April 23, 2016: About 300 Ontario doctors, their families and supporters gathered at Queen's Park Saturday for a rally and a march to protest cuts and a "crisis in health care." (Photo: Jim Rankin/Toronto Star via Getty Images)
Last week, the Ontario Medical Association (OMA) announced that it had reached a tentative agreement on a Physicians Services Agreement (PSA) with the Ontario Ministry of Health (MOH). Physicians were shocked as the OMA hadn't even informed them that they had resumed negotiations with the MOH.
There is rather a lot of very animated discussion about the agreement amongst physicians. Certainly the Concerned Ontario Doctors (COD) group has spoken out publicly against the agreement. There's been quite a bit of discourse amongst various OMA sections about how this came about as well.
Normally, of course, medical politics should be of little interest to the general public outside of the same kind of morbid curiosity that occurs when one is watching "Here Comes Honey Boo Boo. However, I actually think the general public should pay more interest to this particular contract, because if it's approved it's going to significantly damage health care in the province for the next four years. It will hurt your ability to get a family physician if you don't have one. It will increase wait times for diagnostic tests and specialists. It will decrease Ontario's already low physician to patient ratio (currently seventh out of the 10 provinces).
While the agreement itself is supposed to be confidential until it's ratified, it's already been leaked to so many media sources that it's essentially a public document. So let's review it.
First, the agreement proposes a fixed Physicians Service Budget (PSB) in each of the four years of the contract. Currently the manner in which the system works is that physicians get paid for each service they provide a patient. So a fixed budget essentially means that there is going to be a limit on how many services patients get.
This is clearly a win for the bean counters and bureaucrats at the MOH who want a predictable budget. However, no one knows for sure what will happen if patients want more services than is budgeted for. It's to be referred to a joint MOH/OMA committee of some sort. But then what?
Additionally, the OMA has agreed to what are referred to as "progressive discounts" on billings over $1 million. Obviously, this was done because of optics. It could be sold to the general public as cutting back on "fat cat" doctors. The fact that the reason the billings are so high is that patients needed the services (doctors can only bill if patients need to see them) is ignored.
The OMA also gave up the demand to have independent binding arbitration in the negotiation, violating a promise made by OMA President Virginia Walley on the day of her inauguration.
Most alarmingly, it appears that the OMA, while publicly agreeing to a Physicians Human Resource Committee, MAY have had some back door discussions about the possibility of DECREASING the number of medical students that graduate every year. This at a time when there are still about one million people without a family doctor!
So why would the OMA give up all of this? Isn't the goal of a bargaining agent to get MORE for the people you represent? The answer is that the OMA obtained some guarantees to "co-manage" the health care system in return. The OMA hierarchy seemingly grasped at the opportunity to give itself more power.
But why is this bad for patients? Turns out, in the mid 1990s, the OMA struck a similar deal with then-Premier Bob Rae's government. It allowed for a fixed Physicians Service Budget, progressive discounts (in that agreement it was 33 per cent) on physicians who billed above a certain level, enshrined the OMA as a "partner" in jointly finding savings in the health care budget and turned a blind eye to the medical school cutbacks of the early 1990s. Sounds familiar, no? So what happened?
Predictably, the government abandoned its responsibilities to find savings at the first sign of public outcry. (What's that you say? Politicians actually flip-flop on promises they made in the interests of political expediency? Who knew?) Because the government never kept its end of the bargain, the PSB was always over the fixed budget. However, the government insisted physicians stick to their end, and slapped progressive claw backs on their billings to keep the fixed budget at the agreed-upon rate.
Angered by the betrayal, physicians left the province in droves, leading to, at one point, three million people without a family physician.
The so-called high billers did what any other human being would do. Say you normally get $30 for performing a service, up to the first 1,000 pateints. After 1,000 you only get $20 for the same job. You're going to do the first 1,000, but are less likely to do more. The specialists who were over the limit wound up just taking more time off. Problem was, patients still kept getting sick -and now had to wait longer to be seen.
I can completely understand why the Ministry of Health would propose an agreement like this. The Liberals don't care, they just want peace with the doctors before the 2018 election. The way the agreement is set up, the crisis from its bad decisions will likely hit in 2019 and 2020, by which time it'll be the responsibility of the next government to fix.
However, I think it's absolutely shameful that the Ontario Medical Association has ignored the evidence of what happens with this type of agreement. We've been there and done that, and these clauses never work. They sold out the patients of Ontario in the naïve hope that they will be given more power in the health care system. For the sake of my patients, I hope this agreement is not ratified by the membership of the OMA.
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