Revealed: Ontario’s top billing MDs

Top 10 billed OHIP for $3M or more, but MDs deduct rent, other expenses from totals

They are a select all-male group.

All are doctors who billed the Ontario Health Insurance Plan more than $3 million in the 2017-18 fiscal year, making the Top 10 list of OHIP billers in the province — and whose names the Star can finally reveal after a five-year battle to get access to the information.

As part of an ongoing series examining tthe billing data, the Star is showing how tax dollars are spent and pressing for greater transparency in a cash-strapped health system.

Most of the Top 10 billers do not have a record of discipline or cautions with the College of Physicians and Surgeons of Ontario (CPSO), the professional body that regulates doctors in the province.

One has a disciplinary record with the college and recently resigned amid an investigation into infection control at his Kitchener pain clinic. He also agreed never to work as a doctor in Ontario again.

Another was cautioned by the college for his clinical care and professionalism in 2017.

Yet another has no disciplinary record in Ontario but was sued for malpractice in the United States at least 12 times. Patients in at least three cases there received settlements totalling $1.3 million (U.S.).

The doctors’ billings, detailed on pages A6 and A7, are not their net take-home pay.

Doctors deduct their often significant overhead expenses such as rent, staff and a equipment from the billings.

For comparison, the average family doctor gets about $307,000, according to the most recent figure from the Canadian Institute for Health Information (CIHI), an independent research organization.

Ophthalmologists have the highest average, at about $724,000 — and highly trained specialists within specialties can make even more.

The Star has obtained data from the Ministry of Health for the 194 top billers from 2011 to 2018. Some doctors are on the list every year. Others are not. ((Doctors can also earn addi- tional money both privately aand publicly, which is not re- f flected in the data.) Where a doctor’s overall billings do not include every year since 2011, it is noted. The data, below, is for the 2017-18 fiscal year unless otherwise noted.

These are the top billers

#1: Dr. Narendra Armogan

Age: 49 Specialty: Ophthalmology Primary setting: Eye clinic in Mississauga, according to the CPSO. Billings: $5.4 million Total billings while in Top 100 since 2011: $ 42.4 million Overall rank since 2011: 1 Number of patients: 11,128 Patient visits: 34,798 Days billed: 238 CPSO status: Licensed in Ontario since 1993. Also licensed in Barbados. No past disciplinary decisions. Other relevant medical history: N/A

Response: In reply to questions from the Star, Armogan w wrote in an email that his over- head expenses “include at least 50,000-plus square feet, over 70 staff and probably more equipment than any other practice in Canada.”

He does not concern himself wwith the “ranking of physician incomes.”

“What matters to me is the care I give to my patients, helping to save their sight,” he wrote. “We regularly ask for input

from our patients and their approval ratings consistently exceed 95 per cent. That’s what matters to me and I hope that is w what matters to the people of Ontario,” Armogan said.

“We are proud of the contributions that we have made in saving the sight of our patients

and in advancing the scope of ophthalmic surgical care.”

#2: Dr. Stefan Konasiewicz

Age: 56 Specialty: Neurosurgery Primary setting: Pain clinic in Newmarket. Also works at pain clinics in Toronto, Hamilton and Richmond Hill Billings: $4.6 million Total billings while in Top 100 since 2011: $14.5 million ( on list for 3 years) Overall rank since 2011: 25 Number of patients: 1,780 Patient visits: 14,217 Days billed: 303 CPSO status: Licensed in Ontario since1989. Holds active medical licence in Wisconsin and Texas. No past disciplinary decisions in Ontario.

Other relevant medical history: Despite his spotless record with the CPSO, the Star reported in its 2018 Medical Disorder investigation that Konasiewicz faced disciplinary sanctions in Minnesota, Wisconsin and Texas, before returning to Canada to practise. Those sanctions were imposed in response to a 2010 Minnesota medical board decision involving “inappropriate” prac- tices in the treatment of four patients.

The Star investigation also found he had been sued for malpractice at least 12 times in the U.S. involving surgical mishaps that left patients severely injured or dead, according to medical board records, court documents and interviews. Patients in at least three of those lawsuits received settlements totalling more than $1.3 million ( U.S.), the Star found.

The Minnesota cases included a 25-year-old mother of two wwho bled to death after spinal surgery in 2005. An autopsy ruled a “surgically induced” punctured aorta was to blame. A Another patient was paralyzed f from the neck down after sur- gery in 2007, the Minnesota decision found.

The Minnesota board’s 2010 decision imposed several conditions on Konasiewicz, including being supervised by a physician specializing in neurological surgery for some of his procedures. The conditions were lifted two years later.

Response: Konasiewicz did not respond to repeated requests for comment.

#3: Dr. Hany Demian

Age: 43 Specialty: Family practice and general practice Primary Setting: Pain clinic in Mississauga. Also has hospital privileges in Brantford and Simcoe. Billings: $4.3 million Total billings while in Top 100 since 2011: $12.8 million ( only on list for 4 years) Overall rank since 2011: 34 Number of patients: 1,104 Patient visits: 10,358 Days billed: 198 CPSO status: Licensed in Ontario since 2012. Medical Licences in Alberta and Nova Scotia. No disciplinary record. Other relevant medical history: N/A Response: Demian did not respond to repeated requests for comment.

#4: Dr. Christopher Anjema

Age: Specialty: 51 Ophthalmology in Primary Chatham. setting: Has another Eye clinic clinic in hospitals Sarnia in and Chatham. privileges at two Billings: Total billings $4.1 million while in Top 100 since 2011: $ 31.4 million Overall rank since 2011: 3 Number of patients: 6,382 Patient visits: 19,591 Days billed: 225 Ontario as ducting CPSO The of 2018. college since an status: investigation is 1999. currently Licensed Restricted con- into in that Anjema’s In sometimes or c eyelid blepharoplasty the when meantime, tuck), standard he referred performs he will he’s of to (surgery only as practice. cosmet- agreed eye do lift it under supervisor college. the guidance acceptable of a clinical to the

college tion fessionalism In 2017, on his gave in clinical a him following separate a care verbal case, and a com- cau- pro- the plaint dered continuing him from to a education complete patient. It a and also special or- remediation assessed According after program to six a summary months. and be post- reed patient on the went CPSO to a hospital website, emer- the gency cataract department surgery with a week eye after pain aand jema, loss the of on-call vision. ophthalmol- She said An- ogist, or give did her not proper see her treatment. in person The regular next ophthalmologist morning she saw who her diagnosed tion surgery. limited quiries, ports obligations ogist Anjema and Committee on-call vision performed She Complaints told a as serious was and in the the the left he ophthalmol- college’s determined immediate eye. met eye with and infec- all very Re- In- his ation he patient formation cy be careful sideration The room far did committee more required not that in physician. of his from need comprehensive night, the review “Dr. patient’s the ruled to based assess Anjema emergen- and the on histo- situ- con- the and in- towrry tend a poor so. It Other timely and found personally judgment” presentation,rand manner.” relevant he to showed in assess failing medical her “very to to at- do in history: respond for Response: comment. N/A to repeated Anjema requests did not

#5: Dr. Alexander Hartman

Age: 62 Specialty: Diagnostic radiology

Primary Setting: Medical imaging clinic in Thornhill. Other practice locations in Thornhill and Kitchener. Billings: $4 million Total billings while in Top 100 since 2011: $ 31.7 million Overall rank since 2011: 2 Number of patients: 50,754 Patient visits: 96,563 Days billed: 364 CPSO status: Licensed in Ontario since 1982. No disciplinary decisions. Other relevant medical history: N/A Response: Hartman’s administrative assistant replied in an email that as a leading radiologist his “services are in high demand” and he’s routinely referred cases by hundreds of specialists and family doctors across the province.

“His office is open 364 days a yyear and he typically works long hours and seven days per week,” she wrote.

“The majority of Dr. Hartman’s professional billings are used to cover the overhead costs of clinics that serve the general public. These costs include state-of-the-art equipment, facilities, operations, staffing, teaching, and research, all of which promote and advance patient care.”

#6: Dr. Yiu Tam

Scarborough. es and Age: Specialty: Primary Billings: Total in Peterborough. Toronto, Not billings $3.9 available setting: Internal Hospital Ajax, million while Markham medicine Clinic privileg- in Top in 100 Overall Number since rank 2011: of patients: since $23.9 2011: million 1,362 6 Patient Days billed: visits: 251 33,002 Ontario CPSO status: since 1975. Licensed Also li- in censed ciplinary in history. Hong Kong. No dis

Other relevant medical history: N/A

Response: In a written statement to the Star, Tam said his name and billing number were used on behalf of nine team physicians with the Scarborough Dialysis Program in 2017. His billings represent the entire program, which serves about 620 patients.

The program uses the “chronic dialysis team fee,” per patient, per week.

“The team fee is payable to the most responsible physician on the team and cannot be billed by any other physician,” he wrote. “We have found that having only one most responsible physician for the team allows for the most efficient administrative and billing practice.”

Tam is the “most responsible physician” as medical director and chief.

“As such, I bill the weekly team fee on behalf of all physicians that are part of the team,” he added. “That revenue is used to remunerate the program’s physician team members and pay for the program’s expenses.”

Asked about the most responsible physician practice, Ministry of Health spokesperson David Jensen confirmed this is possible for certain services that might involve more than one physician over a time period.

But, “when a physician bills as the most responsible physician, it would be expected that tthe majority of the care is pro- vided by that physician,” he wrote in an email. Tam responded that the unique nature of dialysis care, provided by multiple physicians across multiple sites, wwould make any other form of billing impractical.

He added the schedule of benefits requires the most responsible physician bill the “chronic dialysis team fee.”

#7: Dr. Nadir Al-Jazrawi

Age: 47 Specialty: Family practice and general practice

Primary setting: Pain care clinic in Mississauga. Also practises at pain clinics in Hamilton and Orangeville. Billings: $3.7 million Total billings while in Top 100 since 2011: $12.6 million ( only on list for 5 years) Overall rank since a 2011: 35 Number of patients: 1,598 Patient visits: w 10,974 Days billed: 277 CPSO status: Licensed in Ontario since 2003. No disciplinary history. w Other relevant medical history: N/A

Response: Al-Jazrawi did not respond to multiple requests for comment.

#8: Dr. Kulbir Singh Billing

Age: Not available Specialty: Anesthesiology Primary setting: No longer practising medicine. Previously operated a pain clinic in Kitchener. Billings: $3.5 million Total billings while in Top 100 since 2011: $ 26.8 million Overall rank since 2011: 4 Number of patients: 1,011

Patient visits: 8,565 Days billed: 234

CPSO status: Resigned in late May amid an investigation into his pain management practice in Kitchener and concerns over infection prevention

and control. He has agreed never to work as a doctor in Ontario again.

In November 2016, the CPSO discipline committee found Billing had committed professional misconduct related to improper record keeping, sterilization and overbilling of a pain treatment called nerve blocks. According to the CPSO decision, his Kitchener practice wwas devoted to injection thera- pies for chronic pain. The college found multiple issues with record keeping, including poor documentation of patient consent. It also found “many” patients received more than the eight-per-day maximum of nerve blocks allowed under OHIP billing and that the rationale for this was not always documented.

In June 2017, the college ruled that Billing could practise chronic pain management on- ly under supervision for one year. He appealed and the pen- alty was postponed pending

the appeal outcome. The appeal was dismissed in April 2018.

Four months later, the Kitchener clinic shut down after a joint inspection by the college aand the local public health au- tthority amid concerns over in- fection f prevention and control practices. Other relevant medical

history: In December 2014, Billing was charged with two counts of fraud over $5,000 by

the Ontario Provincial Police anti-rackets branch. He was ac- cused of billing the Ontario gov- ernment for services he didn’t provide. The charges were dropped in January 2015, the Waterloo Region Record re- ported. The Crown prosecutor said at the time there was no reasonable prospect of conviction based on the evidence in

the case. Response: Billing did not respond to multiple requests for comment.

#9: Dr. Jae Kim

Age: 55 Specialty: Diagnostic radiology Primary Setting: Thunder Bay Regional Health Sciences Centre. Billings: $ 3.2 million Total billings while in Top 100 since 2011: $16.1 million Overall rank since 2011: 16 Number of patients: 60,784 Patient visits: 69,194 Days billed: 337 CPSO status: Licensed in Ontario since 1997. Also licensed in Saskatchewan and Arizona. No disciplinary histo- ry. Other relevant medical history: N/A Response: Kim did not respond to multiple requests for comment.

#10: Dr. Rajeev Muni

Age: Not available Specialty: Ophthalmology Primary Setting: St. Michael’s Hospital, Toronto. Also has hospital privileges at the Hospital for Sick Children, and practises at an eye clinic in Toronto. Billings: $3 million Total billings while in Top 100 since 2011: $20.5 million Overall rank since 2011: 8 Number of patients: 5,957 Patient visits: 18,047 Days billed: 335 CPSO status: Licensed since 2002. No disciplinary history.

Other relevant medical history: N/A

Response: Muni said he works as a vitreoretinal sur- geon at the settings noted above

and is also a researcher at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital.

“In addition to treating many patients, my research has been game-changing in preserving and even restoring vision in people who might otherwise have gone blind,” he said in an email.

“I am very proud of the work I do to help Ontario’s residents suffering from eye disease and visual impairments, which if left untreated, could lead to blindness.”

Marcia Kim, executive director of Eye Physicians and Surgeons of Ontario (EPSO), also responded on his behalf. She said in an emailed statement tthat there has been a “signif- icant increase in the need for ophthalmology services,” with tthe growing and aging popula- tion. Medical advancements have led to early detection and treatment of eye conditions, but this also means ophthalmologists see more patients more often. Ophthalmologists work on a

fee- for-service payment model, she added, meaning every billing submitted to OHIP represents a patient examined, test interpreted or procedure performed. These billings do not represent take-home pay as doctors have to cover often significant overhead expenses. These costs can add up to as mmuch as 50 per cent of gross billings, and ophthalmologists do not have benefits, sick time, or a pension plan associated

with billings, she said. Kim said the EPSO did not support the public disclosure of physician billings “because without context, the data doesn’t tell the full story.” The data for Muni, she added, represents billings for his on-call work as well as work he does in his clinic which is open 12.5 hours a day. He is one of the “few ophthalmologists that provide citywide retinal emergency call” which includes the GGTA but also attracts patients from across Ontario.

“Effectively Dr. Muni makes himself available 24/7 yearround for patients requiring emergency care,” she added.