and pulmonary function tests?

  • Yes. OHIP will continue to provide coverage for electrocardiogram and pulmonary function tests that are medically necessary.

What are the savings from this change in the first year (12/13)?

A total of $5million is projected to be saved as a result of this fee change.

When is this fee change effective?

  • This fee change is effective on April 1, 2012.

Supporting Evidence and For more Information

Screening for Chronic Obstructive Pulmonary Disease Using Spirometry: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2008;148:529-534

Screening Asymptomatic Adults With Resting or Exercise Electrocardiography: A Review of the Evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155:375-385

www.Clinipearls.ca/BCGuidelines

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Intermediate Assessment Fees

What does OHIP cover?

OHIP covers all physician assessment visits that are considered to be medically necessary and are listed in the Schedule of Benefits for Physician Services.

Changes to Fees for Intermediate Assessment Fees

On May 7, 2012,the government announced changes to fees paid to physicians for intermediate assessment visits.

What has changed and why?

  • The fee paid to a physician for an intermediate assessment visit has been reduced by $1.00 per visit. The new fee for intermediate assessments is still higher than the rate paid in October 2010.
  • Over the years, physicians have been claiming an increasingly higher number of office visits using this more expensive office visit code rather than using the lower fee for a minor assessment.
  • A growing number of family physicians practice in ‘primary care models'. A physician in a primary care model receives an overall fee for each patient enrolled with them. Because of the overall fee, primary care physicians are paid for a patient visit at 15 per cent of the rate that they would be paid if they were being paid on a per visitor ‘fee-for-service' basis.
  • The fee change for physicians in primary care models has therefore been reduced by only $0.15 per visit, not the full $1.00 reduction that a fee-for-service- physician would receive.
  • Fee changes are shown below:

Date

Intermediate Assessment Fee

Physicians in Primary Care Models

October 2010

$33.10

$4.97

October 2011

$34.70

$5.20

April 1, 2012

$33.70

$5.05

Will patients continue to be covered by OHIP for intermediate assessment visits to their physician?

  • Yes. OHIP will continue to provide coverage for these patient visits.

What are the savings from this change in the first year (12/13)?

A total of $25.1million is projected to be saved as a result of this fee change.

When is this fee change effective?

  • This fee change is effective on April 1, 2012.

For More Information

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Internal Medicine

What does OHIP cover?

OHIP covers all internal medicine services which are considered to be medically necessary and are listed in the Schedule of Benefits for Physician Services.

Changes to OHIP Internal Medicine-Related Fees and Services

On May 7, 2012, the government announced changes to several fees related to internal medicine including:

1. Cardiac Loop Recording

What is it?

Cardiac loop recording is a tool used by internal medicine physicians to measure a patient's heart rhythm over a time period, typically 14 days, to find infrequent rhythm changes in the heart. This tool can help an internal medicine specialist diagnose a heart condition.

Internal medicine specialists are paid a professional fee to interpret cardiac loop recording results and a technical fee to cover the cost to buy and maintain equipment and supplies.

What has changed and why?

  • The cost of cardiac loop recording equipment has gone down over the past 10 years.
  • There were two separate cardiac loop recording technical fees ($167.20 and $113.55) that could be billed.
  • These two fees have been combined into one new fee of $168.45.

Will patients continue to be covered by OHIP for cardiac loop recording tests?

  • Yes.

What are the savings from this change in the first year (2012/13)?

A total of $6.7 million is projected to be saved as a result of this fee change. These savings are from all physicians.

2. Electrocardiograms

What is it?

An electrocardiogram is a tool used to diagnose heart disease such as atrial fibrillation; fluttering of the heart.

What has changed and why?

  • The fee for an electrocardiogram has been reduced by 50 per cent from $9.90 to $4.95.
  • Since this tool was introduced in the 1960s there have been significant advances in technology.
  • For example, physicians now use computerized measurements to interpret results. It now takes significantly less time to interpret results and the number of electrocardiograms that can be processed in a time period has increased.
  • There has been a 26 per cent average increase in electrocardiogram services billed to OHIP per physician, per day, between 2006 and 2011.
  • In addition to the fee for an electrocardiogram, a cardiologist can also bill $157.00 for a consultation or $38.05 for a follow-up visit, if it is needed.

Will patients continue to be covered by OHIP for electrocardiograms?

  • Yes. Electrocardiograms will continue to be an OHIP insured service.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $21 million is projected to be saved as a result of this fee change.

3. Intensive or Coronary Care Unit Premium

What is it?

Intensive or coronary care is care provided to patients in a hospital who are being cared for in an Intensive Care Unit (ICU) or Coronary Care Unit (CCU).

What has changed and why?

  • A premium fee was paid to a physician, who was not the Intensive Care Unit physician, who visited an Intensive Care Unit or a Coronary Care Unit.
  • This premium fee of $9.10 will no longer be paid.
  • Patients in an Intensive Care Unit/Coronary Care Unit are treated by an intensive care specialist who is paid a daily fee.
  • If a different physician visits the patient, they are paid a visit fee and may also be paid an additional amount for the time to properly attire to enter the care unit.
  • This extra premium fee will not be paid in addition to the visit fee in the Intensive Care Unit as this is a requirement for attending any patient in the hospital.

Will patients continue to have access to intensive and coronary care?

  • Yes.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $3.4 million is projected to be saved as a result of this fee change. These savings are from all physicians.

4. Oximetry

What is it?

An oximetry test measures the oxygen available in the blood and is a common way to test the function of the lungs at rest and during exercise.

What has changed and why?

  • Payment for oximetry is included in the fee for echocardiography or cardiac monitoring. The additional fee will no longer be paid.
  • This change is being made to eliminate duplicate payment for the service.
  • An oximetry test is a specific diagnostic test that is needed to measure pulmonary or lung function. However, oximetry is being billed for monitoring during some procedures such as cardiac stress testing, where this monitoring is included in the procedure fee.
  • Oximetry fees are for the diagnosis and management of pulmonary disease and not for monitoring.

Will patients continue to be covered for oximetry testing by OHIP?

  • Yes.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $1.2 million is projected to be saved as a result of this fee change. These savings are from all physicians.

5. Chronic Dialysis Team Fee

What is it?

Dialysis is a medical process that removes waste and water from the blood. It is mostly used to treat people whose kidneys do not work well. Chronic dialysis is dialysis for patients who need this service on an ongoing regular basis.

What has changed and why?

  • Dialysis team management fees have been reduced by 10 per cent from $141.35 to $127.20 per week.
  • Physicians who specialize in kidney illness also care for patients who need dialysis. These physicians work in teams to manage patient care along with nurses and technicians. Physicians are paid a weekly fee per patient to do this.
  • This fee change was made because technology and improvements have made it easier and faster for physicians to run dialysis programs for patients. The use of teams to care for patients has also made it easier and faster for physicians to provide this service.
  • Between 2005 and 2010, there was an increase of almost 10 per cent in the number of patients for whom dialysis team care fees are being billed by physicians.

Will patients continue to be covered by OHIP for chronic dialysis services?

  • Yes.

What are the savings from this fee change in the first year (2012/13)?

A total of $13 million is projected to be saved as a result of this fee change.

6. Colonoscopy and Gastroscopy

What is it?

A colonoscopy is a test that looks at the inside of the large bowel or colon using a flexible scope. The scope is a tool that helps an internal medicine specialist to see the inside of the colon.

A gastroscopy is a test that looks at the inside of the stomach with a flexible scope. The scope is a tool that helps an internal medicine specialist to see the inside of the stomach.

What has changed and why?

  • Colonoscopy and gastroscopy fees have been reduced by 10 per cent. The complete fee for a colonoscopy was $218.90 and is now $197.20. The complete fee for a gastroscopy was $92.10 and is now $82.90.
  • This fee change has been made for both services because technological advances have improved productivity, and there has been no reduction in the fee for at least 10 years.
  • Colonoscopy and gastroscopy are now easier and faster for physicians to perform.
  • There has been a 29 per cent increase in colonoscopy services per physician per day between 2004 and 2010.

Will patients continue to be covered by OHIP for colonoscopy and gastroscopy tests?

  • Yes.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $10 million is projected to be saved as a result of this fee change.

7. Sole Procedure Premium

What is it?

A 'sole' procedure occurs when the only reason for a visit to a physician is for a diagnostic test and the physician does not assess the patient.

What has changed and why?

  • The sole procedure premium fee of $5.10 has been removed from nine procedures where there is a technical fee for the test already as the sole procedure premium fee is a duplication of payment.
  • For example, some tests such as electrocardiograms have a technical fee to pay for the operating costs of the service. The extra sole procedure fee is no longer payable in addition for this service as this would mean that the physician would be paid twice for operating costs.

Will patients continue to be covered by OHIP for sole procedure premium visits?

  • Yes.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $5.5 million is projected to be saved as a result of this fee change.

When are these fee changes effective?

  • These fee changes are effective April 1, 2012.

About Internal Medicine Fees

  • The average gross payments to internal medicine specialists are approximately $312,211.00 per year, as of 2011/12.
  • These billings have increased by 90 per cent since 2003/04.

Supporting Evidence and For more Information

Cardiac Loop Recording
Long-Term Continuous Electrocardiographic Recording: Recording Techniques
http://www.ncbi.nlm.nih.gov/pubmed/3529907

Electrocardiogram
Screening Asymptomatic Adults With Resting or Exercise Electrocardiography: A Review of the Evidence for the U.S. Preventive Services Task Force
http://www.ncbi.nlm.nih.gov/pubmed/21930855

Evidence Fails to Support ECG Screening for Those Without Heart Disease Symptoms
http://jama.jamanetwork.com/iedetect.aspx

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Intra-operative Monitoring of Neural Structures

What does OHIP cover?

OHIP covers procedures that are considered to be medically necessary and listed in the Schedule of Benefits for Physician Services.

Changes to the Fee for Intra-operative Monitoring of Neural Structures

On May 7, 2012, the government announced changes to the fee for intra-operative monitoring of neural structures.

What has changed and why?

  • The separate fee payable for intra-operative monitoring of neural structures has been eliminated because monitoring nerves is a necessary component of any surgery and already is included in the surgical fee. Intra-operative monitoring of neural structures is considered standard care for the patient in any surgery where it is needed.
  • The majority of surgical procedures do not include this separate fee.

Will patients continue to be covered by OHIP for intra-operative monitoring of neural structures?

  • Yes. Intra-operative monitoring of neural structures is considered to be a standard of care.

What are the savings from this change in the first year (2012/13)?

A total of $600,000 is projected to be saved as a result of this fee change.

When is this change effective?

  • This change is effective on April 1, 2012.

For More Information

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Joint and Spine Manipulation

What does OHIP cover?

OHIP covers all procedures that are considered to be medically necessary and listed in the Schedule of Benefits for Physician Services.

Changes to Fees for Joint and Spine Manipulation

On May 7, 2012,the government announced changes to fees for joint and spine manipulation.

What has changed and why?

  • The fee for joint and spine manipulation was removed from the Schedule of Benefits for Physician Services, except in specific circumstances where it is done under general anaesthesia for problems such as ‘frozen shoulder'.
  • Chiropractic services, which often include spinal manipulation, are no longer insured by OHIP as of 2004.
  • The decision to no longer pay physicians for this service is consistent with the decision to remove funding for chiropractors.

Will patients continue to be covered by OHIP for joint and spine manipulation?

  • Yes. When it is performed under general anaesthesia for problems such as "frozen shoulder," joint and spine manipulation will still be insured under OHIP.

What are the savings from this change in the first year (12/13)?

A total of $0.7million is projected to be saved as a result of this fee change.

When is this fee change effective?

  • This fee change is effective on April 1, 2012.

Supporting Evidence and For More Information

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Laparoscopic Surgical Fee Premiums

What does OHIP cover?

OHIP covers all surgical procedures that are considered to be medically necessary and listed in the Schedule of Benefits for Physician Services.

Changes to Fee Premiums for Laparoscopic Surgery

On May 7, 2012, the government announced changes to fee premiums for laparoscopic surgery.

What has changed and why?

  • The laparoscopic surgical premium of 25% which is added to the basic surgical fee will be reduced to 10%.
  • Laparoscopic surgery was once uncommon. Technology improvements in the 1980 and 1990s have meant that it is now often used. This benefits patients, because this type of surgery is much less harmful to the body.
  • When it was first introduced, laparoscopic surgery was complicated and new so surgeons received a higher premium for this type of surgery.

Will patients continue to be covered by OHIP for laparoscopic surgery?

  • Yes.

What are the savings from this change in the first year (12/13)?

A total of $1.1million is projected to be saved as a result of this fee change.

When is this fee change effective?

  • This fee change is effective on April 1, 2012.

For More Information

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Ophthalmology

What does OHIP cover?

OHIP covers all ophthalmological procedures that are considered to be medically necessary, and listed in the OHIP Schedule of Benefits for Physician Services.

Changes to OHIP Ophthalmology-Related Fees and Services

On May 7, 2012, the government announced changes to several fees related to ophthalmology, including:

1. Cataract Surgery

What is it?

Cataract surgery is the replacement of a diseased lens in the eye with a clear lens to improve eyesight.

What has changed and why?

  • The physician fee for cataract surgery has been reduced by 10 per cent, from $441.95 to $397.75.
  • This fee change was made because this surgery now takes less time to do.
  • Before the mid-1980s, cataract surgery took up to two hours, and the procedure was invasive and complicated. In the 1990's more advances in technology were made to implanted lenses.

Advances in technology and productivity, as well as changes in surgical technique, and the newer materials for lenses means less time to do the surgery and less risk to the patient. Cataract surgery now takes only about 15 minutes.

  • Ophthalmologists can now see more patients, perform more procedures in less time, and achieve better results than in the past. Will patients continue to be covered by OHIP for cataract surgery?
  • Yes. Cataract surgery is still covered by OHIP.

What are the savings from this change in the first year (2012/13)?

A total of $6.4 million is projected to be saved as a result of this fee change.

2. Intravitreal Eye Injections

What is it?

Intravitreal injections are mainly used to treat “wet” macular degeneration by ophthalmologists. The ophthalmologist injects a drug into the eye of the patient.

What has changed and why?

  • The physician fee for intravitreal eye injections has been reduced from $189.00 to $105.00 per injection.
  • This fee change was made because it now takes less time to give this type of injection.
  • The time taken to perform eye injections for retinal diseases now takes five to 30 minutes, down from approximately two hours, 10 years ago. Will patients continue to be covered by OHIP for intravitreal eye injections?
  • Yes.

What are the savings from this fee change in the first year (2012/13)?

A total of $9.9 million is projected to be saved as a result of this fee change.

3. Optical Coherence Tomography

What is it?

Optical Coherence Tomography (OCT) is a tool used by ophthalmologists to diagnose retinal disease of the eyes. Ophthalmologists use this tool to take a picture of the retina of the eye.

What has changed and why?

  • The physician fee for OCT has been reduced from $63.00 to $25.00.
  • Based on best medical evidence, the annual limit for the number of OCT tests has been changed from six per year per patient to four per year.
  • Technology has made OCT easier and faster for physicians to perform.
  • OCT machines now cost less, and physicians are performing more tests.
  • When it was first introduced, the fee for OCT was based on machines that cost $100,000.00 and a physician performing an average of 700 services per year. Now, the machines cost $75,000.00 and physicians are doing an average of 1,300 tests per year. Will patients continue to be covered by OHIP for OCT?
  • Yes.

What are the savings from this fee change in the first year (2012/13)?

  • A total of $18 million is projected to be saved as a result of this fee change.

4. After-Hours Procedural Premiums

What is it?

After-hours procedural premiums are extra payments for services provided to a patient between 5:00 p.m. and 7:00 a.m., or on weekends. These premiums increase payments by 20 to 75 per cent, depending on when they are provided.

  • Physicians who provide services in the evening, on weekends, or after midnight, will continue to receive an additional premium. The amount of the premium is being reduced by ten percentage points. For example, if the premium was 50 per cent, it will be reduced to 40 per cent.
  • There have been significant improvements in payments for consultation, assessments, and visits over the last eight years, especially when physicians need to make special after-hours visits to the hospital. These payments are over and above the after-hours procedural premiums.
  • The following fee example is for an appendectomy, done by a general surgeon:
    • A general surgeon is paid a consultation fee, a fee for a special visit to the ER, a fee for surgery, and an after-hours premium
    • Total fee during the day: $503.30
    • Total fee in the evening: $657.94
    • Total fee after midnight: $785.09
    • In this example, it is likely that the general surgeon would be on-call for evening and after-midnight procedures and would also be entitled to Hospital On Call Coverage payments, which on average pay $472.00 per day.

Will patients continue to be covered by OHIP for surgery after-hours?

  • Yes. Procedures performed in the evening, after midnight, and on weekends, will continue to be covered under OHIP.

What are the savings from this fee change in the first year (2012/13)?

A total of $13 million is projected to be saved as a result of this fee change.

When are these fee changes effective?

These fee changes are effective April 1, 2012.

About Ophthalmology Fees

  • The average gross OHIP payments to ophthalmologists are approximately $666,477.00 per year, as of 2011/12.
  • These gross payments have increased by 61 per cent since 2003/04.

Supporting Evidence and For more Information

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Paediatricians Treating Adult Patients

What does OHIP cover?

OHIP covers all paediatric treatment that is considered to be medically necessary and listed in the Schedule of Benefits for Physician Services.

Changes to Fees for Paediatricians who Treat Adult Patients

On May 7, 2012, the government announced changes to fees for treatment of adult patients by paediatricians.

What has changed and why?

  • The Schedule of Benefits for Physician Services has been changed to give clear direction about when a paediatrician will be able to bill for services to adults using paediatric fees, and when they will be paid as a non-specialist.
  • Paediatric fees, like other specialist fees, are paid at a higher rate than non-specialist fees. For example, an intermediate assessment done by a general practitioner (a non-specialist) pays $33.70, while a similar assessment provided by a primary care paediatrician pays $42.15. This change was made because in some cases paediatricians see adults and claim paediatric fees when it is more suitable for them to be paid using family or general physician fees.
  • It is appropriate for a paediatrician to be paid as a paediatrician when they assess or treat an adult who is developmentally delayed or has a childhood disorders such as cystic fibrosis and is not able to be treated by an adult specialist because of this condition. Similarly, a paediatrician who has other special training, for example as an allergist, may see adult patients for allergy treatment and be paid as a specialist for providing this care.
  • In other cases, a paediatrician seeing an adult should be paid as a non-specialist. For example, if a paediatrician works in a walk-in clinic and treats adults in the clinic, the paediatrician would be paid as a general practitioner for providing that care. In a case where a paediatrician sees a 30 year old man with low back pain in a walk-in clinic that physician is not using their speciality training to assess the patient.
  • There are exemptions to this fee change for physicians outlined in the Schedule of Benefits for Physicians. Paediatricians may also write to the OHIP regional office to request an exemption.

Will adult patients continue to be covered by OHIP when they are cared for by a paediatrician?

Yes.

What are the savings from this change in the first year (12/13)?

A total of $6million is projected to be saved as a result of this fee change.

When is this fee change effective?

  • This fee change is effective on April 1, 2012.

For More Information

OHIP bulletin for Paediatricians Treating Adults
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4565.pdf

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Positron Emission Tomography (PET) Scans for Oesophageal Cancer

What does OHIP cover?

OHIP covers procedures that are considered to be medically necessary and listed in the Schedule of Benefits for Physician Services.

Changes to the Coverage for PET Scans for Oesophageal Cancer

On May 7, 2012, the government announced changes to the coverage for PET scans for oesophageal cancer.

What has changed and why?

  • Before April 1, 2012, PET scans for oesophageal cancer were available through research-based programs administered by CCO, but were not insured by OHIP. The ministry paid Cancer Care Ontario (CCO) for the scans that were done in these programs and (CCO) paid providers for the test.
  • On April 1, 2012, PET scans for oesophageal cancer became an OHIP-insured service. This evidence-based change was made based on recommendations of the Ontario PET Steering Committee who said there was now enough evidence to show that PET scans were helpful in the diagnosis and treatment of oesophageal cancer for the test to be insured by OHIP.
  • A PET scan for oesophageal cancer helps to determine the form of treatment.

What are the savings from this change in the first year (2012/13)?

  • There are no cost savings from this change because the PET scan fee for the tests covered by OHIP is the same rate that was paid by the ministry for scans through Cancer Care Ontario.

When is this change effective?

  • This change is effective on April 1, 2012.

Supporting Evidence and for More Information

Cancer Care Ontario's Program in Evidence-Based Care: PET Recommendation Report 4 Version 2, 'PET Imaging in Esophageal Cancer', updated November 30, 2010. https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=43135

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Physician to Physician E-Consults

What does OHIP cover?

OHIP covers consultations between physicians that are considered to be medically necessary and listed in the Schedule of Benefits for Physician Services.

Changes to Fees for Physician to Physician Consultation

On May 7, 2012, the government announced a new service for physician-to-physician consultation.

What has changed and why?

  • Physicians will now be paid a fee for consulting with other physicians using secure email.
  • In many cases, family physicians will be able to receive advice from a specialist by secure email and there will be no need for a face-to-face visit for the patient with the specialist.
  • Consulting by email will help provide better access to care for patients. It will allow physicians to care for patients more quickly, reduce wait times and visits for patients and reduce duplication in the system.

Will patients continue to be covered by OHIP for consultations between physicians?

  • Yes.

What are the savings from this change in the first year (2012/13)?

No savings will be achieved as a result of this fee change

For More Information

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Quality of Diagnostic Tests and Technical Fees for Diagnostic Tests

What does OHIP cover?

OHIP covers fees for all diagnostic tests that are considered to be medically necessary and listed in the Schedule of Benefits for Physician Services.

Changes re: Quality of Diagnostic Tests and Technical Fees for Diagnostic Tests

On May 7, 2012, the government announced changes to technical fees for diagnostic tests and to the accountability for the quality of the tests that are done.

What has changed and why?

  • The Physician Schedule of Benefits has been changed to state the physician is personally responsible for the quality of the service or test for which he or she submits a technical fee to OHIP.
  • Changes have also been made to reduce technical fees for all diagnostic tests by $20million per year for four years.
  • Improvements in technology for diagnostic services have increased productivity. Canada Health Infoway's's Diagnostic Imaging Benefits Evaluation Report cites a 25-30% increase in productivity due to the introduction of a Picture Archiving and Communication Systems (PACS).

Will patients continue to be covered by OHIP for diagnostic tests?

  • Yes. OHIP will continue to provide coverage for diagnostic tests for insured persons that are medically necessary.

What are the savings from this change in the first year (12/13)?

A total of $20 million is projected to be saved as a result of the technical fee reductions.

When is this fee change effective?

  • This fee change is effective on April 1, 2012.

For More Information

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Self-referred diagnostic tests

What does OHIP cover?

OHIP covers all diagnostic tests which are considered to be medically necessary and listed in the Schedule of Benefits for Physician Services.

Changes to Fees for Self-Referred Diagnostic Tests

On May 7, 2012, the government announced changes to fees for self-referred diagnostic tests.

What has changed and why?

  • The Ministry of Health and Long-Term Care is currently seeking expert advice on implementation of this fee change through the Expert Panel on Appropriate Utilization of Diagnostic and Imaging Studies, chaired by Dr. Barry Rubin, vascular surgeon at University Health Network.
  • The ministry's goal is to ensure correct use of diagnostic and imaging studies in Ontario.
  • This amendment reduces the professional and technical fees for diagnostic tests that a physician refers to him or herself, by 50 per cent.
  • Until the ministry receives recommendations from the Expert Panel, fee codes that could be impacted by the self-referral regulation will continue to be paid at 100 per cent because the Ministry has not implemented the systems changes to reduce the specific fee codes to 50 per cent.
  • These payments may be impacted by the recommendations from the Expert Panel.
  • A technical fee is a fee towards the overhead costs for a diagnostic service. It covers the cost of premises (e.g., rent, lease, equipment, supplies and staff).
  • A professional fee is a fee paid to a physician for reading, interpreting and/or directing a test.
  • This change is based on a review of best medical evidence which has shown that self-referral for diagnostic tests can lead to unnecessary testing.
  • Literature from the Canadian Medical Association Journal from March 2004 showed that physicians who referred testing to themselves were up to seven times more likely to self-refer if they owned the equipment to do the test.

Will patients continue to be covered by OHIP for diagnostic tests that are self-referred?

  • Yes. OHIP will continue to provide coverage for diagnostic tests that are self-referred.

What are the savings from this change in the first year (2012/13)?

A total of $44.1 million is projected to be saved as a result of this fee change.

When is this fee change effective?

  • This fee change is effective April 1, 2012.
  • Until the ministry receives recommendations from the Expert Panel on Appropriate Utilization of Diagnostic and Imaging Studies, fee codes that could be impacted by the self-referral regulation will continue to be paid at 100 per cent because the Ministry has not implemented the systems changes to reduce the specific fee codes to 50 per cent.
  • These payments may be impacted by the recommendations of the Expert Panel.

Supporting Evidence and For more Information

Unregulated private markets for health care in Canada? Rules of professional misconduct, physician kickbacks and physician self-referral
http://www.cmaj.ca/content/170/7/1115.full.pdf

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Sole Procedure Visit Premium Fee

What does OHIP cover?

OHIP covers all visits and procedures, including diagnostic tests, which are considered to be medically necessary and listed in the Schedule of Benefits for Physician Services.

Changes to the Sole Procedure Premium Fee

On May 7, 2012, the government announced changes to sole procedure premium fees for patients who are cared for by a physician who is part of a Family Health Network or a Family Health Organization.

Family Health Networks and Family Health Organizations are specific health care models called capitation models. Physicians who work in these models are paid a flat fee for each patient that is assigned to them. The fee covers a specific basket of services.

What has changed and why?

  • When a patient is enrolled in a Family Health Network or Family Health Organization capitation model health care group, the premium fee for a sole procedure visit has been reduced by 85 per cent, from $5.10 to $0.77.
  • The sole procedure premium fee has been reduced to align payment of a service that is already included in the capitation payment amount.

What does the physician receive over and above the sole procedure visit premium?

  • The physician will receive the fee associated with the particular diagnostic test, in addition to the sole procedure premium fee. The fees for diagnostic tests vary, depending on the test.

Will patients continue to be covered by OHIP when the only reason for a visit to a physician is for a diagnostic test and the physician does not assess the patient?

  • Yes. OHIP will continue to cover all patient visits and procedures, including diagnostic tests, when they are medically necessary.

What are the savings from this change in the first year (2012/13)?

A total of $2.2million is projected to be saved as a result of this fee change.

When is this fee change effective?

  • This fee changeis effective on April 1, 2012.

For More Information

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

Vein Surgery and Sclerotherapy

What does OHIP cover?

OHIP covers all vein surgery and sclerotherapy procedures that are considered to be medically necessary and listed in the Schedule of Benefits for Physician Services.

Changes to Fees for Vein Surgery and Scleropathy

On May 7, 2012,the government announced changes to the criteria or conditions where vein surgery and sclerotherapy will be insured by OHIP.

What has changed and why?

  • Fees for vein surgery and sclerotherapy have not changed; however, specific medical conditions have been added to identify when a patient will be eligible for OHIP coverage for vein surgery or sclerotherapy. Coverage will be provided when these services are medically necessary.
  • These changes have been made because recent reviews by the Ontario Health Technology Advisory Council provided specific conditions or circumstances when vein surgery would be medically necessary. Before this change, the conditions for treatment were not clearly laid out in the Schedule of Benefits.

Will patients continue to be covered by OHIP for vein surgery and scleropathy?

  • Yes. Those who need the treatment will receive it. It will be up to the physician to decide whether the treatment is medically necessary.

What are the savings from this change in the first year (2012/13)?

A total of $100,000 is projected to be saved as a result of this change.

When is this fee change effective?

  • This fee change is effective on April 1, 2012.

Supporting Evidence or For More Information

Ontario Health Technology Advisory Council:
http://www.health.gov.on.ca/english/providers/program/ohtac/tech/recommend/rec_rfa_vv_20110216.pdf

For More Information

OHIP InfoBulletin #4561
Amendments to the Schedule of Benefits for Physician Services
http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4561.pdf

For More Information

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