Twenty-twenty was a brutal year for doctors. The COVID-19 pandemic struck, lockdowns forced the cancellation of scores of non-essential surgeries, hospitals faced a capacity crisis and health-care workers of all kinds endured threats of violence and even death.
For most physicians in Canada, the first full year of the pandemic also delivered a financial gut punch, according to a CBC News analysis of government health plan payments to 58,000 doctors in six provinces that make such data available.
A quarter of those doctors suffered a drop of at least 20 per cent in their billings compared with the year before, according to CBC's analysis. In a country where the average doctor makes $350,000 a year, that means that on average, one in four of those physicians was out around $70,000 in revenue.
"People need to remember right back at the beginning of the pandemic, things were really shut down hard," said Michael Green, a family physician and a professor and chair of the department of family medicine at Queen's University in Kingston, Ont.
In the early months of the pandemic, he noted, everyone was told to stay home, so few people saw their doctor in person. For about 60 per cent of physicians who get paid for each procedure or service they do — a payment system called "fee-for-service" — the lack of patients in the first few months of the pandemic meant a noticeable dent in their revenues for the year.
Ophthalmologists among most impacted in 1st pandemic year
But for a select group of highly paid doctors, it was a different story, CBC's analysis found.
Among the 100 doctors in each province who billed the most to their provincial health plan — a group that mostly comprises specialist physicians — only about seven per cent suffered the same 20 per cent drop in payments during the first year of the pandemic.
In fact, twice as many of these high-billing doctors had a 20 per cent increase in their fee-for-service revenues.
CBC's analysis also found a large number of them got federal money, too, in the form of the Canada Emergency Wage Subsidy.
Woe for pediatricians, dermatologists
Plenty of governments publish "sunshine lists" of public-sector salaries, but provincial health-plan payments to physicians are a bit of a slippery fish. Only five provinces (B.C., Saskatchewan, Manitoba, New Brunswick, and Newfoundland and Labrador) routinely make the data public, while a sixth, Ontario, requires an access-to-information request.
The figures come with caveats: Generally only fee-for-service payments are included, which leaves out the many doctors paid by salary, hourly wage or by how many patients are enrolled in their family practice. And the payment numbers don't account for overhead, which typically ranges from 13 to 43 per cent of a doctor's billings.
The provincial payment data shows that COVID-19 lockdowns hit some specialties particularly hard. For instance, 45 per cent of ophthalmologists in Ontario lost at least a fifth of their billing revenue. The figure was nearly as high for pediatricians (42 per cent), dermatologists (40 per cent), ear-nose-and-throat specialists (39 per cent) and plastic surgeons (37 per cent).
Other specialists in Ontario fared relatively well. Only five per cent of endocrinologists saw their billings drop by a fifth, as well as nine per cent of hematologists and 11 per cent of vascular surgeons.
Green, the Queen's University professor and doctor, theorizes that some of these differences in how the pandemic affected doctors might be because once lockdowns ended, certain kinds of physicians had backlogs of work they could burn through, while others who tend to treat transient illnesses did not.
"Groups that would [be] able to, say, catch up on numbers of procedures later in the year — to make up for their backlog — would have a chance to get their billings back up overall for the whole year, even if they had a very low period during those initial months," he said.
Among them was Gdih Gdih, a Winnipeg ophthalmologist who was the fifth-highest-billing medical doctor in Manitoba last year, and one of the highest-billing doctors in all of Canada, according to the publicly available data gathered by CBC.
He said the first weeks of the pandemic were a trying time for his laser eye surgery clinic.
"When Covid hit, things went so slow and we literally had close to no income to pay 10 salaries… rent, insurance, equipment, lease, etc.," Gidh wrote in an email in response to questions from CBC News. He said his overhead costs normally run above $80,000 a month, or close to $1 million a year.
By the end of the year, though, business was booming for the ophthalmologist. On average, he had billed about $2.2 million a year in services from 2016-17 to 2019-20. But for the fiscal year from April 1, 2020, to March 31, 2021, his total billings climbed to $3 million.
Cardiologist's revenues jumped from $1.5M to $2M
Gdih said there are a "few reasons for the unexpected increase," including heightened demand for some of the higher-paying interventional procedures he performs; more work becoming available because of colleagues who decided to retire early or take stress leave; and extra time in his schedule to do that work since travel was mostly shut down.
The onset of COVID was Gdih's best year for billings since at least 2016, and he's not alone in that regard. An Ontario cardiologist billed the province $1.5 million for his services in the 2019 fiscal year, then upped his billings to more than $2 million during the first year of the pandemic. A urologist in B.C. who averaged $875,000 in revenues for the four years prior to the pandemic billed for $1.24 million in procedures in fiscal 2020.
Mohamed Awad was the 29th-highest-billing doctor in Ontario during the first year of the pandemic. The pain specialist's gross payments from the Ontario Health Insurance Plan jumped from $1.4 million to $2.35 million.
Awad told CBC News in an email that he, too, took on "numerous new patients whose primary physicians retired during the pandemic," and also boosted his work hours. By coincidence, he also opened another clinic in March 2020, just as the pandemic was getting under way, he said.
CBC reached out to a dozen other doctors who saw some of the highest spikes in billings during the first year of the pandemic. Two of them explained it was because they had only begun their medical practice partway through the previous year; another said it was because she was on leave before COVID, so her pre-pandemic billings were unusually low. None of those three doctors agreed to speak on the record.
The rest did not reply.
Overall, CBC News found at least 60 of the 600 highest-billing doctors had their best financial year in the 12-month period that began as COVID took over.
What's more, CBC discovered that some of them even took federal subsidies meant to help slumping businesses keep workers on their payrolls.
WATCH | Some of the country's top-billing doctors accessed COVID-19 benefits:
Federal subsidies for highest billers
Launched in March 2020, the Canada Emergency Wage Subsidy was the federal government's single-largest COVID relief measure, providing up to $960 a week to employers per worker on their payroll so that they could keep paying staff instead of laying them off when business waned.
In the 600-strong group of top-billing doctors from each of six provinces, more than a quarter received CEWS money.
Winnipeg ophthalmologist Gdih resorted to the subsidy in the early months of COVID. He said the uncertainty of how the pandemic was going to affect "the future and the continuity of our business" prompted him to seek out the money.
"However, when we picked up later, I paid it back in full as soon as funds [were] available," Gdih said.
Awad also received some CEWS money. His accountant applied for it without his knowledge, he said, but he never accessed the funds and "promptly repaid" it once it became apparent his billings were surging and not plunging. He provided CBC with his CEWS account statement, which shows offsetting credits and refunds.
It's not known how much CEWS money the top-billing doctors received or for how long, because the federal government has only published the names of CEWS recipients. But there is no suggestion of any wrongdoing or that they didn't qualify under the terms of the subsidy, which only required that a business have a drop in revenue during certain four-week periods in order to receive federal funds.
In an odd quirk, CBC's analysis found that doctors who received CEWS payments during the first year of the pandemic billed more money to provincial health insurance, on average, than those who didn't get the subsidy.
Among the 600 top-billing doctors in the provincial data, the average physician who benefited from CEWS billed $1.7 million, while those who didn't get the federal cash billed their province roughly $1.25 million on average. It's unclear exactly why, but it could be that higher-billing doctors have more — and more specialized — staff who can handle financial matters like applying for a subsidy. Or they might have higher overhead and felt more pressure to shore up their finances when, in the early pandemic, the outlook for all businesses was bleak.
'Give the money back'
Though the doctors were all entitled to get the federal subsidy, York University law and ethics professor Richard Leblanc said it goes against the spirit of the government's COVID emergency relief measures.
"If you're a doctor and your revenue has been at a certain level and then during the pandemic it jumps 20, 30, 40, 50, 60, I think I saw a figure close to 90 per cent… That wasn't the intent of CEWS," Leblanc said.
"The spirit of CEWS is not a windfall. The spirit of CEWS is to make you whole."
He suggested that doctors who got the subsidy but, at the end of the year, showed a marked improvement in their bottom line during the pandemic should do like Gdih, the Winnipeg ophthalmologist.
"Do the right thing and give the money back. Because it's not their money. It's taxpayers' money."
CBC News asked the Department of Finance, which designed the $100.7-billion CEWS program, whether it was always intended that businesses could collect CEWS money early on in the pandemic and not have it clawed back if they ended the year with extra revenues.
The department said forcing employers to pay back CEWS for that reason wouldn't have been wise.
"Had additional conditions such as these been introduced to the program, together with anti-avoidance rules necessary to maintain the integrity of the conditions, they would have added considerable complexity to the rules and their administration," a Finance spokesperson wrote in an email.
"Such complexity and the accompanying uncertainty would have undermined the primary objective of the program, which was to support Canadian workers in a timely manner."
How did CBC News analyze doctor billings data?
To build a database of the highest-billing doctors in each province, CBC News compiled doctors' gross fee-for-service billing totals that five provinces publish every year, with information for Ontario obtained via an access-to-information request. The full names, specialty, years of practice and gender of the 100 doctors who billed the highest amount to their province's health insurance plan during fiscal year 2020-21 (April 1, 2020 - March 31, 2021) were compiled, as well as historical billings for fiscal years 2016-17 to 2019-20.
The full data sets of all doctor billings in each province were used to calculate the percentage change in all doctors' billings for fiscal years 2018, 2019 and 2020. Our analysis identified doctors in both data sets who had seen their billings increase or decrease by 20 per cent or more during fiscal years 2019-20 and 2020-21.
To find doctors who had received the Canadian Emergency Wage Subsidy (CEWS), CBC compared a Canada Revenue Agency list of CEWS beneficiaries dating back to Jan. 19, 2021, against the names of top-billing doctors as obtained from public records. When a corporate entity was composed of multiple doctors registered as partners, their names were separated and matched individually. Matches between the CEWS list and doctor names were confirmed through supplementary research, including professional licensing information, corporate registry searches, associated clinics and other documentation. The CRA's CEWS list does not specify the amount of each subsidy or how long it was provided.
In order to develop its methodology and better understand the data and any caveats, CBC consulted Dr. Michael Green of Queen's University and three other academics who have done research on fee-for-service physician billings.
Data analysis: Valérie Ouellet, Katie Newman (April-August 2022)
Additional research: Madeline McNair, Zach Dubinsky, Mohammed Abdul-Hussain (April-August 2022)
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