Patients wait in pain as a surgeon fights to get paid all in a battle over health-care dollars

Christine Kaschuba first noticed a strange bend in her spine as a teenager.

For years, it seemed manageable: she played sports, ran marathons and had three children. But slowly and steadily, her back deformity worsened. Her spine's C-shaped curve, a hallmark of severe scoliosis, is now roughly 70 degrees.

The pain is unrelenting. It ripples from Kaschuba's back to her lopsided hips, sometimes shooting down her legs, all while her lungs struggle to take in full, deep breaths. Most nights, she says, the ache is so all-consuming she just wants to close her eyes and not wake up.

For the last few years, the 44-year-old Whitby, Ont., resident has been waiting for a risky, complicated spine-straightening surgery with one of the few Ontario surgeons capable of handling the most challenging scoliosis cases.

But in January, that Toronto surgeon told her for reasons she didn't fully understand that he was no longer offering the procedure to correct her curve.

In a moment of desperation a few months later, Kaschuba drafted an email to the patient relations team at Toronto Western Hospital, one of two downtown facilities where her doctor has privileges, begging to know why her long-awaited procedure was no longer happening.

"I don't understand how things changed from me being on a wait list at your hospital to now not having this surgery at all," she wrote in April. "As a patient, I deserve answers."

The answer, she found out, was that the physician was no longer doing this kind of complex surgery. And the reasons why, CBC has learned, are tied to a years-long, behind-the-scenes battle between her surgeon and the province over delayed payments and rising pressure to tackle backlogs of other, more common procedures.

Kaschuba's case provides a window into the inner workings of Canada's complex health-care system. Money, staff and operating room time are all finite resources, government funding is funnelled into different buckets and both hospitals and surgeons have to make tough decisions about which patients to prioritize and which to deny.

WATCH | Why an Ontario surgeon is hitting pause on his toughest operations:

Ontario surgeon pausing operations because he says he's not getting paid

1 year ago

Duration 4:55

A specialized surgeon who fixes the spinal condition scoliosis in Toronto has stopped surgeries because he says the province is not paying for the procedure.

Physician 'begging' to get paid

The physician at the centre of this protracted conflict is Dr. Stephen Lewis, a highly specialized orthopedic surgeon.

A typical day's work for Lewis usually lasts 12 hours. Much of it is spent inside a hospital operating room, carefully cutting open someone's back, exposing their spine, removing sections of bone from multiple vertebrae, then realigning the spinal columns to correct painful, complex deformities all while ensuring these high-risk procedures don't lead to paralysis or death.

As Lewis told CBC News in a sit-down interview, the surgeries themselves aren't the only challenging part of the job.

For years, he says there's been a growing push for hospitals to prioritize more common procedures, leaving little money or operating room time for complex work. Meanwhile, Lewis has also been locked in discussions with the province about getting properly paid for these kinds of complicated surgeries, which long made up thebulk of his practice.

"There's a lot of pressure because most of the cases come towards me," he said, "and I'm spending an inordinate amount of time begging to get paid for the procedures that I'm doing."

Lewis claims that by early 2023, he was still awaiting payment for close to 30 surgeries from 2022.

He also lost an appeal to be fully paid by the province for a particularly complex case from a few years before. That hearing last November, he said, was the final straw.

"I think we need a bit of a crisis in order for them to solve the problem," he said.

Patients left in limbo

In recent months, Lewis decided to take a step back from his toughest cases.

One by one, he told patients who'd waited years for surgeries to correct serious spinal deformities that he wouldn't and in his mind, couldn't take on that kind of work any longer if the system around him didn't seem to support it.

Kaschuba said she remains on his wait list, which Lewis said contains roughly 200 to 300 patients. (Wait lists in Canada are typically linked to individual specialists, and aren't centralized, so it's usually not simple for patients to swap physicians, or figure out where they land on a list.)

One of the two hospitals where Lewis has privileges Toronto Western has not reduced the number of extensive reconstruction surgeries it provides, a spokesperson said in an email following up on Kaschuba's concerns, which she shared with CBC News.

"However," the spokesperson continued, "we have confirmed Dr. Lewis has indicated he will not be providing certain types of extensive reconstruction surgeries. We recognize this is not the answer you were hoping for, and sincerely empathize with your situation."

In a statement later provided to CBC News, Dr. Thomas Forbes, surgeon-in-chief for Toronto's University Health Network (UHN), which includes Toronto Western, noted these types of complex spinal surgeries require "significant resources."

"We are committed to the needs of those requiring this care and UHN continues to offer extensive reconstructive procedures to our patients," his statement continued.

Lewis requested approval from Ontario's Ministry of Health to have Kaschuba's surgery taken care of out of province instead, which was denied earlier this year. (He later said every other patient he had recommended for outside care was also denied.)

Several other patients and family members also spoke to CBC News, sharing similar accounts of being denied long-awaited surgeries, with no clear answers on what to do next.

Debbie Powell, who has severe scoliosis that causes chronic pain and mobility issues, had been on Lewis's wait list for three years. In late April, Powell learned that Lewis was trying to get approval for her to have a spinal procedure elsewhere.

The 57-year-old Whitby resident said Lewis mentioned he was awaiting government payout for dozens of similar surgeries, and would escalate her case in hopes of getting the green light for it to happen south of the border.

"[He] keeps saying I am still young and wants me to have as much mobility as possible after surgery," she said, by email. "Yet myself and many other adult patients continue to wait."

Bonnie Ho fears her 18-year-old daughter with scoliosis will also remain stuck in limbo. The young woman was told she may be getting too old to have surgery at the Hospital for Sick Children in Toronto where Lewis still conducts pediatric spinal surgeries but was also among his adult patients being told "no" at Toronto Western Hospital.

In the meantime, Ho's daughter, who CBC News has agreed not to name to protect her privacy, is dealing with debilitating pain and has had suicidal thoughts, her mother says.

Jessica Beck was lucky enough to get one surgery with Lewis, back in November 2022. It was a spinal fusion to fix spondylolisthesis, a condition that affects a small portion of scoliosis patients and happens when one of the bones of the spine slips out of place, causing ongoing back pain.

Given Lewis's concerns over payment, Beck doesn't expect to have full spine-straightening surgery anytime soon. But she doesn't hold it against him.

"He's amazing at what he does. And there's nobody else like him," Beck said. "Who's going to want to replace him?"

'I'm not asking for more money than I deserve'

Lewis stressed that he feels bad for the patients stuck waiting for operations.

"It's the patients that deserve this care," he said, "and it shouldn't be on the doctors alone to be taking 100 per cent of the risk for these surgeries."

In his latest communication with CBC News, on Tuesday, he said he's trying to slot in "a few" of his most urgent cases throughout the summer.

There have been years of tension over surgeons' billings for these kinds of procedures, according to Lewis.

"I have to do the surgeries, and then I have to wait for some adjudicator to review the file to decide whether I deserve to get paid or not," Lewis said. "I am putting the work in and I'm not asking for more money than I deserve."

Rather than receiving a salary, surgeons like Lewis get paid by billing for each piece of the surgical process. The payments they get back from provincial insurance plans are used to manage offices, pay staff and cover other expenses which can eat into the surgeon'stake-home pay.

A Toronto Star investigation into Ontario surgeons' billings showed Lewis billed for more than $750,000 during the year of 2017 to 2018, ranking him 36th out of 650 doctors specializing in orthopedic surgery. The figure doesn't account for his clinic costs.

Lewis said for complex cases, the delays are unsustainable, and payments often end up being less than what he billed for. He also said he's currently waiting on back-payments totalling hundreds of thousands of dollars.

"My staff need to get paid, my office rent needs to be paid, I have other expenses that have to be paid immediately. I can't say, 'I'll pay you when the government pays me,'" he said.

"I'm not sure of any other public servant that waits over a year to get paid for his work and most people would not tolerate that."

WATCH: Teen's scoliosis surgery delayed over and over:

B.C. teen waited almost 2 years for scoliosis surgery

2 years ago

Duration 2:09

Long waits for elective surgery in Canada's health-care system left one teenage boy in Peachland, B.C., feeling like the Hunchback of Notre Dame after he waited nearly two years for surgery to treat his scoliosis. Its a crisis that has some doctors pushing for private care, while others urge Canadians to keep their faith in the public system.

Dr. Henry Ahn, an orthopedic surgeon at St. Michael's Hospital in Toronto who also tackles spinal deformity cases, echoed Lewis's concern about having to wait months, or sometimes beyond a year, to be reimbursed.

"At that point, you're not even sure if you'll get paid, or how much will come back," he said.

Ahn hasn't put a pause on offering those kinds of procedures, but agreed it is quite difficult to schedule the most complex operations. He also said he mixes minimally invasive procedures alongside more complicated surgeries to ensure delayed payments don't impact his ability to pay his clinic and office staff but it ends up creating longer waits for patients requiring specialized care.

For someone like Lewis, who built the majority of his practice on complicated spinal cases, the situation is more challenging, Ahn said. "Certainly Steve does the most volume in Ontario. They're the most stressful cases. They're long days in the operating room."

For Lewis, one particular effort to get paid for a lengthy scoliosis-related surgery dragged on for years.

A November 2022 decision from the province's Health Services Appeal and Review Board sided with the Ontario Health Insurance Plan (OHIP) to deny Lewis a variety of payments for a spinal surgery performed several years earlier. The case amounted to dozens of charges for various procedures to remove bone from someone's spine and correct a spinal curve, piece by piece.

Though Lewis provided letters from three outside physicians, which he felt supported his position, the appeal board sided with OHIP in denying payment for four components of the surgery totalling hundreds of dollars saying they were part of the broader compensation.

In a statement provided to CBC News, Ontario's Ministry of Health said: "Prior to payment, some complex surgical claims are subject to pre-payment adjudication activities to ensure they are eligible for payment as billed. This adjudication process ensures that physicians do not receive payments from OHIP that do not meet the payment requirements set out in the regulations."

Push to prioritize more common procedures

Multiple surgeons who spoke to CBC News also stressed that there's a growing provincial push to address backlogs of more common, standardized spinal procedures such as disc replacements or laminectomies to relieve pressure on the spinal cord leaving little room for complex cases like spinal deformity surgeries to get booked in the first place.

Like many parts of the country, Ontario funds surgeries in several specific ways.

There is one bucket of funding that hospitals can use to support all sorts of procedures, including complex ones. There's also a bucket of streamlined priority funding for a list of more common, standardized procedures ranging from hip replacements to cataract surgeries known as "quality-based procedures," or QBPs.

For spinal QBPs, the province's latest handbook for clinicians outlines the need for an annual increase of nearly 1,400 more prioritized procedures each year over the five-year period starting in 2022. That would involve hiking the rate of in-patient spine surgeries from 7.51 cases per 10,000 to 10.5 per 10,000 an increase of roughly 40 per cent.

There's no such push for non-priority procedures, like scoliosis-related surgeries.

UHN spine surgeon Dr. Raja Rampersaud chaired the team of experts who developed Ontario's latest QBP handbook for spine care, and said the goal was helping as many people as possible. But there's a key caveat.

"It would be irresponsible to say that nobody gets left behind," Rampersaud said. "It's just the nature of a fixed system, with a fixed budget."

WATCH | Data shows private health care is pricier than public:

Private surgeries cost twice as much as public, Quebec data shows

2 years ago

Duration 2:47

Recently available data from Quebec shows that the cost for surgery in a private, for-profit clinic costs the government up to two-and-a-half times that of the same treatment in public facilities.

The upside of the priority-based model, said Dr. Albert Yee, a spine surgeon at Sunnybrook Hospital in Toronto, is that it provides funding support for routine, high-volume procedures. "But it's at a cost to cases that don't fall under that umbrella," he said.

Yee described it as "competing priorities for limited funding," with less-common, highly specialized procedures taking up far more resources, including additional staffing and ICU time for patients. There's simply not a dedicated funding stream for that, he said.

"You can maybe do one scoliosis case a month, because it's too resource-intensive, and not under the QBP envelope," he said. "The simpler procedures that can be done as an outpatient are easier to get into the system."

Surgeon and researcher Dr. David Urbach, a professor in the department of surgery at the University of Toronto, agreed the priority funding model can impact care for people with rare or complex conditions, given the trade-offs at play.

"It's not that those patients aren't valued but that type of activity is not incentivized in the same way," he said. "So there is a risk that it will become deprioritized."

Some of Lewis's patients feel they're among those stuck, and are not getting prioritized for what they say would be life-changing treatment. The surgeon himself would like to see a better approach to ensure patients get the care they need while their surgeons are paid in a timely manner and not forced to pick between priority procedures and more complicated cases.

Lewis suggested redefining quality-based procedures to include "more complex work." He also said a centre specializing in spine care, including a focus on the trickiest cases, could help ensure people get the treatments they need without the responsibility falling on individual surgeons to chase down payments and juggle competing priorities.

Until then, he warned, the same challengesremain for both doctors and patients.

"I think the patients deserve better," he said.