Fee code creep

CMAJ 1998;159:316-18

In response to Dr. Wells's question about funding and potential bias, I would like to point out that this study was paid for exclusively by the Institute for Clinical Evaluative Sciences. Our results were provided in advance to various joint Ontario Medical Association–Ministry of Health working groups dealing with fee schedule reform, and our analysis was well received by both sides as objective and informative.

Ms. Mitchell-Gill suggests that fee code creep occurs because patients are being discouraged from returning for re-assessment because of physicians' increasing workloads. The logic of this argument is unclear: if physicians' workloads are expanding, the response would more likely be to perform shorter (i.e., minor) assessments; indeed, this is what we saw among physicians with a high volume of office visits. Perhaps Ms. Mitchell-Gill's point is that follow-up visits, which tend to be minor assessments, are being eliminated with the increasing patient load. However, this assertion is inconsistent with the data, which indicate that the number of intermediate and minor assessments per patient has risen substantially, from 2.7 in 1981/82 to 3.6 in 1994/95 (values based on a re-examination of our data). Patients are getting more follow-up from their physicians over time, not less.

The letters prompted by our articles provide an interesting counterpoint: one of them notes that our paper on fee code creep is excessively cautious and avoids the "g" word, whereas another criticizes the reference to supply-induced demand and the potential for physicians to "maintain their incomes" through coding practices. Perhaps this is the best time to address the question that appears to be on many readers' minds: Is fee code creep the result of physicians trying to give themselves a raise? The letters from Drs. Richardson and Hanley do not quite suggest this, but they do suggest the similar hypothesis that doctors have been using their discretionary powers in coding visits to counter the downward pressures on their incomes. Weighing against this hypothesis, however, is our observation that fee code creep occurred long before the expenditure caps of the 1990s. Indeed, the fees for intermediate and minor assessments rose by 2% to 3% per year between 1981 and 1988,² even after adjustments for inflation in the health care sector,³ yet the ratio of intermediate to minor assessments (I–M ratio) rose by 10% per year during the same period.

I would argue that searching for greed as a motive is unproductive. An alternative hypothesis is that the vagueness of the definitions of intermediate and minor assessments may lead physicians to use the mean I–M ratio as a de facto standard. Each time the mean shifts upward (for example, as recent graduates with higher I–M ratios enter the system), the de facto standard also shifts upward. Physicians with lower I–M ratios might examine the mean and conclude that their definition of an intermediate standard is more conservative than that of their peers and raise their I–M ratios accordingly. This behaviour may reflect not inappropriate motives but simply a desire to be treated fairly. Nonetheless, the result is a continually increasing de facto standard. As one family practice colleague suggested to me, the billing profiles that the Ontario Health Insurance Plan sends to each physician may, ironically, be contributing to fee code creep.

An analysis of these group dynamics would make for an interesting dissertation for a psychology major but would not alter the key message of our study: we need clearer guidelines as to what constitutes an appropriate office visit. The demonstrated variation in I–M ratios suggests that there is no consensus on the basic issues of how much time a physician should spend per patient visit and what is an appropriate level of detail for the visit. Some physicians have high-volume practices with brief visits, others have low-volume practices with more detailed visits. Which is preferable for our patients? It is high time that we, as a medical profession, did some hard thinking about the model of care we should be encouraging.

Ben Chan, MD, MPA
Scientist
Institute for Clinical Evaluative Sciences
Toronto, Ont.

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1. Woodward CA, Hutchison B, Norman GR, Brown JA, Abelson J. What factors influence primary care physicians' charges for their services? An exploratory study using standardized patients. CMAJ 1998;158(2):197-202.
2. Schedule of benefits: physician services under the Health Insurance Act (versions 1981 to 1988). Toronto: Ministry of Health; 1981–1988.
3. Statistics Canada. Consumer prices and price index. Cat no 62-010-XPB. Ottawa: Minister of Industry; quarterly.