The reports streamed into the Ministry of Transportation, day after day, week after week.
In each one, the Ottawa doctor informed the government that a patient had a medical condition that may make it dangerous to drive.
For each report – which can lead to a licence suspension for the patient –– the doctor billed the province $36.25.
The doctor filed more of these reports than any of his colleagues at The Ottawa Hospital and more than any other doctor in his specialty of sleep medicine, according to government data.
He has filed more than any other doctor in Ontario.
The median number of these reports filed by Ontario physicians has been five over nearly a decade. The Ottawa doctor filed more than 4,800 –– billing the province more than $175,000.
He is among 20 Ontario doctors who account for 15 per cent of all medical condition reports (MCRs) filed from April 2011 to December 2020. In all, they filed 51,075 reports, worth nearly $2 million in public billings, according to a Ministry of Health database of Ontario Health Insurance Plan (OHIP) claims obtained by the Toronto Star and the Investigative Journalism Bureau (IJB).
“It does raise interesting questions about why you would have such a skewed distribution,” says Dr. Ross Upshur, a physician and researcher based at the Dalla Lana School of Public Health who has studied the ethics of physicians reporting their patients to the transportation ministry. (Upshur sits on the IJB’s academic and editorial advisory board).
Doctors reported their patients to the Ministry of Transportation (MTO) using MCRs, forms meant to flag patients who are potentially unsafe to drive. After filing the report, doctors bill the Ministry of Health for filling out the form.
MCRs result in thousands of licence suspensions every year. Many of them contribute to keeping our roads safe.
But doctors and fitness-to-drive experts have criticized Ontario’s reporting system as inflexible, overbroad, and at times punitive, an ongoing Toronto Star/IJB investigation has found.
Drivers whose licences are suspended unnecessarily often face dramatic consequences, including the loss of jobs, access to everyday necessities, and trust in the health-care system.
The exclusively obtained OHIP data detailing doctors’ MCR billings raises concerns about some doctors filing a strikingly high volume of these reports, potentially ensnaring drivers who do not threaten road safety.
Some doctors have also cited questionable conditions when billing for MCRs. Conditions such as “normal delivery, uncomplicated pregnancy” and “sexual deviations” appear dozens of times in the data. The common cold is cited 148 times. Nearly 200 MCRs were billed citing social, marital and family misfortunes, such as “problems with aged parents or in-laws,” “legal problems, litigation, imprisonment,” and divorce.
The conditions cited by physicians when billing may not always reflect the conditions reported to the MTO for several reasons, but they provide general insight into MCR filing patterns. For example, a patient may have multiple medical conditions, and the code that a physician uses when billing might refer to a different condition than the one reported to the MTO.
“The (Ministry of Health) is clearly not exerting … quality control over the publicly funded resources of this province to the best of their capacity,” Upshur says.
The Ministry of Health said in a statement that it “does not receive a copy of the MCR or a copy of the patient’s medical record when claims are submitted,” adding that “accuracy is not a payment requirement” physicians must meet when billing for MCRs.
Doctors must file MCRs when treating patients with specific high-risk medical conditions. These conditions include certain psychiatric issues, cognitive impairments, uncontrolled substance use disorders where patients don’t comply with treatment, and others. When one of these conditions is reported, the ministry will suspend the patient’s licence, ministry documents say. Doctors may also report patients with other conditions that could make driving dangerous.
Prior to mid-2018, doctors had to report patients with any condition that may make it unsafe to drive, and the ministry reviewed reports on a case-by-case basis to decide whether to suspend patients’ licences.
The 20 top-billing doctors worked under both reporting systems, according to the OHIP data.
The Star and IJB were able to identify some of these doctors by matching information in the OHIP dataset with other public records.
Behind the billings
More than 16,400 Ontario doctors have filed at least one medical condition report from 2011 to 2020 – and some have filed much, much more. Of the 341,660 reports filed:
Toronto Star Graphic
The top-billing doctor is Dr. Robert Dales, a sleep specialist at The Ottawa Hospital. At more than 4,800 MCRs between April 2011 and December 2020, according to the OHIP data, he averaged filing more than one a day, including weekends and holidays.
“As a sleep medicine specialist, a large majority of my practice is caring for those suffering from disorders which may be associated with excessive daytime sleepiness,” Dales said in a written statement. “I have a statutory duty to report medical conditions that may increase the risk of motor vehicle accidents. I report only a small minority of my many cases, and most of those reported do not have their permits impacted because in large part their conditions can be successfully treated.”
Dales’ annual MCR billings have declined since peaking at 675 MCRs in 2016, according to the OHIP data. In 2020, he billed for 140 MCRs, when the median for all other physicians in the data that year was two.
“I can’t confirm these numbers but there is a marked reduction in recent years consistent with changes in MTO reporting requirements which have become less stringent over time,” Dales said.
Almost all of Dales’ MCRs cited OHIP code 307 –– “habit spasms, tics, stuttering, tension headaches, anorexia nervosa, sleep disorders, enuresis,” within the category of “Neuroses and Personality Disorders.” Among the physicians in the OHIP dataset, he accounted for one third of all billings using that code.
At the request of this investigation, nine physicians commented on the volume of Dales’ billings. While some suggested Ontario’s strict reporting requirements could play a role, others questioned the need for filing that many, even taking into account Ontario’s reporting model.
“There’s no reason for that,” says Dr. Ron Cridland, a sleep-medicine physician. Cridland practices in British Columbia, where reporting is more discretionary than in Ontario. Physicians only have to report patients if they ignore a warning to stop driving.
“My job as a physician is to first do no harm…You have to give the patient the benefit of the doubt or else you lose your therapeutic relationship.”
Dr. Ian Gillespie, a contributor to a Canadian Medical Association guide on assessing fitness to drive, says the volume of Dales’ billing “seems excessive, and I don’t know the reasons for that … If a practitioner’s billing is outside of the expected range that may invite review.”
Dales’ high volume of MCRs could partly result from “the draconian reporting rules in Ontario,” says Dr. Alan Hoffman, a B.C. sleep specialist who says he reported about 50 patients each year in a practice of approximately 3,000 sleep-disorder patients.
The MTO did not respond to requests for comment on this story’s findings. In a March statement, the ministry did not say if it has a system in place for reviewing physicians who file an unusually high number of MCRs.
In response to these comments, Dales called into question the legitimacy of perspectives from physicians outside Ontario given the provinces’ different reporting requirements.
A page for Dales on RateMDs, a medical professional review forum, includes reviews from people claiming he reported them to the Ministry of Transportation.
“This man is capable of doing unspeakable damage to you on the basis of nothing,” alleges one anonymous poster who says Dales filed an MCR against them last year based on an initial phone consultation without any proper evaluation or diagnosis.
“He sends a letter to the ministry that results in me losing my driving licence. I have not been provided with ANY copy of this letter or the assertions that may be in it, [sic] He has reported to the Ministry of Transportation but not to me. God knows when I will get my licence back.”
Dales “feels more inclined to share diagnosis with the ministry of transportation rather than his own patients,” reads another review from 2016 complaining of Dales’ “standards and practices.”
In response to these allegations, Dales said, “The comments are selective, anonymous, unverified and without context — though I will note that physicians report the clinical information and the Ministry of Transportation, not the physician, makes the decision about an individual’s permit.”
He also pointed to four recent reviews on his RateMDs page, all of which were five-star ratings. All praised Dales, with one calling him “very knowledgeable and friendly.”
More MCRs are filed at The Ottawa Hospital’s General Campus –– 7,654 over the decade reviewed by the Star and IJB –– than almost any other hospital in the province. Two physicians –– Dales and one other physician listed in the data as a specialist in orthopaedic surgery who filed just over 1,000 while at the hospital –– accounted for about 77 per cent of the hospital’s total.
Hospitals are not involved when physicians bill OHIP for filing MCRs, The Ottawa Hospital said in a statement.
Some doctors have billed thousands of MCRs citing a wide variety of conditions, according to the OHIP data.
A doctor who practiced family/general medicine in Bowmanville billed for 3,687 MCRs from April 2011 to December 2020, many for commonly reported conditions, such as stroke and dementia, the data shows. This doctor’s billings have also cited more unexpected conditions, such as urinary tract diseases, venereal diseases like herpes, hay fever, and “disorders of menstruation.”
The number of MCRs billed “definitely seems excessive,” says Cridland, who used to practice family medicine. “I think that’s extreme.”
At an average rate of roughly one MCR per day, this doctor is the third-highest MCR biller in Ontario, according to the data.
The billing address found in the data matches the address of Dr. Benjamin Fuller, who had a family practice at the Bowmanville Health Centre east of Oshawa. Fuller now practices at Lakeridge Health in Oshawa.
In a 2014 YouTube video, Fuller states the address and suite number of his office, explaining that he was the only doctor at that address: “I’m a solo practice within a group…Once you come through my doors, this is it, this is my practice,” he says in the video.
Fuller did not respond to repeated requests for comment.
More MCRs were filed at Unity Health Toronto’s St. Joseph’s Health Centre than anywhere else in the province –– 10,578 from April 2011 to the end of 2020. But only five physicians filed nearly three quarters of them –– about 7,600. One of them filed 2,459. The Star/IJB was unable to identify these physicians.
Two-thirds of the MCRs filed at St. Joseph’s were between 2011 and 2013.
Hayley Mick, a spokesperson for Unity Health Toronto, said in a statement that St. Joseph’s conducted a review in 2011 following a patient complaint in order to understand the number of MCRs being submitted by physicians in the hospital’s emergency department and “whether proper documentation and patient notification processes were being followed.”
The hospital did not reveal what it found, but Mick said quality measures related to the requirements for physicians submitting MCRs were reinforced.
“We know that for many people, a driver’s license is the key to mobility, independence and social connection. … Any misuse of this process disregards the trust patients place in their physicians and the regulatory framework by which they must operate.”
With files from Abeer Khan, Heidi Lee and Kayla Zhu / Toronto Metropolitan University and Danielle Orr
This story also appeared in the Toronto Star.
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