MSP Accounting - Simplicity - ICBC Example

MSP Accounting - Simplicity - ICBC Example Here's how a reasonable, efficient, and transparent accounting system works. The example is another provincial crown corporation - ICBC - the Insurance Corporation of British Columbia.

Last week I had the windshield on my vehicle replaced. I paid the deductible and the glass shop is collecting the rest of the cost from my insurance provider. ICBC sends me a summary of the invoice, and requests that I contact them if I have any concerns. They want to be sure I am happy with the work that was done, but most of all, they want to be sure the billing is legitimate! They don't ask for an acknowledgement from me, but assume that if I do not respond that everything is above board and they can go ahead and pay the vendor.

Granted that this is an extra procedure, and there is a cost attached, but for most people these days the whole process could be managed electronically and the cost effectively minimized as a programming function rather than mailed documentation. Even with the mailed hard copy, there is likely no human interface in the ICBC process, and the impact of the transparency achieved is obvious.

Moving through the BCHRT process is excruciatingly slow, and the next stage, with partial victory for the system brought a small measure of encouragement.

British Columbia Human Rights Tribunal Complaint

It is now fully two months since I first tried to contact the Medical Services Plan (MSP) on the issue of Accountability and Transparency, and specifically about the blatant age discrimination in not providing for coverage of shingles vaccination under MSP. Consequently, I have laid a complaint with the B.C. Human Rights Tribunal against the Minister of Health and MSP. It's a fairly long form with a lot of pigeonholes to make it flexible, but I think it covers the issue fairly well. Stay tuned for what it may bring...

The form runs to seven pages, and the rest of it, including the first page seen here, is linked here.
When I filed it with the Tribunal on April 9, 2015, I decided to attend the help clinic offered by the Tribunal the following Monday, and the young lawyer who reviewed my complaint documentation had nothing to add or change, and simply commented that it was an unusual type of complaint.

On July 17, 2015, I received in the mail a copy of the Notice of Complaint served on the Ministry of Health. It provides fairly generous time allowances for the process, but a response or an application to dismiss the complaint must be filed by August 17, with a provision for attending an early settlement meeting in October or November. So obviously nothing will come of this process this year, and perhaps we will see progress in 2016. On July 24, I received a copy of a letter to the Case Manager of the BCHRT from the BC Ministry of Justice advising that the Respondent to the Complaint would be represented by Denise Pritchard, Legal Counsel. On August 5, I received a copy of another letter to the Case Manager, this time requesting a month's delay in the proceedings. My response was sent off the following day. That didn't sit well with Ms. Pritchard, who dashed off a note to justify her request for the delay. The registrar at the Tribunal decided on the spot to grant her only half of what she had requested, and the deadline for the response was moved to August 30, 2015.

On August 31, 2015, the response from the Legal Counsel, which had a deadline of August 30, was delivered by courier. It is dated with date of its arrival, so it was a day late to meet the deadline that the Registrar had imposed. That, combined with its principal demand that my complaint be dismissed on a variety of technical and legal grounds, makes it somewhat ridiculous. The technical grounds are that the respondent is incorrectly identified - an issue that had been brought up by a Tribunal official and corrected verbally - and that MSP is not responsible for funding any of the related services - an interesting point, since MSP is the principal funding agency for the Ministry of Health. A further item with which she takes issue is that the complaint refers to this blog, which is "subject to editing" and should therefore be ruled off limits: the material of the complaint should be restricted to what is included in the Tribunal form 1.1 and nothing more. Considering that she completes the main items of the form as "see attached", and specifically responds "no" to the requirement that form 7.2 - Dismissal Application be used to demand dismissal of the complaint, and then demands dismissal in her attachment, it would appear that her submission is not to be subject to the same treatment she demands for mine. The bulk of her argument comprises a bunch of legalese bafflegab about the structure of the Ministry of Health without ever touching on the issue of discrimination. However, she does concede that the Ministry has determined that it is justified in not funding shingles vaccination. Her repeated use of the term "prima facie" pretty well sets the tone for the whole document, and is virtually meaningless in this instance. In any event, her arrogance is breathtaking. The same day, the Tribunal responded with a Respondent's Dismissal Application Deadline, which includes a deadline of October 5, 2015, for me to file a disclosure listing and documentation, which includes details of the remedy I am seeking. Then the Respondent will have until November 9, 2015 to file a response to my disclosure and remedy sought. At this point there is still no date set for an actual hearing, and my list of documents and the remedies have been submitted to the tribunal.

Application to Dismiss
On the afternoon of November 9 a parcel arrived by courier, and it was not until I opened it that I remembered that this was the deadline for the respondent to apply to the Tribunal to dismiss my complaint. It was so impressive that I had to weigh it (2.7 kg or 6 lb) and take a picture.

The contents, comprising 16 items as listed in the "list of documents" are "governed by the rules of confidentiality such that disclosure is given only for the purpose of this hearing": which I take to mean that I may not disclose them here or anywhere: they are for the eyes of tribunal participants only. This is something of a relief, since I certainly am not about to scan and digitize several hundred pages of reference material along with covering legal qualifications and other bullshit. What I can do, without, I hope, the risk of litigation and further intimidation, is summarize what this package contains - and possibly speculate on what it cost. The basic message is : "the complaint should be dismissed in its entirety". That's a lot of paper and documentation for a pretty simple message. It does not say - let's see if this has any merit, or let's see if there are points to discuss, or let's consider if we have all the answers. It states very clearly: let's blow this issue to kingdom come, regardless of the cost of doing so!

There are three witnesses on the list submitted: all high powered and drawn from the top echelons of the Ministry of Health hierarchy - one executive director, and two directors. The second largest item in the above picture is a sworn affidavit by the Executive Director of Public Health Services covering everything you ever wanted to know (and a whole lot you didn't) about immunization in British Columbia.

The largest item in the package is titled "Book of Authorities" and incorporates eleven cases that have been heard by the BCHRT, two that went to the Supreme Court of Canada, as well as the British Columbia Public Health Act (SBC 2008 Chapter 28). Needless to say, they all support the contention that my complaint should be dismissed out of hand. Without attempting to go through them all, I found a measure of encouragement in one of them that touched on a personal note with me. This was titled "Armstrong vs. British Columbia (Ministry of Health)", and concerned having to pay for PSA (prostate specific antigen) testing.  The case, which was heard in December 2006 and January 2007, and decided in January 2008, resulted in the complaint being rejected and the case dismissed: a clear victory for the Ministry of Health. Curiously, by coincidence, in the fall of 2006 I was subjected to testing for prostate cancer, and ultimately treated for it by radical prostatectomy in the spring of 2008. During that period, and at least twice a year since I have had PSA tests, and I have never paid for one out of my own pocket. Again without going into detail, I understand that a good portion of the Armstrong case involved the distinction between "diagnostic" and "screening" PSA tests: the former being covered by MSP and the latter not. I believe that the difference is principally that in order to qualify as a diagnostic test it must be ordered by a physician, whereas screening could be initiated by the patient without a physician's input. I have to admit that before succumbing to prostate cancer I hardly knew I had a prostate, let alone what a PSA test was, and I suspect that most younger men are in much the same state of ignorance in spite of the level of publicity the issue receives today. So the Ministry was successful in defending its position with respect to Armstrong, but what did it actually win? The right to deny an individual a potentially life saving diagnostic procedure? And at what cost? Looks like a pyrrhic victory to me, and it certainly is encouraging in terms of potential outcome, whether my complaint goes any further or not.

This brings me to the issue of appearances, and potentially influencing how our health care dollars are spent. The attitude of the Ministry of Health is obviously that of an entrenched bureaucracy that wishes to be left to its devices without outside interference. Hence the weight of documentation, which at first glance (or prima facie, as I'm sure their counsel, Ms. Pritchard, would prefer to put it) looks like going after a fly with a blunderbuss - which in essence it is. So that rather than look at the complaint on its merits, let's get rid of it so we can continue as before. So first, we get rid of the items that are not specifically within the jurisdiction of the tribunal, and then we go after the ones that are with all the resources that we can bring into play on our side.

In her response to my statement of remedy, Ms. Pritchard begins and ends with the demand that the complaint should be dismissed, and for the rest states that everything in between is not available as a remedy to the complainant. I am sure that any number of legal arguments can be made as to the proper procedure and presentation of my remedies to show that they do not deserve consideration, but the issue of whether or not they represent a positive outcome for the patient and the public at large does not enter the picture. On that basis, I believe it is appropriate to examine the first four, all dealing with efficient communication and legitimacy of billing in light of the most recent commentary on the topic - found in this weekend's (November 14) National Post. The fifth item in my remedies comprises two parts, both of which allege age discrimination. The second, dealing with medicals for drivers over age 80, is deemed by Ms. Pritchard as inapplicable, essentially because I am not yet old enough to have been personally impacted. The first, for which the bulk of this documentation package is aimed, deals with the shingles vaccination, which I predict will fall under MSP coverage within the next five years, and would have done so a good deal earlier if the Ministry spent less on litigation and more on common sense solutions to healthcare issues.

Next Round
On December 7th the mail brought a further extension of proceedings. I now have until the end of the year to respond to the Ministry's application to dismiss my complaint. After that they have until January 14 to provide a written response to my latest submission. Moving at the appropriate pace, I shall send in my next submission on new year's eve, using suitable excerpts from the above review of the Ministry's application to dismiss.

December 31, 2015. My response to the application to dismiss was emailed this morning, and a fairly prompt reply from the tribunal stated that they were unable to access the links, so I had to get the essential ones downloaded and converted to pdf files for attachment to my email.

January 15, 2016. Yesterday the Ministry's response to my year end commentary arrived via email, and it was a bit of a letdown. All Ms. Pritchard could come up with at this time is a legal objection to my bringing up the issue of the 80 plus year old drivers' medical. So now the Tribunal has to decide what next, if anything. My prediction is that it will take at least a couple of months to come up with a firm ruling that the whole effort has been a waste of time, but it's been an interesting diversion.

Official Correspondence - with snail mail as required

On February 18, 2015, I wrote to the Minister of Health to query some of the issues raised in my original healthcare commentary. The (almost) immediate response was less than satisfactory, with a subsequent refusal to handle email, and I responded in kind, with a brief comment about the runaround I was getting...

I have had a response from my M.L.A.'s office, and he has even written to the Minister of Health on my behalf, although the process seems to have been drawn out somewhat - the date of his letter and the postmark on the envelope are a week apart. 

My snail mail response to HIBC/MSP refusal to deal with email had hard copy of all the email correspondence enclosed.

The Minister's response to my queries arrived on April 27th, and appears to address some of my issues. However, in the first instance, the procedure to find the payment schedule is far too onerous and not at all user friendly. To check my own records, once again I am obliged to phone or use snail mail for my request, which will eventually be dealt with in the most inefficient and costly way possible. Obviously, the intent is to discourage queries such as mine.

Regarding the shingles vaccine, I have no idea how long the Ministry's review is likely to take, but until the process is completed, assuming a positive outcome, we the seniors will continue to be on the hook for whatever cost the pharmaceutical delivery system chooses to levy, with no relief in sight. Therefore, I am proceeding with my human rights complaint, and if there is a favorable ruling from MSP before the compliant is heard, that portion of it can be withdrawn.

_______________________________________________________________________

On July 15, 2015, I finally decided to jump through the hoops to get the record of medical claims filed in my name, and I phoned the MSP number provided in the Minister's letter. Since I was provided the option, I left my number for a call back rather than holding for an indefinite period. I was called back two days later, and after providing a series of answers to prove my identity, I was transferred to a "benefit specialist" who asked if I had executed an "Authorization to Release Medical Records". I responded that I didn't think so, and he provided directions for downloading an appropriate form from their web site. From that point on, it's all hard copy by snail mail (Please allow up to 6 weeks for processing), so it will be a couple of months before I see any further progress on this. On August 16, 2015, I received in the mail an unsigned letter from HIBC with a 3 page printout attached listing all medical claims paid on my behalf from August 1, 2008 to July 31, 2015. Why these data cannot be made available on line, is an open question which remains unanswered.

The narrative continues with this link.

Belligerent Inefficiency

Every comment I have received on this topic has confirmed my observations and supported my critique. A number of them added to my list of issues with both the Medical Services Plan (MSP) specifically and the medical system generally. While I am not likely to make a great deal of headway in terms of reforming this sacred cow, I do intend to try and lobby for some changes: particularly in those areas that have impacted me personally and those that I see as egregious abuse of resources.

One relatively minor one that jumps out at me every month is the bill MSP mails me. Most invoices I receive on a regular basis have an option (usually offered with inducement) to convert to electronic billing - and correspondingly, my bank offers me the option of automatic payment, which in the case of MSP has been set up. On an annual basis, if just a portion of MSP subscribers converted and saved the postage, printing, etc., the savings would be significant.

A very common issue is the requirement that patients must return to their physician for routine prescription refills. One friend commented that she has been on the same thyroid medication for 32 years, and although she is able to schedule blood tests herself, she is obliged to visit her clinic for prescription refills - for which the clinic obviously invoices MSP. The same person reports that her clinic only allows one issue to be dealt with per visit, so if she needs a skin rash looked at it requires another appointment rather than dealing with it on her prescription refill visit. I can only quote her comment: "how stupid is that?"

On a personal basis, having just had the shingles inoculation, at a cost of $200 each for myself and my wife, after saving MSP the cost of several visits to the doctor, I have to ask why I am obliged to pay for this, when smallpox, MMR, and other vaccinations for children are fully covered? Is this not a clear case of age discrimination? I haven't reached that particular milestone, but I understand that the physical which is required for a driver's licence renewal (annually?) for drivers over 80 is also not covered. I presume this is principally because 80-year-olds are not aggressive enough to seek parity with younger folk and have no organized advocacy working effectively on their behalf. British Columbia does, in fact, have a "Seniors Advocate" with a supporting bureaucracy, but like every branch of government, this one has its own agenda and has show absolutely no interest in this issue.

Another particularly galling issue for me is the propagation of the myth of "free" medical services. This certainly works on a subconscious level with folk who see value only when a number is attached. I have to go back to the case of my late Father-in-law, when he was still mobile, and would think nothing of "dropping in" on his doctor because he happened to be in the neighborhood. The fact of the matter was that he was lonely, and any attention from a familiar face was welcome. In any event, I am convinced that had he been sent a copy of the doctor's billing to MSP, or had he been subject to even a nominal charge for a visit, the thought of casually dropping-in on his doctor would not even have occurred to him.

Meantime, I set up a paper trail to continue my quest.

Shingles vaccine is not covered...

Unlike my parents and their generation, who generally held their physicians in excessively high regard, if not awe, I regard the medical profession with what I consider a healthy degree of scepticism, and I am prepared not only to challenge their edicts, but hold them fully accountable for their actions. I recently had perfect vindication for my attitude, and I believe that our system would work a lot more effectively, and at less cost, if more of us adopted a similar posture.

My most recent experience was with my family doctor, to whom I relate fairly well, but with substantial reservations – to the point that I will only consult him if all else fails. A principal reason for my reluctance to deal with him is the unnecessary difficulty I find in arranging to see him. I don't know if it is a common physicians' failing, but my doctor's office refuses to arrange appointments by email. He claims that it's because his receptionist is not computer literate, but I believe there is more to it than that. In any event, one is obliged to phone for an appointment, and the process inevitably leads to telephone tag, because Lucy, his receptionist, spends much of her day on the phone returning missed calls. Also she has an interesting recorded message for calls after hours, which could have been lifted almost word for word from Joseph Heller's Catch 22. It states, and I am paraphrasing from memory: “We do not accept messages after hours, so please call during our working hours, which are...”. She does not specifically state that if you call during working hours you will reach an automated recording which asks you to leave a message, but the implication is clear.

In any event, my current interaction concerned getting inoculated against shingles, a precaution I had been considering for some time, but had deferred until now. My first instinct was to call the doctor, which turns out to have been misguided. As expected, I left a message to be called back, but clearly stated my purpose in calling. In the interim I was informed by a friend that a doctor's prescription is not required, and most pharmacies will provide both the vaccine and the service. So I did some comparative shopping by phone, and found every pharmacy I called had the vaccine on hand and the cost was mostly within a 12% spread. So I went off to the most convenient and friendly locale (the least cost, and least convenient, one - at Costco - was booked up for a couple of weeks and erroneously required a prescription), and half an hour later the process was complete. The following day, I finally had a call back from Lucy, who told me right away that the doctor said that I needed a prescription for the vaccine and would therefore need to come in and see him. I thanked her for calling back, and informed her that I did not need a prescription, and that I had already had the inoculation.

This leads me to a couple of comments about physicians' attitudes in general, my doctor specifically, and questions about accountability and transparency regarding our Medical Service Plan (MSP). First and foremost, one of my principal beefs with physicians in general is their absolute conviction that their time is many times more valuable than that of their patients. Perhaps the filthy rich and politically influential are able to avoid medical waiting rooms, but most mere mortals are very familiar with them. I appreciate that scheduling is subject to priorities and emergencies, but it seems to me that effective and efficient planning and scheduling should minimize wait times, and mostly eliminate them. I admit that I have never worked in a medical office, nor have had to interact with dozens of people in a day, but I firmly believe that a minimal time and motion study, combined with a healthy regard for the ever suffering patient's time would save a lot of frustration and waste.

Coming back to my non-appointment with my doctor, leads me to speculate on how much time I would have wasted on the consultation, purchase of the vaccine, second consultation to have the injection, and possible follow up. Further, what would it have cost MSP? Did my doctor deliberately try and mislead me about the prescription requirement, or is he simply ignorant? Either way, it does little for my confidence in the medical profession and the medical system in general.

I am not a frequent user of medical facilities, and therefore may not be the best informed on the processes of our MSP; but I can recall a good number of occasions when I have had medical services provided, and only one occasion on which I had any contact with MSP requesting tacit confirmation that a service had been performed. The lack of communication from MSP leads many folk to the misconception that medical services are “free” and the corresponding abuse of them. I do not understand why MSP does not provide patients with a complete accounting for, and of, services that have been billed on their behalf. The cost, done digitally, would be minimal; and although many, or perhaps most, patients would not scrutinize such documentation, it would certainly encourage the service providers to be prepared to justify their invoicing. I believe it would work much like a constant audit or double entry bookkeeping, and make the public much more aware of where its tax dollars are going.

In pursuing the issue further, I encountered the belligerent inefficiency of a system aligned to serve itself rather than the public.