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Outsourced medical billing and privacy law

The Toronto Star today with the relatively new practice of physicians outsourcing their billing for providing uninsured services, like filling out forms and giving advice over the phone.

Outsourcing the responsibility for billing the "block fees" for such services to a growing industry of private firms is now becoming for Canadians doctors to get paid for doing hundreds of hours of unremunerated work per year, but is it legal?

*Update, Monday, November 26: On Saturday, the Ontario Information and Privacy Commissioner announced she will investigate the information-privacy concerns about uninsured billing agencies, and the College of Physicians and Surgeons of Ontario said it too will look into the matter. Ontario NDP leader Howard Hampton is pushing for a ban on block fees. at the Waterloo Record.

The Star's article explains that many of the letters mailed to patients by one firm, Healthscreen Solutions, in order to explain the block fee service, are designed to appear to be mailed directly from the physicians, and don't inform patients that a third party is involved in the transaction:

The letters imply that patients signing up for the plan are communicating only with their doctors. In fact, their personal information, including financial and other personal details from the doctor's file, are going to a company that handles $1.5 billion a year in billing and other services for 5,000 doctors. [...]

Privacy experts say the packages raise questions about transparency.

Fair information practices, the principles that underpin privacy laws across North America, say individuals should know who is collecting their personal data, where it's going and how it will be used.
But that principle, for better or worse, is not enshrined in Canadian privacy legislation. For an explanation, I defer to Richard Owens and Francois van Vuuren the Toronto-based law firm and their discussion of the legalities of outsourcing private information processing, :
PIPEDA [] requires consent for the collection, use or disclosure of personal information unless one of the exceptions in PIPEDA applies.

The most important exception in PIPEDA to the requirement for data subject consent to a disclosure for outsourcing purposes is Principle 4.1.3 of Schedule 1 to PIPEDA, which provides:
  • an organization is responsible for personal information in its possession or custody, including information that has been transferred to a third party for processing. The organization shall use contractual or other means to provide a comparable level of protection while the information is being processed by a third party.
The Office of the Privacy Commissioner of Canada (Canadian Commissioner), has stated that no consent by the data subjects involved is required for a transfer under Principle 4.1.3, provided the processor only uses the personal information for the purpose that it is transferred and the requirements of Principle 4.1.3 are met. It perhaps bears note that only "processing" services qualify for an exemption under Principle 4.1.3. The term "processing" is undefined. It is worth noting that the ability to transfer data implied by Principle 4.1.3 is just that, an implication, and that it is a bit at odds with the more straightforward prohibitions in the statute itself.
It would seem, then, that although some people might prefer Canadian law to require disclosure and consent in cases of outsourced information processing, no such protection currently exists.

That's probably why the Star wasn't able to drum up much interest from the Ontario government:
The Ontario Information and Privacy Commissioner's office says it can't comment without full details about how Healthscreen operates and how the province's Personal Health Information Protection Act might apply.

But spokesperson Bob Spence said that "if anyone believes their personal health information has been inappropriately collected, used or disclosed, they can file a privacy complaint with our office."

Health Minister George Smitherman said he keeps a "very, very watchful eye" on the issue of block fees. If questions are being raised about disclosure to patients, he said he'd consider reviewing the issue.
The only hope for change is the ongoing Industry Canada review into PIPEDA reform. It was recently announced that the issue would be opened to public consultation, but a seems to indicate that outsourcing is not being considered for reform.

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Taser toll keeps rising

, bringing the death toll to 19 since 2001, according to Amnesty International figures. Four of those deaths happened in the last two months.

The latest death took place November 22 in a Nova Scotia jail. A 45-year-old man was Tasered once or twice during what police call a "violent" struggle as he was being booked at the Central NS Correctional Facility in Dartmouth following an arrest for assault. "But then he went into medical distress, was taken to hospital where he was cleared and released to police and sent to jail [Wednesday]," said Halifax Regional Police Deputy Chief Tony Burbridge. He died 30 hours later back at the jail.

[UPDATE 4:44PM: Halifax police have not yet released the name of the man who died, but his sister (pictured above from a family photo) Ms Hyde said her brother suffered from mental health problems.]

Although the RCMP said it would review its Taser use after the death of Polish immigrant Robert Dziekanski at Vancouver Airport - which has scandalized people around the world - another two BC Tasering cases have emerged in the last week.

. Police also pepper sprayed and batoned the man who was behaving "erratically" in a store.

Yesterday, officials at BC's Northern Health Authority officials revealed that on November 14, the same day the video of Mr Dziekanski's death became public.

The Ottawa Citizen this list of Taser related deaths in Canada:

Robert Dziekanski, 40, in the Vancouver Airport in October.
Quilem Registre, 39, in Montreal after being stopped by police on suspicion of drunk driving, also in October.
Claudio Castagnetta, 32, who died in Quebec City on Sept. 20 two days after being Tasered.

Jason Dean, 28 in Red Deer while running from police in August.

Alesandro Fiacco, 33 in Edmonton, arrested while wandering into traffic in December.
James Foldi, 39, of Beamsville, Ont. while being arrested for breaking and entering in July.
Paul Sheldon Saulnier, 42, while being restrained by police in Digby N.S. in July.
Gurmeet Sandhu, 41, of Surrey B.C., while being restrained during a domestic dispute in June.
Kevin Geldart, 34, in Moncton, N.B. in May during an altercation with police in a bar.

Samuel Truscott, 43, of Kingston, Ont. was tasered by police during arrest. His death was ruled a drug overdose.
Jerry Knight, 29, a semi-pro boxer was tasered by police at a Mississauga motel in July after complaints he had become violent.
Robert Bagnell, 54, while in custody of the Vancouver police in June. He had cocaine in his system.
Peter Lamonday, 33, while being restrained by police in London, Ont. in May.
Roman Andreichikov, 25, high on cocaine and being restrained by Vancouver police also in May.
Perry Ronald, 28, while being restrained by Edmonton police after jumping from a window in March.

Clark Whitehouse, 34, tried to flee the Whitehorse RCMP after being stopped in traffic in September.
Clayton Alvin Willey, 33, of Prince George was also high on cocaine when tasered by police while trespassing in July.
Terry Hanna, 51, was tasered by Burnaby RCMP in April during a break and enter. Cocaine was also involved.
NRM in its latest issue.

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Grand Rounds 4:09 is online

A , the weekly collection of the best offerings from medical bloggers, is online today, featuring Canadian Medicine's entry on Chinese caterpillar fungus.

This week's edition is hosted by Enrico, the blogger and music enthusiast. His Grand Rounds includes audio clips from Aaron Copland, George Gershwin, Samuel Barber and others.

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Quebec joins the call for hospital funding reform

Dr Jean-Bernard Trudeau, the president of the Quebec Medical Association, that the province consider implementing service-based funding in its hospitals, echoing the calls for reform that Dr Brian Day has been shouting from the rooftops for over a year.

It is interesting to note that hospital funding in Quebec - the primary expenditure in our health-care system - is not very realistic. A hospital's budget is still very largely allocated on a historical basis, determined by the budget from the previous year.

This funding model creates some major adverse effects. Patients are seen as an expense. Rationing becomes a management method.

Why not introduce market forces that promote competition among public institutions? A recent OECD report (Toward High-Performing Health Systems, 2004) observed that these forces reduce the cost of hospital services even when they are administered primarily by the state.

The Quebec Medical Association advocates public patient-focused funding. In other words, clinicians and managers should see patients as a source of revenues, and not as a source of expenditure. Hospitals should be financed according to the services and care that are actually dispensed. The money should follow the patient, so to speak.

It is clear - and this is supported by experience in Europe - that such a funding mechanism would increase the system's production capacity.

Dr Day outlined the case for service-based funding .
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CPSO carves out new cosmetic surgery rules

In response to mounting pressure to rein in the hundreds of GPs in the province who are doing largely unregulated cosmetic surgery procedures, the College of Physicians and Surgeons of Ontario (CPSO) today requiring cosmetic surgeons to undergo assessment.

The CPSO also released the results of a survey it conducted of 500 doctors who were performing cosmetic procedures. Sixteen have been placed under investigation for possible violations, and 20 doctors have been warned for failing to respond to the survey. (The CPSO refused to name them.)

The issue has been in the news lately because of the September death of 32-year-old Krista Stryland in Toronto during a liposuction operation performed by an FP named Behnaz Yazdanfar. NRM in our October 15 issue:

[...] Unlike plastic surgeons, in most of Canada doctors calling themselves cosmetic surgeons need no special licence to ply their trade.

Dr Yazdanfar's clinic didn't respond to NRM's request for an interview, but released a statement saying it wasn't operating out of bounds, but followed College guidelines on what treatments it was allowed to offer.

That claim seems to be true — and that's exactly the problem, say plastic surgeons. "The public may think that there's a universal level of education, training and experience, but in the area of cosmetic surgery there's no program or licence," says Dr David Kester, president of the Canadian Society for Aesthetic Plastic Surgery (CSAPS) and a BC plastic surgeon. "Anyone can do it if they can get into a clinic."

"A variety of names are used by cosmetic practitioners. It's confusing," agrees Dr Jeffrey Turnbull, president of the College of Physicians and Surgeons of Ontario. "When someone calls themselves a surgeon, people think they're a surgeon."
The regional coroner's office, under Dr James Edwards, is .

Update, November 20: for the lax standards on cosmetic surgery in Ontario squarely on the College of Physicians and Surgeons, citing years of "dithering" and failure to implement effective guidelines or enforce what guidelines did exist.

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Brainsuckers: a doctor's worst nightmare

Here's a new piece of medical slang you may not have heard before: brainsuckers.

That's how Dr Scott Haig describes the frustrating "medical googler" patients he sees, in published November 8 that has stirred up some controversy among patient advocates, reports the

Mary Shomon, who blogs about thyroid diseases at, says Dr Haig's article demonstrates why it's important patients are . She also notes that such patients are also called "petit papier patients," because they often bring in papers for their doctors to interpret.

Here's how begins:

We had never met, but as we talked on the phone I knew she was Googling me. The way she drew out her conjunctions, just a little, that was the tip off — stalling for time as new pages loaded. It was barely audible, but the soft click-click of the keyboard in the background confirmed it. Oh, well, it's the information age. Normally, she'd have to go through my staff first, but I gave her an appointment.

Susan was well spoken and in good shape, an attractive woman in her mid-40s. She had brought her three-year-old to my office, but was ignoring the little monster as he ripped up magazines, threw fish crackers and Cheerios, and stomped them into my rug. I tried to ignore him too, which was hard as he dribbled chocolate milk from his sippy cup all over my upholstered chairs. Eventually his screeching made conversation impossible. [...]

Meanwhile, Mom launched into me with a barrage of excruciatingly well-informed questions. I soon felt like throwing Cheerios at her too.

Susan had chosen me because she had researched my education, read a paper I had written, determined my university affiliation and knew where I lived. It was a little too much — as if she knew how stinky and snorey I was last Sunday morning. Yes, she was simply researching important aspects of her own health care. Yes, who your surgeon is certainly affects what your surgeon does. But I was unnerved by how she brandished her information, too personal and just too rude on our first meeting.

Every doctor knows patients like this. They're called "brainsuckers." By the time they come in, they've visited many other docs already — somehow unable to stick with any of them. They have many complaints, which rarely translate to hard findings on any objective tests. They talk a lot. I often wonder, while waiting for them to pause, if there are patients like this in poor, war-torn countries where the need for doctors is more dire.

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Feds "picking and choosing" which Agent Orange-related diseases they'll cover

An organization representing victims of Agent Orange poisoning from a New Brunswick military base says the federal government is , reports the Canadian Press.

The federal government's compensation offer was released in September, but excludes residents who claim the toxic herbicide caused their high blood pressure or AL amyloidosis.

The Agent Orange Association of Canada says the government is using a list of Agent Orange-associated conditions from a by the US Institute of Medicine in order to determine the extant of their coverage, rather than an , which includes the two conditions.

"It's not morally correct," [Agent Orange Association of Canada president Ken Dobbie] said in an interview from Ottawa.

"You can't just say, 'We're going to use an older list because it contains fewer diseases.' The science is showing us these two diseases have been accepted by the Institute of Medicine and they should be on our list for ex gratia payments to veterans and civilians."

Dobbie said Ottawa is "picking and choosing" to its benefit rather than the benefit of the people they are supposed to be helping.

The evidence for a link between the conditions and Agent Orange exposure is growing stronger
and stronger as more research is done. (See ,

The , worth a total of $96 million, proposes to give $20,000 apiece to residents who have a condition associated with Agent Orange and lived or worked at or near CFB Gagetown between 1966 and 1967. The chemical was sprayed as part of an American military testing program.

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The Poison Pita Pit

Medical officer Dr Byrna Warshawsky of Middlesex-London, Ontario is on the trail of the source of a new salmonella outbreak at the University of Western Ontario. The investigation has now spread beyond fast-food restaurant Pita Pit, which was initially the prime suspect.

Twenty-nine of the 42 cases reported in the past several weeks have been definitively linked to the Pita Pit, but the new cases appear to be connected to a school cafeteria's central kitchen, . (Another count -- from the same department, oddly -- puts the.) Five affected people have been hospitalized.

One student who fell ill after eating at Pita Pit:

Up until now, if you asked me where to dine, I would have praised the Pit through and through. Little did I know evil bacterial minions were invading my body and plotting to destroy my intestinal tract while I munched on my wrap.

By Monday, I was doubled over in pain. I won’t go into graphic depictions of the items expelled from my body that day - let’s just say Hostel couldn’t hold a candle to it.

Genuinely concerned for my life by Tuesday morning, I booted it over to Student Health Services to speak with the docs. My physician greeted me with, “So you’ve got the runs, eh?”

Funny enough, he didn’t even ask me if I had been to Pita Pit lately. Of course, I visit the Pit at least once a week, so there’s no doubt in my mind the culprit was a delicious, but tainted, falafel.
The father of a girl who may have to sit out the rest of the semester is :
"She is no shape to go back. It knocked her for a loop."
According to the man, his daughter had been diagnosed with a "sensitive stomach." (Is that in the ICD-9?)

But last week when a London Free Press reporter showed up at the Pita Pit, one pre-med student was "munching away." "I didn't hear anything," said Breat Ghummar.

Image: (Doesn't the anthropomorphic pita look as though it's experiencing stomach pains?)

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