Canadian work week example (with billing info)

[CanGas]

Hi all,

The majority of this site is USA focused but I occasionally get asked about what practice in Canada is like. The general impression being that we must be starving up here in universal health care land.

Well, I escaped residency for 2 weeks using some of my accrued vacation time to do a 2 week anesthesia locum in a major peripheral hospital.

Here is a breakdown of my 10 weekdays and 1 Saturday call.

The billing data is all straight FFS billings. No special locum rate or deals, this is what everyone else in that province is billing the government. Single insurer, no uninsured, no billing agent required to track different insurance companies, submit codes and 2 weeks later get your direct deposit.

From the list you can also see you need to know your billing codes backwards and forwards. 2.5 mg labetolol IV during a total hip = "controlled hypotension" = extra $150. 15 mcg Fentanyl in that spinal = extra $75, ect.

After nearly 13 years of post secondary education and hellish hours in residency it sure is nice to see the end in site. It was also nice to finally get some true independence. It sure is a different feeling though when "the buck stops with you", I'm returning to residency with a renewed motivation to improve some weak areas (upper extremity regional) and a desire to hit the books so these 2 weeks were great for the pocket book, mental health, and my board exam studying.

Monday (Orthopedics)
66 F - Total Hip
- Spinal w narcotics, controlled hypotension. ($682)
73 M - Rotator cuff
- GA ($283)
3rd Rotator cuff canceled as not NPO so I picked up 2 emergencies (Damn, let him go without a "consult" so no $’s for me)
30 F - Diagnostic Laproscopy
- GA ($252)
60 F - cystoscopy, double J insertion
- GA ($220)

Total time: 07:45 – 16:00
Total billings: $1436

Tuesday (Urology)
56 F (MALIGNANT HYPERTHERMIA +++ family history) - Cystoscopy
- IV sedation. Went apnic with very little sedation, much more difficult mask ventilation than expected, no air entry with oral airway, desaturated to 60’s before I could place LMA which resolved the obstruction. ($126)
78 M (severe CAD with 2 MI this year stented x 3, currently stable (ish)) - Cystoscopy
- Low dose hypobaric spinal with narcotic ($229)
65 M (Ankylosing spondylities w old C2-3 fracture with partial quadraparesis) - Circumcision
- LMA – GA ($157)
66 M - cystoscopy
- IV sedation/MAC ($110)
76 M - cystoscopy
- IV sedation/MAC ($110)
78 M - cystoscopy
- IV sedation/MAC ($110)
75 M - cystoscopy
- IV sedation/MAC ($110)
39 M - cystoscopy
- IV sedation/MAC ($110)
69 M - TURP
- Spinal w narcotics ($308)

Total time: 07:45 – 15:40
Total billings: $1370

Wednesday (Gynecology)
40 F – Laproscopic tubal ligation
- GA – ETT ($173)
42 F – Endometrial ablation
- GA – Mask ventilation ($141)
31 F – Diagnostic laproscopy
- GA – ETT ($173)
26 F – Laproscopic tubal ligation
- GA – ETT ($173)
37 F – Vaginal hysterectomy
- GA – LMA ($204)
36 F – Vaginal hysterectomy
- GA – LMA ($204)
29 F – D&C w laproscopic tubal ligation
- GA – ETT ($157)
19 F – D&C
- GA – Mask ventilation ($110)

Total time: 07:45 – 16:10
Total billings: $1335

Thusday (General Surgery)
75 F – (5’1” – 100kg (BMI 41, severe GERD, colon obstruction 2nd to bowel CA with feculent material coming from NG tube) - Coloscopy with colonic stenting
- GA – RSI – ETT ($346.50)
57 F – (5’4” – 120 kg (BMI 45), severe GERD, remote CABG x 4, old inferior MI, stable angina <4 mets) - Laparotomy, TAH-USO + staging (for ovarian Ca)
- Thorasic epidural, arterial line, GA – RSI – ETT, RIJ CVC ($1114.07)

Total time: 07:45 – 17:55
Total billings: $1460

Friday (Orthopedics)
76 F – Revision total knee replacement
- GA – ETT, Controlled hypotension ($661.50)
37 yo F – Knee arthroscopy w debridement
- GA – LMA ($189)
82 F – Removal hardware clavicle
- GA – LMA ($157.5)
71 M – (stable CAD, Afib, DMII) Total hip replacement
- Pt refused spinal. Arterial line, GA – ETT, controlled hypotension ($551)

Total time: 07:45 – 17:05
Total billings: $1559.25

Saturday (On call) (35% premium during day, 50% after 5pm)
Acute pain service visits – 8 on PCA, 2 epidural ($526.02)
54 M – (mentally handicapped, POD 9 loop ileostomy) – Major consult for possible intubation on surgical floor.
- Evaluated, stabilized (NG placed – suctioned 900cc fluid from stomach with resolution of respiratory distress, transferred to ICU, agreed with ICU no current indication for intubation) ($131.5)
66 M – Cystoscopy, ureteroscopy, Laser+basket for stones
- GA – LMA ($403.99)
72 M – Bilateral biopsy for presumptive temporal arteritis
- Local + sedation ($346.5)
54 M – (mentally handicapped, POD 9 loop ileostomy – crashed returning from CT scan – suspect pancreatitis) – Intubation and resuscitation in ICU
- RSI intubation in ICU ($141.75)
67 F – (afib, metallic MVR (off coumadin x 5 days), 5’3” – 110kg, angina <4 mets, severe GERD) – closed reduction with percutaneous pinning wrist
- arterial line, GA – RSI – ETT ($565.55)
30 F – labour epidural during am then C/S after midnight
- labour epidural + C/S ($637.88)
86 F – (afib, severe MR, LVEF 39%, old inferior MI per ECHO, moderate pulmonary hypertension, oxygen dependent in hospital) – Bipolar hip replacement for hip fracture
- arterial line, spinal with fentanyl, controlled hypotension (BP post spinal 150-170 systolic, labetalol decreased BP to 120 systolic) ($1021.94)
75 F – Major consultation for pre-operative assessment ($131.5)
57 F – (recent stable L1 spinal fracture in brace, new bimalleolar ankle fracture) – ORIF bimalleolar ankle fracture
- GA – LMA ($519.75)

Total time: 07:45 Saturday – 01:50 Sunday
Total billings: $4294

Monday (Urology)
82 M – cystoscopy, bil retrograde pyelogram
- IV sedation/MAC ($157.5)
39 F – cystoscopy – bladder dilatation
- GA – Mask ($110.25)
67 F – cystoscopy, ureteral stent
- GA - Mask ($126)
65 M – scrotal exploration – excision spermatocoele
- GA - LMA ($157.5)
40 F – (severe GERD) - cystoscopy – bladder dilatation
- GA – ETT - RSI ($110.25)
54 M – (Quadriplegic, afib, CAD, DMII) –cystoscopy
- canceled 2nd INR 3.5 = limited consult ($131.5)
84 M – cystoscopy – fulgeration
- GA – Mask ($220.5)
33 F – cystoscopy – bladder dilatation
- GA – Mask (good scare here too. While emerging from mask GA, at 0.3 MAC some secretions probably hit her cords and she went into laryngospasm. Peep did not work, couple cc's propofol did not work, 10mg Sux worked. She only hit 88%. ($110.25)
68 M – cystoscopy – bladder dilatation
- GA – Mask ($189)
33 F – cystoscopy – bladder dilatation
- GA – Mask ($189)

Total time: 07:45 – 16:50
Total billings: $1501.75

Tuesday (ENT until 12:30 when last 2 cases canceled due to lack of beds so I took over 2 nightmare patients in Urology to let an old staff guy go home early and let me bill a little more for the day) *** Here's another billing tip, never let a canceled patient leave without seeing them and writing a note/consult. The T&A I did paid $126, one T&A that was canceled that I saw before the nurses let them go = $131.5 for a “consult”. Unfortunately the nurses let the 2nd canceled case leave before I could see them.
4 M – PE tubes
- GA – Mask (no IV) ($110.25)
8 M – tympanoplasty with patch
- GA – Mask (no IV) ($126)
8 F – T&A
- GA – ETT ($220.5)
14 M – T&A
- GA – ETT ($126)
10 M – T&A
- canceled 2nd lack of beds = limited consult ($131.5)
55 F – FESS
- GA ETT ($220.5)
49 F – (5’1”, 100kg, BMI=41, COPD/Asthma with 4 admissions this year alone (still smoking), CAD, DMII, GERD) - cystoscopy, retrograde pyelogram
- IV sedation/MAC (her lungs scared me more than her GERD and they have no proseal LMA’s so did her with Propofol/Ketamine to keep her breathing and maintaining some tone without instrumenting her airway) ($157.5)
67 M – (5’9”, 98kg, BMI=35, afib, moderate AS (AVA=0.8), EF 39%, CAD – prior inferior MI with recent angio = 70% RCA, Pacemaker dependent, GERD) – bilateral spermatocoele
- GA – ETT, arterial line pre-induction ($307.25)

Total time: 07:45 – 15:40
Total billings: $1399

Wednesday (Ortho)
57 F –Total knee replacement
- (refused spinal) GA – ETT, Femoral block post ($401.75)
41 F – Knee arthroscopy
- GA - LMA ($126)
42 M – Knee arthroscopy
- GA - LMA ($126)
61 M – (CAD w MI 2004, 6’, 106kg, OSA on home CPAP (not known to surgeon), Wolf-Parkinson-White with 4-5 episodes SVT/month) – Carpel tunnel
- MAC (no narcotics, defib in room) – originally booked for sedation but OSA history nixed that. ($126)
68 F –Total knee replacement
- (refused spinal) GA – ETT, Femoral block post ($401.75)
48 M – Cardioversion for recurrent afib (emergency case added on)
- IV sedation ($126)

Total time: 07:45 – 16:00
Total billings: $1307

Thursday (Ortho)
88 M – Total knee replacement
- Spinal + intrathecal opioids ($356.43)
44 F – (5’1”, 100kg, severe GERD) - Knee arthroscopy
- GA – ETT - RSI ($157.5)
50 F – (5’4”, 106kg, severe GERD) - Knee arthroscopy
- GA – ETT - RSI ($157.5)
43 M – (5’8”, 100kg, OSA not on home CPAP) - Knee arthroscopy
- Spinal ($157.5)
86 F – (5’4”, 100kg, remote MI, HTN, hypothyroid) Total knee replacement
- Spinal + intrathecal opioids ($450)

Total time: 07:45 – 15:55
Total billings: $1278

Friday (Gynecology)
33 F – Excision vulvar lesion
- GA – Mask ($189)
42 F – (5’3”, 105kg, severe PONV) - Endometrial ablation
- GA – Mask ventilation on TIVA ($157.5)
42 F – (5’4”, 102 kg) – Hysteroscopy + D&C
- GA – Mask ventilation ($126)
37 F – (5’1”, 87 kg) - Endometrial ablation
- GA – Mask ventilation ($141.75)
41 F – (5’4”, 82 kg) - Abdominal hysterectomy
- GA – ETT. (Difficult intubation, grade II-III with laryngeal pressure despite initial positioning into sniffing position with 3 pillow “ramp”. 1st look medical student. 2nd look me – unable to pass ETT w stylet. Came out, bagged, success with 3rd look using bougie. Rest of case marginal oxygenation. Ran full differential, then when passed NG into stomach to get idea of stomach contents suctioned 75-100cc gastric fluid = suspected aspiration. Got sat up to 95% on FiO2 50%, 97% on FiO2 100% by end of case so extubated awake in OR went to floor on overnight O2 sat monitoring.) ($252)
45 F – (5’1”, 83 kg, Hiatus hernia with severe reflux – she was having regurgitation when she lay flat on the OR table) - Endometrial ablation
- GA – RSI – ETT (also challenging intubation. Grade II-III with laryngeal pressure despite initial positioning into sniffing position with 3 pillow “ramp”. Success on 1st look with ETT w stylet) ($153)
30 F – (5’2”, 86 kg) – Vaginal hysterectomy
- GA – ETT. ($189)

Total time: 08:00 – 16:05
Total billings: $1228.5

Total billings for 10 weekdays = $13,876.5
Billings for 1 Saturday call = $4294.88
Grand total billings for 2 week locum = $18,171

So assuming a 42 week working year (10 weeks off) my estimated earnings would be $381,591 base on these 2 weeks of billings (which were nothing spectacular and only 1 day on call). My malpractice cost is ~$3000/yr. I have universal healthcare. I have a great public school system. The Cdn dollar is close to par with the US. Sure my taxes are higher (top marginal tax rate 46% but if you toss in the "freebies" such as healthcare and schooling, the difference out of pocket for a family of 4 is not that great. I'm not putting down the USA at all, just giving a direct example that before making broad statements such as "MD's are starving up in Canuckistan" you need to have some real #'s.

Hope you found this interesting.

P.S. It's interesting to think that the entire population of Canada is the same as the number of non-insured/under-insured Americans. It blows my mind to essentially think that every single patient I see every day would be uninsured and I would get paid nothing.

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[Planktonmd]

Very informative, Thank you.

 

[urge]

You are a resident, yet billing as an attending?

Does not compute.

Why don't you quit residency and work?

Or is this what you think you could have made?

Shouldn't physicians, including you, stop scamming the system (spinal fent, labetalol 2.5mg-controlled hypotension for hips-"know your billing") under Universal Healthcare?

 

[jetproppilot]

WOW!

Cool post.

Thanks for your time.

 

[CanGas]

double post from stupid hospital computers. Sorry.

 

[CanGas]

urge, it's called a "defined" or "designated" licence. In Canada we have GP Anesthesists - 2 years family med + 1 year anesthesia who often staff more peripheral hospitals and do bread and butter anesthesia cases. These are sites that given the current anesthesia shortage, have a hard time to find locums. So, the government and college of physicians and surgeons figure that 4th and 5th year residents (Anesthesia is a 5 year residency, including intern year, in Canada), are at least as qualified as a GP-A (hell, I have 9 months of CCU/ICU to their 1 month, 3 months of Peds to their 1 month, 2 months of pure OB anesthesia + untold nights on call, to their 1 month, and over 2 years of adult anesthesia by now to their 9 months) so we are elegible for a defined licence to do anesthesia locums.

Why not quit and just do locums? Because I have not spent nearly 5 years of residency to be a GP-A and limited in my scope of practice when I finish. I want to do the cases I want, in the location I want. That's not going to stop me however from taking some vacation time here and there to pay down some debt (pleases the wife) and buy some toys (big screen tv from last locum = pleases me).

As for scamming the system? The system says if I give a sympathetic blocking agent by IV with the express purpose of decreasing bp (they do not specify a % drop needed to make criteria) they will add $150 to my case. If that only takes 2.5mg of labetolol, so be it. Are you saying that if a payor WILL pay you for doing something, you are not going to take it? Sure, 15mcg of fentanyl in a spinal does not complicate my anesthetic but since there is a billiing code for it I should not bill for it? An art line is simple and I'll put one if indicated. Should I not get paid for an art line if there is a code for it, even if it is simple? Sure, some provinces consider art lines part of the anesthetic fee, others let you bill for them, should I not bill for them if I can?

Do we think Radiologists should give back some of their $500k for reading films and CT/MRI's from 8-4pm because it is less challanging than our job? Have the cataract guys lobbied to have their reimbursment drop since a cataract 20 years ago would take 3 hr but now takes 10 min but they still bill $300-$500?

I don't consider this scamming the system. If that is what they will pay me I am going to take it. There are plenty of times I am sitting around waiting for a surgeon or having a case cancled due to a lack of beds or nurses or ICU space and I am not paid then. I just consider these things as evening it out a bit.

There are always going to be some fee codes that we think we are getting paid more than it is worth, JUST as there are always going to be some fee codes that we KNOW we are getting paid less than it is worth. That's just the way things are.

 

[zippy2u]

Thanks for the informative post. Now just need some buds from Oz and Kiwi lands to do the same. Regards, ----Zippy