BOARD MEMBERS

Dr. David Goldstein

President

Dr. Alfred Margulies

1st Vice President

Dr. Robert Grossman

2nd Vice President

Dr. Michael Ross

3rd Vice President

Dr. George Rado

Secretary

Dr. Jack Richman

Treasurer

Dr. Arthur Ameis

Immediate Past President

Dr. Kathleen Armitage

 Member at Large

Dr. Harold Becker

Member at Large

Dr. Richard Finkel

Member at Large

Dr. Douglas Friars

Member at Large

Dr. Irving Grosfield

Member at Large

Dr. Robert Notkin

Member at Large

Dr. L. Edward Puodziukas

Member at Large

Dr. Don Ranney

Member at Large

Dr. Howard Seiden

Member at Large

The Canadian Society Of Medical Evaluators had its AGM on November 24, 2003.  After approving the minutes of last year's AGM, Dr. Goldstein informed members that CSME had been asked to submit a proposal to the Liberal government, identifying further cost-saving measures to the system.  This was followed by an open discussion from all those in attendance.  Based on this input, Dr. Goldstein informed members that he would attempt to articulate their suggestions to Mr. Michael Colle.  Readers are referred to the actual submission enclosed with this newsletter.

In October 2003 and after more than a year of discussions, the Government Of Ontario introduced a new Statutory Schedule For Accident Benefits.  While a number of changes were introduced, one of the most significant ones affecting CSME members relate to the role of Insurer Examinations.  Specifically, the Government restricted insurers from requesting Insurer Examinations under section 42 to determine entitlement to medical/rehabilitative benefits unless the claim for benefit was subject to a mediation or arbitration proceeding.  As a result, insurers have had to review their approach to ordering Insurer Examinations and the issues they want addressed. 

On December 4, 2003 CSME members gathered at a breakfast seminar to discuss the Economic and Related Parameters in MedicoLegal Service Billing.  CSME has been attempting to influence the OMA in regard to revising and updating the existing fee guidelines with a more current set of fees and qualifiers.  The current Guidelines do not adequately address many of the issues related to the provision of third party medical examinations in the current, often highly adversarial medicolegal environment. 

November 25, 2003

Mr. Michael Colle

Parliamentary Assistant to the Minister of Finance

7 Queen’s Park Crescent

Frost Building, 7th Floor

Toronto, Ontario

M7A 1Y7

RE:    CANADIAN SOCIETY OF MEDICAL EVALUATORS SUBMISSION

          PRESENTATION DATE – TUESDAY, NOVEMBER 25, 2003, 9:30 AM

 Who We Are

The Canadian Society of Medical Evaluators (CSME) represents the doctors who, in addition to their clinical activities, complete independent medical examinations.  In the context of Ontario car insurance, our members perform plaintiff, insurance and DAC examinations.  We are the group of physician and surgeon experts that the judiciary, industry and the legal communities rely on.

Scope Of Recommendations

This submission will be restricted to an analysis of the provision of care and the effective utilization of medical experts in order to assist the government in identifying insurance cost savings resulting in lower automobile insurance premiums, and importantly, a reduction in the morbidity and cost to society of poorly managed clinical conditions associated with motor vehicle trauma.

Summary of the AGM

The Canadian Society Of Medical Evaluators had its AGM on November 24, 2003.  After approving the minutes of last year's AGM, Dr. Goldstein informed members that CSME had been asked to submit a proposal to the Liberal government, identifying further cost-saving measures to the system.  This was followed by an open discussion from all those in attendance.  Based on this input, Dr. Goldstein informed members that he would attempt to articulate their suggestions to Mr. Michael Colle.  Readers are referred to the actual submission enclosed with this newsletter.

The floor was then opened to a discussion as to expanding the associate member category to attract non-physician members.  The definition of an associate member was altered and approved as follows:

 "Physicians or others who do not meet the qualifications for active membership status may apply to the Membership Committee, to become an associate member.  Associate members may attend the annual general meeting, without the right to vote and must abide by the Canadian Society Of Medical Evaluators standards."

With this wording, those in attendance voted that the Board be given the authority to make an appropriate decision as to which professional groups would make up "others" as referred to above.  Members interested in participating in this discussion should plan to attend the next executive meeting where this is listed as an agenda topic.

Continuing medical education was discussed.  It was decided that CSME would run one or possibly two programs in the upcoming years, with perhaps some smaller, breakfast-type seminars.  The objective here, being to attract more sponsors and generate larger revenues for conferences, as opposed to running four smaller and less attended programs.

Dr. Michael Ross provided feedback to the membership regarding his interaction with the OMA and with specific respect to fees.  He informed the group that the OMA would not agree to set minimum fees for third party medical examinations, as they felt this was an individual physician issue and would lead to unacceptable limits on others.  They informed Dr. Ross that the third party fee guideline was going to be sent to the committee on economics for review spring 2004

On standards, Drs. Ameis and Ross agreed to review and update a variety of position papers as well as the information pamphlet on third party examinations.  Following this, the Treasurer's Report was reviewed and approved and elections were carried out.  The same executive will continue to fulfil its second year of service.  The meeting was then adjourned.

Commentary on Auto Insurance Reform

In October 2003 and after more than a year of discussions, the Government Of Ontario introduced a new Statutory Schedule For Accident Benefits.  While a number of changes were introduced, one of the most significant ones affecting CSME members relate to the role of Insurer Examinations.  Specifically, the Government restricted insurers from requesting Insurer Examinations under section 42 to determine entitlement to medical/rehabilitative benefits unless the claim for benefit was subject to a mediation or arbitration proceeding.  As a result, insurers have had to review their approach to ordering Insurer Examinations and the issues they want addressed. 

Based on input from our members, there has not been consistency in how insurers have dealt with med/rehab issues in the context of Insurer Examinations.  Some insurers have alluded to treatment aimed at reducing or eliminating disability.  Others have continued to ask a wide spectrum of treatment related questions, while others have confined their questions solely to disability and impairment matters. 

It would appear that all med/rehab issues have now been deferred to med/rehab DACs.  However, while the conservative government had proposed expansion of the DAC system and while many members were involved in these submissions, this entire process would seem to have been shelfed by the recently elected liberal government.  In addition, while many concerns have been raised about the DAC model of assessment based on peer review, this has not been addressed.

The net result is that physicians completing Insurer Examinations may now have less input and influence on treatment issues while those with lesser levels of clinical training  (based on peer review) have been designated to do so.  This is of obvious concern to physicians and especially CSME members who have substantially greater levels of clinical expertise than non-physicians assessors within the DAC system. 

More concerning, is that while a number of changes have been introduced and little time given to adjust, the newly formed Liberal Government is working quickly on further revisions to auto insurance.  As part of this process, the Canadian Society Of Medical Evaluators was asked to provide a submission as one of many stakeholders in the process.  On November 25, 2003  CSME prepared a submission to the government, which was presented by Drs. David Goldstein and Howard Seiden to Mr. Michael Colle, MPP, assistant to the Minister Of Finance.  Also in attendance were representatives from the Financial Services Commission Of Ontario.  A copy of this submission can be found within this newsletter.

Economic and Related Parameters in MedicoLegal Service Billing:
Introducing the CSME Draft Guideline Initiative

On December 4, 2003 CSME members gathered at a breakfast seminar to discuss the Economic and Related Parameters in MedicoLegal Service Billing.  CSME has been attempting to influence the OMA in regard to revising and updating the existing fee guidelines with a more current set of fees and qualifiers.  The current Guidelines do not adequately address many of the issues related to the provision of third party medical examinations in the current, often highly adversarial medicolegal environment. 

Dr. Michael Ross and Dr. Arthur Ameis offered attendees a forum to discuss the current guidelines and offer suggestions for the revised guideline.  Dr. Ross explained that before CSME wrote the draft guidelines many different groups were polled.  The poll showed a wide range of doctors' fees and protocols, with a striking lack of uniformity and clear need to share cumulative wisdom and experiences.

The majority of participants felt a doctor of little experience should be charging $250-$300/hour and more experienced doctors should be charging a minimum of $350/hr.  There is broad support for these figures and keen support for establishing a minimum hourly charge, but not a maximum.

Dr. Ameis went on to explain that hourly rates are not the only things CSME needs to address in their draft guidelines.  There are many modifiers to the billing process.  Physicians need to address whether to bill hourly, unitary or at a block rate.  Cancellation policies, time stress, risk determination, travel time/kilometres, retainers vs. prearranged fees, court testimony, and office costs were all discussed as relevant fee modifiers.  For example, the work of court testimony is more difficult and should be at a higher fee level than office examinations.  Moreover, the unexpected requirement to reattend court a second or further day is typically much more disruptive to the office and personal schedules and concomitantly more stressful, requiring a 'laddering' of fees for office, first court and subsequent court activities.

CSME is striving to draft guidelines that are fair and include all possible modifiers.  Have your voice heard; attend the next CSME discussion on third party service billing.

CSME Submission to the Minister of Finance

November 25, 2003

Mr. Michael Colle

Parliamentary Assistant to the Minister of Finance

7 Queen’s Park Crescent

Frost Building, 7th Floor

Toronto, Ontario

M7A 1Y7

RE:
CANADIAN SOCIETY OF MEDICAL EVALUATORS SUBMISSION

PRESENTATION DATE – TUESDAY, NOVEMBER 25, 2003, 9:30 AM

 Who We Are

The Canadian Society of Medical Evaluators (CSME) represents the doctors who, in addition to their clinical activities, complete independent medical examinations.  In the context of Ontario car insurance, our members perform plaintiff, insurance and DAC examinations.  We are the group of physician and surgeon experts that the judiciary, industry and the legal communities rely on.

Scope Of Recommendations

This submission will be restricted to an analysis of the provision of care and the effective utilization of medical experts in order to assist the government in identifying insurance cost savings resulting in lower automobile insurance premiums, and importantly, a reduction in the morbidity and cost to society of poorly managed clinical conditions associated with motor vehicle trauma.

Background Analysis

Under Bill 59, there was an open-ended and very costly system for the delivery of healthcare benefits paid by insurers.  Multiple service providers could simultaneously render ongoing rehabilitative and physical treatments.  In a portion of non-resolving claims, it could be difficult to determine which, if any of the treatments were beneficial, which were of no value or worst still, which might be doing potential harm by aggravating the conditions they were meant to be treating.  Insurer Examinations were utilized to determine the impairments and resulting disability, and to define the necessity for and reasonableness of the treatment plans submitted;  MED/REHAB DACs were designated to resolve treatment disputes. 

Bill 198 created two all-inclusive pre-approved treatment programs (PAFs) to address the rehabilitative needs of those who had sustained Grade I and II Whiplash Associated Disorders; this group making up approximately 85% of injury claims.  There is however limited scientific evidence that the treatments incorporated into the PAFs are therapeutically effective.  There is also a large body of medical research that suggests minor soft tissue injuries have a benign, self-limited natural history; ending for the overwhelming majority of people, in resolution within a short period of time and without any interventions.  There is no statistical evidence that the PAFs will have a positive effect on healing times, symptom relief or claims for disability.  The PAFs were devised by a small group of health care professionals (involved in providing MVA-related treatments) and negotiated with the insurance industry to provide an acceptable approach to treating Grade I and Grade II Whiplash Associated Disorders.

One can anticipate that if there are significant numbers of injured individuals who do not receive treatment other than the PAF or following completion of the PAF, there will be savings to the system.  However, given the high prevalence of individuals who have historically claimed disability at six months post-injury, it may well be that the group of people who were responsible for the majority of rehab costs under Bill 59 will continue to claim for medical/rehabilitative and disability benefits after completion of the PAF treatment.  This will result in additional treatment plan submission and the need for more complex and expensive multi-disciplinary examinations. 

CSME has concerns about these examinations.  As part of an effort to enforce the PAF, Bill 198 empowered the DAC system.  It provided protection for DACs against civil litigation and restricted the insurer from requesting Insurer Examinations (most often completed by physicians under Section 42) in relationship to medical rehabilitation benefits (rendered under Sections 14 and 15). 

MED/REHAB DACs, which were initially introduced to resolve treatment disputes, have now been mandated to recommend appropriate treatment, while those completing insurer examinations have been asked to restrict or defer their opinions related to the provision of medical care.  As a result, accident victims are subjected to redundant examinations, solely for the purpose of providing treatment recommendations that physician experts providing Insurer Examinations could readily provide without any conflict of interest.  Without this input, injured persons must rely solely on the opinions of other providers who, for reasons as outlined below, are problematic.  

Based on the model of peer review, Med/Rehab DAC Examinations do not provide the level of medical expertise needed to sort out complex medical issues.  Many of the assessors are not licensed to prescribe medications or to order the diagnostic tests needed to direct treatment. 

There are many conflicts of interest within the DAC system;  those groups completing MED/REHAB DAC exams are the same groups who have been responsible for the high utilization of rehabilitative benefits to date.  In addition, conflicts arise when peers examine one another’s patients.  CSME is deeply concerned that the same professional groups who negotiated the PAFs are the individuals now responsible for making decisions with respect to PAF implementation, while at the same time, these groups are lobbying for an increase in fees.

CSME acknowledges the efforts of government and all stakeholders who have worked to create a system to reduce examination bias.  CSME believes the system is important but requires further revisions as outlined below.

Recommendations

1. That the DAC system be restructured to incorporate higher levels of physician expertise at the level of the Minister’s Committee.  The current makeup of that committee is compromised by self-interest and is substantially lacking the medical knowledge or clinical experience required to deal with many of the issues it must address. 
2. That another level of medical expertise, either in the form of a tribunal or another body, be assembled to develop quality assurance measures and review DAC complaints.
3. That the model of peer review be replaced with one that recognizes medical expertise and the role of evidence-based clinical decision-making.  
4. That experts used to provide assessments be restricted from providing physical treatments to car accident victims.
5. That physicians completing Insurer Examinations not be restricted from rendering opinions on issues of diagnosis, impairment, causality or medical management and that they be directed to comment on any issues within their scope of expertise   that will prevent duplication of examinations.  This is in keeping   with the ability to physicians conducting plaintiff, defense, or  Section 24 examinations being unrestricted in their ability to opine in any relevant area.
6. That a method for reducing examiner selection bias be developed which would place all qualified centres on the same level and that this be followed by elimination of the arbitrary designation afforded to DACs.
7. That all assessors providing services within the system are afforded the same level of protection against civil litigation for opinions rendered in analyzing claims

Summary

The Canadian Society of Medical Evaluators anticipates that the changes outlined above will result in substantial savings to the system with a reduction in   morbidity and cost to society on the whole.

The Canadian Society of Medical Evaluators