Monday, November 14, 2011

Getting Stiffed!

Most doctors outside of Soviet Canuckistan (as an American commentator called us) assume that doctors in Canada are salaried employees of the state. While it would be nice to have paid holidays and a pension plan, this fortunately or unfortunately is not the case. We do get over 90% of our income from the government either through the provincial health plan or through Workers Compensation, however we do this in a fee for service fashion. This means that we have to eat what we kill and as anaesthesiologists we are dependent on what the surgeon brings to the OR for our living. Depending on your outlook this either gives you the best or the worst of the public and private systems. We are fortunate in only having to deal with a small number of payers.

All Canadians citizens and landed immigrants are theoretically eligible for health care in Canada. I emphasize the word theoretically. It is first of all necessary to register. This is not automatic, when you are born you are registered with your parents, when you turn 18 or when you finish university it is necessary to re-register. Nobody tells people that and so some people don't bother. Some people apparently believe Medicare violates their religious or other freedoms and intentionally refuse to register. I get a list of their numbers about once a year. Some provinces also charge premiums. Our province did until 3 years ago, as an election promise, premiums were removed. Every province that charged premiums also had premium assistance for low income patients including the working poor. Some people of course proudly refused to apply for premium assistance, considering it to be a form of welfare. They weren't too proud of course to stiff the doctor. Some people intentionally didn't pay their premiums knowing that they were unlikely to use the healthcare system, if it was minor the fee would be less than their premiums and if it was major the province would allow them to "back pay" their premiums. One of these people wrote me a nasty letter after I billed $47.00 for seeing her daughter for an earache at 0600. And no, there wasn't a cheque in the letter.

Things have improved but at one time up to 20% of patients in the provinces that charged premiums did not have medical coverage. When we did have premiums, they were often paid by employers. If the patient changed jobs or his company went out of business or if they "forgot" to pay their premiums, they weren't covered anymore and you didn't get paid. One lady I saw in the Pain Clinic was supposed to have her ex-husband pay her premiums as part of the divorce settlement. When I advised her that her last billing had "bounced" she burst into tears. Not very therapeutic.

Some people also move around a lot. During the oil boom we had many people from other provinces presenting to the OR. Most have them had lived in our province for a year or more but still had their original province's healthcare number. Surprisingly I got paid for most of these. Because all Canadians are supposed to get healthcare, the federal government has agreed to cover those people for whom no province will cover. This is a bureaucratic process but may be worthwhile if you have a particularly long case.

It is actually visitors to our country who are the most likely to stiff you. Most people are smart enough to buy travel insurance. Travel insurance however, typically has a ceiling which, if hospitalization or ICU is involved is quickly reached, with the hospital getting all the money before there is any consideration of paying you. I did a fellow from New Zealand years ago who came to Canada to ride in the rodeo. He had an insurance policy which had a $200 per day limit. I did send a bill to the Canadian address he provided and it came back "return to sender". Insurance companies also require you to send the bill to the patient who is supposed to pay you and send the bill to them for reimbursement. Most patients don't bother. There are exceptions of course. One very wealthy American that we did an emergency subdural on, not only paid but phoned me to make sure I had gotten the cheque.

In the scheme of things, we are well paid and at the end of the year, the couple of hundred bucks someone didn't pay you doesn't really affect your income that much. The problem is that many of these cases were emergency cases where you either got out of bed, as for the American hunter who shot himself in the foot requiring an emergency debridement at 0400 or stayed late as in the case of the kick-boxer from Switzerland who had the 5 hour ORIF of his mandible (I stayed late because most surgeons take only a hour to do these; this surgeon let the resident do the case and then had to re-do himself). I have heard some anaesthesiologists advise guests to Canada requiring surgery, "The fee is ____, there is a cash machine in the lobby." I have never had the cojones to do this.

What has often bothered me about getting stiffed is not the lost income; I do lots of things for free. I just wish sometimes people would just tell me that they can't or won't pay; I could then decide whether or not to do the case and if I did do the case I could get the moral feel-goodness that you just can't put a price on.

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