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Jul 25th 2016

Weighing the merits of the Proposed 2016 Ontario Physician Services Agreement

Weighing the merits of the Proposed 2016 Ontario Physician Services Agreement

A lot has been made about the acrimonious relationship between Ontario physicians, their negotiating arm, the Ontario Medical Association and the Ontario government, particularly over the last year and a half. As essential partners in the delivery of healthcare to all Ontarians, physicians have long cared for their patients, guided by long-standing physician services agreements negotiated with government in good faith and revisited every three to four years. To look at these agreements certainly over the course of my career is to see times when the public sector is both flush with resources and when it is not. These contracts have little to do with whether there is a Liberal or Conservative government in power.  Physicians have continued to deliver care to their patients despite the absence of a physician service agreement since 2012. To follow along casually in the background and perhaps focus on the occasional headline, the public may only see a battle that pits seemingly affluent, self-serving physicians against a government that is championing the cause of the taxpayer. Since 2012 there have been at least two reconciliation exercises by the Ministry of Health on physician compensation to make up for shortfalls in healthcare funding. These roll backs currently amount to 7%. Given that Ontario's population continues to grow and age, that funding deficit will inevitably spiral upwards.

To be very clear, the current impasse is very much about money and how it might be spent but it is definitely not about income.

Two Mondays ago while running my typical heavily booked, stressful office, the family practice resident that was spending time with me (I was teaching as an added task to my day as I often do) casually mentioned during a short break that an agreement had been reached between the government and the OMA earlier that morning. After seemingly no progress over the last 24 months, this obviously caught most people by surprise. Up until that morning there had not even been the slightest sense that the two sides had even started to negotiate again. I committed to reviewing the document at day’s end. Since that time there has been significant debate across the profession as to the merits of this agreement.

A six page summary was quickly released for membership review. The OMA, while admitting that this is not a very good agreement, has endorsed it, recommending ratification so that physicians are not subject to further unilateral reductions at the discretion of the Ministry.  Daily emails reinforce the same message. The argument is that we will be allowed to be partners in reforming the system as we move forward with promises to look for efficiencies and modernize the fee schedule. Some have complained that the six page report is not long enough or filled with enough detail to make an informed decision; that it is too vague and incomplete. There has been a lot of debate about what the numbers mean and how much really will be available into the future.  Infographics from the OMA suggest the hope of stable healthcare funding over the next four years. I do think that OMA leadership has tirelessly worked in good faith for countless hours to try and navigate us to this point.  They have earnestly tried to articulate a comprehensive message.  They have earned my respect and thanks for all of this.

 

 

 

 

 

 

 

In my mind however, I don't need to really read past the first few lines. I can make up my mind essentially there. To accept the proposed agreement requires as a starting measure that the 7% cuts that were put in place to reconcile the funding deficit in the healthcare remain intact. The profession cannot agree to this in principle. It is not for me to know whether physicians get paid too much or not enough. Perhaps we should be paid less. I just don’t know. However, what I do know is that if as a society we all value good public health care then I think we all own a share of that responsibility when resources are inadequate to fund that system. Accepting this agreement establishes as fact that a funding deficit for the care that physicans provided their patients existed in Ontario between 2012 and 2016 and that physicians have agreed to accept sole responsibility to make up the difference in that gap.

 

That is a dangerous precedent.


There are five basic principles to the Canada Health Act. It basically enshrines what Canadian citizens collectively value. I think these are all very reasonable. They are worth reviewing again:  

1. Public Administration (healthcare shall be carried out by a public authority in a non profit manner. Accountability to the taxpayer, healthcare users and providers is also made clear)
2. Comprehensiveness (this is self evident and implies all meaningful care be covered)
3. Universality (the latest in best evidence care should be made available to everyone regardless of means)
4. Portability (ensures coverage as people travel across provincial borders)
5. Accessibility (This mandates an expectation of reasonable access to health care facilities and for physicians, hospitals and others to be provided reasonable compensation).  

Clearly this fifth responsibility is given to our governing bodies.

 

I do think physicians have an important role to play in protecting the Canada Health Act. My recent visit to Malawi, Africa reinforced in my mind that access to quality healthcare for all is a basic human right. It becomes clear however as one reads through these five tenets that government also bears an important responsibity. Indeed, so do all Ontario citizens.

For most of my 20 year career we have been trying to streamline healthcare. The relative cost of technology continues to rise while patient expectations continue to and quite rightfully demand the best. Hospitals such as mine have nobly continued to balance their budget despite being given less and less by government, to fund what is necessary. Surgical blocks have been reduced or closed for years across every hospital in the province. These manoeuvres predate the current post 2008 fiscal crisis by many years.  Up until now, the work always seemingly gets done. Hospital administrators, doctors, nurses and others tirelessly triage the important things like cancer care. Other things (kidney stone surgery as one example over the summer) get pushed down the road a little further every year. However, I have long said that 2016 is the year that things might come to a head. Budgets are no longer so easy to balance. Cuts to patient care go a little deeper. The increasingly generous philantropic nature of Canadians has masked many shortfalls with respect to capital expenditures and much needed equipment for years. Even this is not an endless resource as many other worthy causes outside of healthcare also compete for the same dollars.

It begs the question then that if everyone within the system is seriously trying to address the funding gap, work harder and make sure patients are cared for, should we not expect the same level of commitment from government?  After five years of 0% hospital budget increases, this past February this government announced that it was "investing” in hospital care. It prompted this banal tweet that amounts to 1% in new funding for hospitals relative to the prior year:

The Ontario Hospital Association which should be lobbying for better and more sustainable funding for all hospitals and understanding that 1% hardly made up for the increasing gap created over the last few years could only manage this response:

 

 

If Ontario physicians accept this current offering then we are basically agreeing to be the only ones to disproportionately reconcile any funding deficit. That is a very big problem.  The profession is an easy target as certainly we all do 'well enough'. The populist strategy has its merits.  We would declare that we are willing to make up the difference while such silly, pandering public declarations with an eye to the next election will continue to propagate the myth of a well-funded healthcare system into the future. Yes we need to tighten our belts. Perhaps we do need to rollback the fee schedule but this has to be done in true partnership with government, policy workers and citizens at large. Anything less than that will eventually still lead to the demise of this public system over time. You can only kick the can down the road so far. The current course is not sustainable. Good public healthcare, its stewardship through difficult times and its long term health is a social contract that binds us all. 


Is the six page summary too short? I think it is long enough. It is time for all parties to get serious about what our healthcare system will look like into the future, well beyond election cycles and move forward with broad consultation, mutual respect and in good faith.


RS

Comments

Posted: July 25, 2016

By: keith dyke

Great post and so true. The population of Ontario have no idea how bad things are because we as physicians keep plugging the holes. Since 2012 with our own personal incomes.

Posted: August 05, 2016

By: Dennis Kendel

In Saskatchewan the SMA is taking a bold leadership role in dialogue our Ministry of Health and Regional Health Authorities about health system redesign based, in part, on the Kaiser Premature model. In that model the KP "Medical Group" in each state is accorded both the opportunity and responsibility to organize and deliver medical services to a defined population with a fixed annual budget. The Medical Group determines the number and mix of physicians needed to care for the enrolled population and sets the compensation (salary) for members of The Group. They select physician colleagues committed to team-based care, expect and support positive collegiality and sever physicians who prove to be unable or unwilling to work together in a collegial manner. Do you think such a model of "physician led" medical services within a fixed budget could work in Canada?

Posted: August 09, 2016

By: James Sean Elliott

I couldn't agree with you more, Dr. Singal...having been the recent recipient of absolutely superb care here in Ontario, I'd hate to think that doctors were also partially footing the bill for it! I don't think the general public quite understand that.

Posted: August 09, 2016

By: Peter K

Thanks for sharing this Rajiv.
In my very humble opinion, Canadians should be provided with data on the efficacy of the healthcare system. Point being, my view on the question about current funding would be based on the efficacy of the system and deliverables to the public. In lieu of, our opinions are probably based on our own, most recent experience - a lousy substitute for the facts. Is that too much to ask?
We have a reasonably homogeneous view of the standard of care should be - if there was a report card, I believe Canadians would 'generally' agree on how well it is funded (or not). My analogy would be the Canadian Pension Plan - there is a report, done by a board that operates independently from the government, to ensure the long-run sustainability of the plan.

Posted: August 09, 2016

By: Marvin

Thanks for an enlightening explanation of where we're at with Ontario's health care system. It is a bit daunting to think of just how much work is going to be required to put things right -- but, as you say, "broad consultation, mutual respect and good faith" would really be a terrific place to start.

Posted: August 09, 2016

By: David Bellamy

Rajiv well put. If not for this blog I am not sure how I would have ever gotten to the bottom of what just happened. It is NO secret that I am NOT a fan of the Wynne government and what you have highlighted has confirmed that once again. This government has systematically mismanaged the Education File, the Energy File, and now the Health File. For each of these the doctrine applied is very different but the result is consistently very detrimental to Ontario. If this continues, we will all be asking, as the Wynne governments TV advertisement says, Where am I. Ontario?

Posted: August 09, 2016

By: Mike Holmes

Having know many close friends for over 30 years that are doctors in this province and knowing Dr Singal for over 5 years the doctors are the heart and soul of being on the front line in this fight on a daily basis. Dr Singal has put it in a very simple form to help solve the ongoing problem that has always been the short sighted ness of the government.

Posted: August 09, 2016

By: Paul Freedman

As an individual who shares ++ patients with you and works and teaches ++ I agree wholly. I also know that we are virtual slave to the government which is totally against the rights and freedoms afforded all of society. At some point we need to mount a constitutional challenge re our position. I have spoken to several judges and Lawyers who agree wholeheartedly that the time has come to mount such a challenge we are worse off the endenchured servants from a rights point of view except that we actually get pay.

Posted: August 09, 2016

By: Paul Freedman

We need to use the courts for justice for us and the patients we serve. I am sick of using the court of public opinion. Like medicine they often do not understand the depth of where we are at or the true consequences of government having and wielding total control without checks and measures! We must move beyond that morally and ethically.

Posted: August 12, 2016

By: Carlene Ledwidge

You articulate it so perfect.government prefer to waste money on stupid things instead of healthcare What can i say.

Posted: August 18, 2016

By: Geoff Bowes

Thank you for putting this into perspective for me,Dr. Singal. A very succinct eye opener.I shall pass the word as best I can.

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