Chatham ophthalmologist Christopher Anjema has billed the Ontario Health Insurance Plan for treating patients suffering from common eye problems such as cataracts and glaucoma.
He has also charged the province for doing a not-so-common eyelid reconstruction procedure 鈥 again and again.
Known as a Tenzel flap, it鈥檚 performed when a patient is missing a hunk of flesh from an eyelid, often because cancerous skin had to be removed. The surgeon makes a small, semicircular incision beside the eye to be able to slide some extra tissue over to repair the eyelid.
Anjema, one of Ontario鈥檚 top-billing doctors, charged the province between 2011 and 2018 for 3,305 treatments under the fee code associated with the Tenzel flap, according to billing data released by the Ministry of Health and Long-Term Care.
That鈥檚 more than all of the other doctors in the province combined, including the oculoplastic surgeons who specialize in these kinds of procedures.
鈥淭hat鈥檚 more than most busy oculoplastic surgeons do in a career,鈥 said Dr. Timothy McCulley, chief of oculoplastics surgery at the renowned Johns Hopkins Wilmer Eye Institute in Baltimore.
McCulley says he performs fewer than 10 Tenzel flaps a year. Anjema, who refused repeated requests for comment from the Star, has billed for as many as 26 in a single day, according to the ministry data.
A Star investigation has found Anjema and at least two other top-billing doctors have charged tax-funded OHIP for procedures or tests at frequencies much higher than what experts say is standard or, in some cases, even possible.
At least two of the doctors鈥 billings were flagged by an internal Ministry of Health audit in 2016, which examined whether they were 鈥渦pcoding鈥 鈥 charging OHIP using fee codes for more expensive procedures.
The audit noted concerns that the high-billing doctors may be charging for procedures that were 鈥渕edically unnecessary鈥 or had not actually been done. One of the doctors says the auditors found 鈥渘othing improper鈥 with his billings.
Despite the government鈥檚 scrutiny, the two doctors continued billing for the treatments at high frequencies, the Star has found.
The payments have persisted under a flawed oversight system, which critics say prioritizes sending education letters to doctors about their concerning OHIP charges over policing improper billing.
Fee-for-service compensation, in which doctors bill OHIP for each service they provided using a unique fee code, is done on the honour system.
鈥淭he whole system is based on trust, and that gives a wonderful opportunity for someone to take advantage of that trust,鈥 said Joan Brockman, a Simon Fraser University professor who has researched health-care fraud in Canada.
Ontario spent roughly $6.7 billion on fee-for-service payments to physicians in fiscal year 2017-18. The billings are not the doctors鈥 take-home pay and do not take into account the often hefty overhead costs physicians pay for expenses like equipment, staff salaries and rent. These costs come out of their billings.
When limited health-care dollars are spent where they鈥檙e not needed, it takes away money from other medical services, Brockman said.
鈥淥ne of the major impacts is there are all kinds of medical services that aren鈥檛 being provided because there is not enough money,鈥 she said. 鈥淭here is lots of money in the system if you just went out and found it.鈥
The Star obtained extensive data for the 100 top-billing doctors for fiscal years 2011-12 to 2017-18. In total, 194 physicians were included in the database, which details each fee code they billed, an anonymized patient ID, the date and the amount billed. The data does not include the patients鈥 diagnoses.
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In an online bio, Mississauga doctor Narendra Armogan is described as an 鈥渋nternationally recognized leader鈥 in ophthalmology and a trailblazer responsible for 鈥渓eading several surgical firsts in Canadian medical history.鈥
He was also the top-billing doctor in Ontario every year from 2011-12 to 2017-18 except for one. That year, in 2016-17, he ranked third.
“The ministry has asked many questions, including some in 2016 ... They found nothing improper,” wrote Dr. Narendra Armogan, who on one day in October 2012 billed for 128 photocoagulation treatments on a total of 83 patients, ministry data shows.
occeyecare.caOver seven years, he charged OHIP more than $42 million for assessing, testing and treating patients, according to ministry billing data. A portion of those billings go toward overhead, which Armogan says 鈥渋nclude at least 50,000-plus square feet, over 70 staff and probably more equipment than any other practice in Canada.鈥
During that time, the procedure he billed the most money for was a laser treatment called photocoagulation.
Billed under fee code E154 (with a remuneration of $182.75 per service for one eye), this laser procedure is used to treat a range of problems including a blood blockage in the eye鈥檚 veins and diabetic retinopathy.
Retinopathy is a common eye disease for diabetics. Over time, high blood sugar levels weaken the tiny blood vessels within the retina, the thin layer of tissue at the back of the eye that converts light into neural signals so the brain can interpret what is being seen.
The damaged blood vessels starve the retina of oxygen. In a bid to improve blood circulation, abnormal blood vessels may start to grow, but these are fragile and prone to rupturing, causing serious vision loss or even blindness.
The standard treatment for a severe case is to use a scatter laser, also known as pan-retinal photocoagulation, to minimize oxygen demand.
It鈥檚 a tradeoff: deliberately destroy part of the peripheral retina to save the eye from irreversible vision loss. A patient loses some peripheral vision but in most cases not enough to affect their daily life.
鈥淵ou鈥檙e essentially burning the peripheral retina with the laser so the tissue is obliterated,鈥 said Dr. Leo Kim, a professor at the Harvard Medical School and surgeon with Massachusetts Eye and Ear hospital.
鈥淭here is only limited real estate there.鈥
The average patient would receive this pan-retinal photocoagulation over the course of about two to eight laser treatments per eye, according to Kim and five other ophthalmologists interviewed by the Star.
These experts included the lead author of Canada鈥檚 clinical and members of the committee that produced a for Ontario鈥檚 health ministry.
The lasering is uncomfortable 鈥 it鈥檚 been likened to an intense ice-cream headache 鈥 so a patient with a low pain tolerance might need more sessions.
But as there鈥檚 only so much tissue in the peripheral retina a doctor can laser, 鈥測ou run out of retina to treat,鈥 said Dr. Sherif El-Defrawy, chair of the University of Toronto鈥檚 department of ophthalmology and ophthalmologist-in-chief at Toronto鈥檚 Kensington Eye Institute.
鈥淎fter the entire periphery of the retina has been treated, further laser therapy of this area would be ineffectual,鈥 he said.
Six ophthalmologists told the Star that the worst-case patient they could imagine, who suffers from multiple eye problems in both eyes, may warrant at the most 30 to 40 photocoagulation treatments in total.
Armogan, the province鈥檚 top-billing doctor, routinely charged for that and more, ministry data shows.
From fiscal years 2011-12 to 2017-18, more than 500 of his patients received retinal lasering at least 40 times, according to the ministry鈥檚 billing data. For some patients, two treatments were billed in one session in what鈥檚 known as a bilateral procedure, which may be used when a doctor does the same procedure on both eyes during the same appointment.
Armogan charged OHIP for two of those patients getting the lasering more than 200 times each, the ministry data shows.
In written responses, Armogan called the Star鈥檚 analysis of his billing data 鈥渇lawed and grossly incorrect.鈥 He said he has no recollection of any of his patients receiving pan-retinal photocoagulation treatments more than 100 times each.
Armogan says the photocoagulation laser fee code can be used when treating more than 20 different ocular conditions, including fixing retinal tears and sealing leaking blood vessels that cause swelling of the macula, essential for sharp central vision.
His clinic has spent millions of dollars on cutting-edge laser systems, he said. With a micropulse laser, he uses a 鈥渟ubthreshold鈥 treatment method featuring low-intensity shots, 鈥渨hich is clinically effective鈥 without causing detectable injury to the retina, he said.
鈥淭his absence of retinal damage allows for unlimited retreatment,鈥 Armogan said. 鈥淲ith this in context, it is clear why my partners and I use this type of laser treatment routinely.鈥
Armogan described his 鈥渟kills as a versatile laser expert鈥 as 鈥渦nmatched.鈥
He said he employs a range of different laser settings and techniques to help patients avoid needing surgery or medications injected into their eyes, which he says are costlier to the health-care system.
鈥淭he concept that there is a 鈥榝ixed number鈥 of laser treatments is foreign to me since every patient is different,鈥 he said.
By 鈥渢itrating (patients鈥) laser treatments to ensure a successful outcome,鈥 he avoids 鈥渞ushing and subjecting them to unnecessary surgeries and injections,鈥 which Armogan said come with more risk.
In breaking up lasering into multiple 鈥渕anageable, lower energy鈥 sessions, there is less pain for the patient, Armogan said, which he said leads to a higher number of patients completing the treatment.
Armogan said he treats 鈥渘umerous complex patients鈥 with multiple serious eye problems, adding that it鈥檚 impossible to fairly assess the treatments his patients received without their accompanying medical charts, which the ministry鈥檚 data does not include.
A typical retinal photocoagulation treatment takes roughly 15 minutes, including the time spent preparing the patient and documenting what was done, said Dr. Bernard Hurley, a retina specialist at the Ottawa Hospital鈥檚 Eye Institute.
An efficient ophthalmologist with a dedicated 鈥渓aser day鈥 could do as many as six to 12 an hour, Hurley said.
On one day in October 2012, Armogan billed for 128 photocoagulation treatments on a total of 83 patients, the ministry data shows.
At 12 per hour, that would take more than 10 straight hours with no meals or bathroom breaks for one doctor to do.
On top of that, Armogan billed for tests, assessments and procedures related to an additional 144 patients that same day, according to the ministry鈥檚 data.
The date of a billing should reflect the day the service was provided, the ministry of health said.
Physicians are expected to bill only for services such as assessments, surgical procedures and the interpretation of test results that they personally performed. There are some 鈥渄elegated鈥 services, such as drawing a blood sample, that can be performed by trained staff as long as the doctor is around to ensure they鈥檙e done competently, .
Armogan did not respond to questions about the 128 laser treatments billed in a single day, as the ministry data shows.
He told the Star 鈥渢here are no members of staff who use my billing number鈥 to charge OHIP.
A doctor performing more than 100 retinal laser treatments in addition to assessing or treating 144 other patients in a single day is unquestionably an outlier, said El-Defrawy of the University of Toronto.
鈥淭hose numbers do raise my eyebrows. Logistically, they don鈥檛 make much sense,鈥 he said.
El-Defrawy said ophthalmology as a specialty has been transformed over the last decade or so with efficiencies, allowing some doctors to see many more patients than previously possible.
鈥淏ut these numbers seem far in excess of that,鈥 he said.
In a 2016 audit into the province鈥檚 12 top-billing doctors, the Ministry of Health noted that Armogan鈥檚 clinic has a 鈥渧ery efficient business model.鈥
The ministry redacted the names of the doctors from its audit, which was obtained by the Star under Freedom of Information legislation. The Star identified the doctors by matching the descriptions of their days worked, patients seen and their income rank with the physician billing data.
The auditors examined Armogan for allegedly upcoding and billing incorrectly, and homed in on the doctor鈥檚 鈥渉igh frequency of retinal photocoagulation per patient per year.鈥 The audit noted concern of 鈥渕edically unnecessary procedures鈥 including retinal photocoagulation.
The audit says Armogan鈥檚 records were 鈥渆valuated as satisfactory.鈥
It鈥檚 unclear what, if any, conclusions auditors reached about Armogan and other doctors鈥 billings as the ministry kept secret the section describing 鈥渞ecommended action鈥 that was taken. The ministry鈥檚 options included educating doctors on proper billing practices, asking money be repaid or referring a case for investigation.
Armogan said in a statement that he is happy to answer questions from the province about his clinic鈥檚 operations.
鈥淭he ministry has asked many questions, including some in 2016,鈥 he said. 鈥淭hey found nothing improper.鈥
Armogan bristled at the Star鈥檚 questions about his billing patterns.
鈥淭he problem in this situation is that you are seeking information that is not in the public interest at all,鈥 he said.
鈥淚 also provide what I believe to be a vital service, and in fact an indispensable public service to the citizens of Ontario. I save sight,鈥 Armogan continued. 鈥淵ou are conducting a hatchet job to destroy my reputation and 鈥 livelihood.鈥
Ophthalmologist Narendra Armogan, the province’s top-billing doctor whose OCC Eyecare is headquartered in Mississauga, averaged more than 140 patients per working day, according to seven years of billing data analyzed by the Star.
Andrew Francis Wallace / 海角社区官网StarArmogan鈥檚 OCC Eyecare Mississauga clinic, a three-storey building not far from Pearson International Airport, is often bustling with patients. Armogan is one of six doctors listed on the clinic鈥檚 website. OCC Eyecare also has a clinic in Vaughan.
Over the seven years of billing records analyzed by the Star, Armogan averaged more than 140 patients per working day. Some of those patients underwent procedures, while others were there for tests or assessments.
On one day in March 2018, Armogan billed for 249 separate patients, according to the ministry data.
Armogan told the Star his clinic regularly asks 鈥渇or input from our patients and their approval ratings consistently exceed 95 per cent.鈥
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Every day for five straight years, Dr. Dalia Rosen-Zaidener billed OHIP, according to the ministry鈥檚 data.
Rosen-Zaidener treats patients at multiple clinics operated by Canadian Addiction Treatment Centres (CATC), a chain of approximately 70 methadone clinics owned by a U.S. health-care company.
She said she has consistently worked seven days a week to fill a health-care gap in rural areas for patients suffering from opioid addiction, 鈥渁 public health crisis that is plaguing our country.鈥
鈥淚 felt personally obligated to help, making many sacrifices to dedicate most of my waking hours to helping people who were destined to become an overdose statistic,鈥 she wrote in an email to the Star.
Her billing records show some of her patients are undergoing urine drug tests at a greater frequency than what some addiction doctors say is medically necessary.
Read more from the Star鈥檚 Operation Transparency series:
Provincial guidelines across Canada generally recommend patients receive frequent urine screens when they begin treatment, so the doctor can check for the presence of other drugs and adjust the dosage if necessary.
Once a patient has stabilized, generally after several months of treatment, urine tests can be reduced from weekly to monthly, or even less frequently, guidelines say. The doctors follow a similar practice at CATC, Rosen-Zaidener said.
Yet more than 50 of Rosen-Zaidener鈥檚 patients have undergone twice-weekly urine tests for years at a time, according to OHIP billing data. A handful of her patients have provided urine samples twice a week for five straight years.
A 2016 report by a provincial methadone treatment advisory committee found no evidence that sustained frequent urine tests improve patients鈥 clinical outcomes.
Instead, these 鈥渂urdensome requirements ... can severely restrict a patients鈥 ability to conduct daily living activities鈥 because they spend so much time travelling and waiting around the clinic, the committee鈥檚 report said. This can lead to frustrated patients dropping out of the treatment program, said Dr. Meldon Kahan, co-chair of the advisory committee and medical director of substance-use service at Women鈥檚 College Hospital in Toronto.
The advisory report also warned that OHIP鈥檚 fee schedule, which will pay for as many as nine urine tests per patient each month, 鈥渋ncentivizes clinics to require patients to provide frequent urine samples and attend frequent office visits.鈥
Rosen-Zaidener said by email that stabilization 鈥渢akes different lengths of time for each patient and is addressed using an evidence-based approach.鈥
She said her demanding patient load prevented her from answering questions about her billings in more detail, adding that the Star鈥檚 analysis of her OHIP billing data appeared 鈥渇lawed.鈥
Of the roughly $8.7 million Rosen-Zaidener charged OHIP for all her billings from fiscal years 2013-14 (her first year among the top 100 billers) to 2017-18, more than half of the payments were for urine tests, which do not require the doctor to interact with the patient. (More than 50 per cent of those billings go toward overhead costs of running the clinics, the doctor said.)
Of the 194 doctors included in the ministry鈥檚 data, Rosen-Zaidener ranks 62 in total dollar amount billed.
Each month, a doctor can bill OHIP $15 for each of a patient鈥檚 first five urine tests (fee code G040) and $7.50 for the sixth to ninth tests (G043).
That compensation is substantially less than what it was. In 2015, the government, feeling it was shelling out too much for a simple test, cut remuneration in half, a move some doctors said hurt patients and led a number of addiction treatment clinics to reduce their services or close altogether.
The first full fiscal year following those cuts, the dollar amount Rosen-Zaidener billed for urine tests dropped by 20 per cent.
Dr. David Marsh, medical director for CATC, said the clinics provide excellent care to their patients. He said he was not concerned that the billing data showed some patients underwent frequent, ongoing urine tests because there will always be a small number of patients whose needs go beyond what鈥檚 outlined in treatment guidelines designed for 鈥済eneral, common situations.鈥
鈥淭he frequency of the urine drug screens is less important than what you do with the results,鈥 he said.
At his clinics, he said urine tests are 鈥渢ied to鈥 a stable patient getting upwards of six take-home doses of methadone, a potent opioid itself.
鈥淚f (Ontario鈥檚) going to have liberal take-home policies that allow patients who are stable to get back to work, one of the risks is that some of that methadone will be diverted and people who are not methadone patients may die from methadone overdoses,鈥 Marsh said.
鈥(We) need to do a lot of urine drug screening to make sure those patients are safe and other members of the public are safe.鈥
Dr. Robert Tanguay, who leads opioid dependency treatment training for Alberta Health Services, said urine tests are too often relied on by doctors instead of taking the time to build a relationship with a patient.
鈥淭here is no evidence to suggest that making someone do twice-weekly urine screens reduces death rates,鈥 Tanguay said. 鈥淭he only value is in the pocketbook of the physician or the clinic owner.鈥
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Back in Chatham, ophthalmologist Christopher Anjema鈥檚 anomalous billing has previously come under review.
In its 2016 audit of 12 top billers, the ministry zeroed in on Anjema鈥檚 鈥渉igh volume (of) temporal flap rotation鈥 (fee code E227, $514.80). A temporal flap 鈥渋s the same as a Tenzel flap,鈥 confirmed the Eye Physicians and Surgeons of Ontario.
As part of the ministry鈥檚 audit, three external experts reviewed Anjema鈥檚 鈥減oor鈥 billing records and noted concerns the procedure鈥檚 fee code may have been used for 鈥渕edically unnecessary services and services not rendered.鈥
And Anjema remains under scrutiny.
In May 2018, the College of Physicians and Surgeons of Ontario began investigating Anjema鈥檚 鈥渟tandard of practice.鈥 During the probe, he can perform cosmetic blepharoplasty procedures 鈥 sometimes referred to as eye lifts 鈥 only 鈥渦nder the guidance of a clinical supervisor acceptable to the college.鈥
The OHIP billing data obtained by the Star is as recent as March 2018. That month, Anjema billed for the fee code associated with the Tenzel flap 12 times.
Over seven years, he charged the province more than $1.6 million for that fee code 鈥 part of the more than $31 million he billed in total.
It鈥檚 not just the number of Tenzel flaps for which Anjema has billed that stands out. It鈥檚 also how many patients he claims have received it multiple times.
Anjema charged OHIP for two patients receiving the treatment 11 times each, according to the ministry鈥檚 data. More than 100 others had it done at least four times.
It鈥檚 鈥渟imply impossible鈥 to perform a procedure like the Tenzel flap more than once per eyelid, said Dr. Howard Loff, a long-time oculoplastic surgeon in the U.S. who now owns multiple health-care companies.
Loff is also the son-in-law of Richard Tenzel, the now deceased ophthalmologist who developed the 鈥淭enzel flap鈥 procedure decades ago.
鈥淭here is no question: once you do it, you can鈥檛 repeat that same procedure on that eyelid. That tissue is not available anymore to be rotated over,鈥 Loff said.
鈥淚t just defies logic.鈥
One of an ongoing series of stories.
With files from May Warren
