When doctors become numb to money

Taureef Mohammed

“IN MEDICINE you can make how much ever money you want – it is entirely up to you,” a Canadian physician once told me.

I had asked her for some advice on billing for services provided and after some discussion it was obvious there was no clear answer. She was right: it was entirely up to me.

In Canada, all essential healthcare is free, meaning patients do not pay out-of-pocket for any essential service. Hospitals and clinics are privately run, but the government pays all the bills. It is a single-payer system, funded mostly through taxes.

Every four years, the government negotiates the fees with the doctors’ representative associations, and issues a standard fee schedule – the latest edition is 980 pages – that every physician is bounded by. Although the price of each service is fixed, there is flexibility in how the fee schedule is applied, leading to large discrepancies in how physicians bill.

This made the news circuit a few years ago when the Toronto Star published a list – which they compiled based on data from the Ministry of Health accessed through a freedom-of-information request – of the highest billing physicians in Ontario. Let us look at internal medicine specialists as an example.

According to the Canadian Medical Association – Canada’s national doctors’ association – the average annual income of an internal medicine specialist in Canada is 437,000 Canadian dollars (CAD). The internists who made The Star’s list billed upward of one million CAD annually.

Now, based on the fee schedule, it is expected that physicians’ billings will vary based on different factors; for example, how often one is on-call, how many patients one sees, how many procedures one performs, etc. But it is naive to think that’s all there is to it. Everybody in Canada knows there is more to it, and knows that some doctors intentionally haemorrhage the system. There are some safeguards in place to limit the haemorrhage.

In Canada, that the government pays all the bills is itself a kind of protection. Doctors negotiate with and bill the government, not the individual patient who is facing his mortality and will pay anything – will empty his bank account without blinking twice – to live.

The fee schedule, although not perfect, provides a standard to which doctors are held to. The ministry of health conducts audits on medical records and billing claims to identify discrepancies. And, like in everything else, transparency is a kind of auto-regulator.

But despite all of this, as the Toronto Star investigative report showed, “In medicine, you can make how much ever you want – it is entirely up to you.”

What is the situation like in TT?

There are two parallel healthcare systems in TT: a public system where doctors are salaried, and a private system where doctors bill for every patient they see. In the private system the patient is the customer and pays out-of-pocket. In TT, the cost of private healthcare is largely unregulated.

I asked a couple colleagues who work in the private healthcare system in TT about the guiding principles for billing patients in the private sector.

“There is no governmental organisation that regulates the cost, so people (doctors) can do as they please,” an internist told me.

Saying that TT was a small place, where everybody knew everybody’s business, he added: “Some doctors bill according to how much they know a person could pay.”

Another colleague, a family physician, described how she had noticed that some specialists charged higher prices simply because, it seemed, they were more well-known, and charismatic.

“I don’t refer my patients to them,” she said, matter-of-factly, adding she referred to specialists who were less well-known, less glamorous, less expensive, and just as smart.

A friend who recently needed surgery told me about her experience with two private surgical practices in Trinidad. One quote was double the other. Perhaps there was an explanation – maybe the more expensive quote was based on a more advanced technology. But this is my thinking, as an insider, a doctor. The public does not see these nuances – and the medical profession is not transparent enough to allow them to. It leads to mistrust.

Speaking about the surgeon who charged a lower price, my friend said: “He is just a good man.”

Those who strived to be reasonable, the Trinidadian internist pointed out, would seek out advice from mentors and try to find common ground. “It’s something that you have to think about when you start. In the end, it comes down to what is within. But some doctors become numb.”

Taureef Mohammed is a physician from TT working in Canada

E-mail: taureef_im@hotmail.com