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December 31, 2001 

(Sent by fax and by mail)

Dr. John Wade, Chair
RBRVS Commission of Ontario
56 Wellesley Street West, 15^th Floor
Toronto, Ontario M7A 2B7
(416) 327-6389
(416) 327-7091 fax

Dear Dr. Wade and fellow members of the RBRVS Commission,

RE:  September 2001 Draft Report

As the current leader of the Coalition of Family Physicians of Ontario, which has a growing membership nearing 3000, I present to you a few comments pertaining to your September Draft Report.

I first wish to commend you and your colleagues for the huge effort that has gone into your work to date.  Having been at a number of your presentations over the years as well as being involved in one of your several-hour long information-gathering exercises has provided me with a good understanding of the work you are doing.  You and your colleagues have expressed that this process is not new, and that it is not entirely successful in other countries or provinces.  If an ideal RBRVS existed in the world, then your work would be simple.  This is obviously not the case.  You have had to make a number of choices in your methodology to come up with these results.

It is a shame that there is a perception that the current OHIP Schedule of Benefits is so flawed that an entire over-haul is required.  This is in spite of the ongoing work of the OMA’s Tariff and other committees.

To provide you this letter, I have tapped into the knowledge our executive and feedback from our members.  Contrary to the OMA prediction that our total billings would increase by 4%, we see that there is generally no change at all for the primarily office-base family doctor.

We have a number of concerns and the following are our key points:

1. This RBRVS draft does not resolve this key fundamental issue that specialists receive far greater remuneration relative to family physicians.  Relative to specialists, our current net incomes are close to only 60%.
   
2. Using Revenue Canada data for practice costs is a mistake and likely does not accurately reflect true practice costs.  We also question how you acquired such data.
   
3. The intensity multiplier formula used is entirely arbitrary and seems unfair.  You modestly increase codes at the lowest end and nearly double the codes at the highest end.  It is a shame that our “bread and butter” codes A001A and A007A fall in the range of virtually no multiplier effect.
   
4. Our knowledge and judgment, work time and intensity ratings are too low.  We family physicians have a huge knowledge base for every body system.  Our patients have multi-system symptoms.  We have to formulate new diagnoses from these.  It is common to see patients with chest pain, abdominal pain, headaches, fatigue, dizziness and emotional distress in a single visit.  This respectfully contrasts to specialists for whom we send patients many already bestowed with most of their diagnoses and tests.  In addition, we do our work at a very intense high volume rate.  This in turn results in a large amount of unpaid work time for interpretation of results, reviewing consultant and hospital reports, CME, and dealing with large amounts of office scheduling, chart maintenance, phone calls, and prescription continuation.  Lastly, it makes no sense that your current intensity ratings for our office visits codes fall far below those of psychotherapy codes.
   
5. Our communication and interpersonal skills are rated far too low as well.  Every day, our patients come to us to communicate to them what their specialists cannot.  They also come to us for ongoing support and reassurance.  These critical skills create a strong and special bond with our patients to give them the emotional support they need at every visit.
   
6. Lastly only one fee example:  The proposed A001A = $13.18 is simply offensive.  This amount to schedule and appointment, take a history, physical exam, diagnosis, plan, treatment, and documentation is not plausible.  Family physicians who charge for telephone prescription repeats usually charge a greater fee of $15.00.

In summary, you and your colleagues have done a tremendous amount of work.  It is not clear why there is a need to replace the current fee schedule.  My colleagues and I are concerned with several issues: a perpetuated large family doctor to specialist pay inequity, the use of Revenue Canada data for overhead costs, the intensity multiplier issue, the low ratings for our work in time, intensity, knowledge and communication/interpersonal skills, and the A001A example.

Presently, this draft is unacceptable.

Here is one final thought.  All doctors simply want to be fairly remunerated for their work with respect to its amount of time, risk and responsibility relative to other professionals in society.

Sincerely,

Douglas J. Mark M.D.

President

CC          OMA President Dr. Ken Sky and Board Members
                OMA SGPFP Chair Dr. Kathryn Lockington
                OAR
                OCFP
                OPA
                PAIRO