Ontario MDs vs. the Ontario government: We need better

Like most Ontario physicians, I’ve spent the past 24 hours trying to digest our failed negotiations with the Ministry of Health and Long-Term Care (MOHLTC).

I don’t typically consider myself to be someone who is particularly passionate about matters of remuneration. I generally feel I’m paid adequately for the services I provide, and I think most physicians would agree with that sentiment. When the negotiations fell apart in 2012 and a 0.5% clawback on our services was unilaterally imposed by the government, I didn’t feel too aggrieved. I understood that our economy and the provincial coffers were in tatters, and that some degree of austerity would be expected from public sector workers. Perhaps naively I assumed that as a result of the 2012 negotiations that the province would feel the urgency to craft a sustainable strategy that ensured no further cuts to physician compensation and adequate patient access to care. Then yesterday happened.

As frustrating as the proposed cuts were, I am infinitely more irritated at the spin that Health Minister Dr. Eric Hoskins has been weaving both in interviews and on social media. I understand that in any labour negotiation, his job is to craft a message to the public to put the government in a good light. He has inherited an absolute mess from his predecessors, and I don’t envy him in the least. But I expect honesty from him. He has repeated his mantra of the “average physician making $360,000”, knowing full well that the public will interpret this as a net pay and not understand the weighty overhead expenses and other fees that physicians pay. And that physicians receive no pension or benefits. He has asserted that overall compensation to physicians will be unchanged, again glossing over the fact that the users within the system will continue to increase. He is intentionally confusing the public by conflating overall physician compensation with individual compensation.

“The OMA wants you to believe that doctors in this province can’t provide the same level of care as last year unless they receive a pay raise and we simply don’t agree,” Hoskins said.

Except they aren’t asking physicians to provide the same level of care. They will be asking physicians to provide more care as the system grows, without any funding to account for growth, and without any plan for managing the growth.

One of his other favourite criticisms is that physician compensation has increased 60% since 2003. Again the obvious deceit in this is that he is describing overall compensation (which accounts for more users) while knowing the public will interpret this as individual compensation. I would actually prefer that he come right out and say who he blames for the increases. Is it physicians in FHOs? (Disclosure: I am a fee-for-service physician). Is it ophthalmologists? Other specialists? Lumping all physicians into one group of fat cats muddies an already messy situation. He mentioned in a Tweet that in the negotiations, “We wanted to focus more on high earners. OMA did not accept.”. This seems to be directed at high-income specialists, but he didn’t provide any further clarification. The OMA is in a tricky position representing many group of physicians with varying financial interests, and understandably will not criticize any specific group of members, while trying to appease everyone. It is then incumbent on the Ministry to be crystal clear in communicating to the public and to physicians where they identify the remuneration problems to be. For instance, even as a family physician, I have no idea how the Ministry views the sustainability of FHOs/FHTs. Their sound bites frequently describe their commitment to these groups, but they then complain about exponential growth in physician income. Clarity is much needed.

A quick overview of Hoskins’ comments on Twitter over the past 24 hours demonstrates that he is of the opinion that physicians in Ontario are overpaid. Which is an argument that he is entitled to defend. But in addition to his above mischaracterizations to the public, he has also brought up physicians’ ability to incorporate and income split as justifications for fee cuts. An issue that was negotiated years ago in a different era, now being used to justify a fee decrease seems a bit questionable. He also notes that physicians are allowed to charge yearly block-fees for uninsured services, but he fails to mention that only a small minority of physicians actually charge that fee. I personally do not charge block-fees to patients, so to see Hoskins use that as some sort of justification for fee cuts makes me scratch my head.

Can you imagine any other public sector employees facing a long-term freeze, let alone the cuts that are being proposed to physicians? There would be mass hysteria. The Ministry started off in the negotiations looking for $740 million in savings. That’s one heck of a jumping off point. I won’t veer off track by criticizing other provincial scandals in other sectors, but trying to recoup that magnitude of funds in one fell swoop sure as hell better be supported by a great plan moving forward.

Here’s my question to the ministry. Let’s assume that the OMA accepts the proposal from the MOHLTC including all cuts, with a total savings of $650 million. What happens in 2017? Inevitably utilization of health care will increase, and the deficit will still be a major issue for the government. So more cuts to fees? What is the end game? That’s the part I struggle with the most. There has been no strategy communicated from the Ministry for how they plan on funding health care moving forward. They will likely point to the proposed “Task Force on the Future of Physician Services in Ontario” and the “Minister’s Roundtable on Health System Transformation” from Judge Winkler as the solution to our system’s ills. And while both of those initiatives are badly needed, the Ministry is asking physicians to sacrifice financially in the short-term, and asking us to trust that they will be able to solve things by 2017. Colour me skeptical. Judge Winkler articulated the problems we face in his report from Dec 14, 2014:

It is apparent that these positions are irreconcilable in the longer term. Absent some rationalization, the system may not be sustainable. Thus, the consensus emerged that without systemic changes to the health care system, the Parties seemed to be on a collision course so that a PSA (Physician Services Agreement), at some point in the future, may not be achievable.

Having reviewed the proposal from the Ministry, I don’t necessarily disagree with all of their proposals. Their argument that they shouldn’t be funding Continuing Medical Education for only certain groups of physicians is a logical one, and if they were to provide a framework for more evidence-based CME (similar to their Low Back Pain Strategy), that would be a positive development. Their proposal to eliminate patient enrollment bonuses has been criticized as being unfair to new grads, but I think at the very least physicians should be obligated to be responsible to those patients for a minimum period (5-10 years) to retain those bonuses.

One issue that is rarely addressed by the Ministry is how they plan on dealing with impending tsunami of health care utilization. Their strategy appears limited to putting our small fires with grand funding announcements, but an embarrassingly small amount of effort seems to be put towards patient health education and self-management promotion. Teach patients these principles, and they will require less costly care. If this doesn’t become a priority, we will continue to aimlessly throw money at political hotspots and fail to make any real progress.

Physicians are desperate to be part of the solution in our health care system. We see how poorly it functions, and we are in the best position to aid in the recovery. It’s part of our nature as healers to want to help. That’s why a major component of the negotiations included suggestions from the OMA on how to find efficiencies in the system. And I fear that the stance taken from the MOHLTC will embolden some physicians to withdraw from roles where they can help our system. I sincerely hope that this controversy prompts physicians to become more engaged in local system improvements, as clearly our government is sorely missing any top-down solution in the near future.

Here are a few interesting infographics from the OMA about patient education, increasing demand, and understanding overhead. They are a tad politicized of course, but provide some important numbers to the public.

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15 thoughts on “Ontario MDs vs. the Ontario government: We need better

  1. Shawn Whatley

    Thanks so much for writing this, Dr. Elia!

    I find Hoskins’ messaging misleading to the point of frank dishonesty. I like the way you ended with physicians being part of the solution. What other industry would attempt to banish its most educated professionals to the sidelines while legislators and bureaucrats run it?

    Thanks again for writing. Great to have found your blog.

    Cheers

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  2. Tim Nicholas

    The way the ministry has conducted these negotiations if you can call this never really occurred .To continue to be responsible for increasing utilization is a travesty and even physicians who wish to believe in the intentions of this agreement need to take a second look!! Tim Nicholas

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  3. Ed Weiss

    Thanks for a very well-reasoned analysis of the situation. As a new family doctor, seeing my income go up considerably since finishing residency really makes me question what the huge fuss is. A pay cut, even of the degree being imposed by the government, and even keeping in mind overhead and other expenses, still leaves us in the top 1% of the population. Are we really in a position to grouse about a relatively small absolute decrease in our income?

    I agree that there’s been gross mismanagement at the provincial level that, had it not taken place, could have avoided this situation, but we’re still arguing from a point of privilege. We may not have paid benefits, but we have heavily subsidized extended health insurance. We may not have paid sick leave, but we can easily get locums to cover extended absences.

    Interesting that you mention block fees — I’ve encountered a number of situations in which potentially illegal block fees were being charged to patients, mostly obstetricians and abortion clinics.

    You’re right about the difficulty moving forward — we really do need an organized effort to optimize care and be more preventative. I’m sure the community of physicians could come up with endless smart ideas. If only governments could see further than the next election.

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    1. Mbtb

      Your comments are slightly misleading. You say that we can easily get Locums- I tried for 7 months to find a Locum to cover my 6 month mat leave, with no success. I know some other docs in the same boat. Perhaps Locums are easier to get in family med (I am a specialist). As far as our incomes go, I agree that we gave healthy incomes. I also think we work darn hard for them. I can live with some cuts if I could more easily get other services for my patients, but that never seems to be the trade off. Home care for my patients is next to impossible to come by, for example.
      If the government wants a fee for service model, then the amount paid in fees will go up as health care utilization goes up. Do the math!

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      1. Dr. Ed Weiss

        Well, fair enough regarding the availability of locums (and you’re probably right about family medicine vs. other specialties), but at least we have the capability to do so.

        I would also agree with you about equal access to other services, such as home care. It certainly doesn’t seem to be equitable depending on where one practices. I wonder if this issue is even on the OMA’s radar, though…

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    1. supermarioelia Post author

      Hi Gerry, thanks for the comment. I only mentioned ophthalmology because the MOH has danced around criticizing ophthalmology fees in the past, essentially as a means of vilifying the entire profession. Great article there, thanks for sharing.

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  4. Ann Onymous

    “I fear that the stance taken from the MOHLTC will embolden some physicians to withdraw from roles where they can help our system. I sincerely hope that this controversy prompts physicians to become more engaged in local system improvements, as clearly our government is sorely missing any top-down solution in the near future.”

    To be honest, I’m one of those people. I’ve never colored myself to be political and growing up, but I’ve felt more and more jaded about our system, its organization, and its funding model. In short, I’ve felt increasingly jaded by the whole mess.

    The ruling from MOHLTC is short-sighted at best. Cutting after-clinics and fee-for-service…I feel that will ultimately increase in ER visits and wait times. I’m unfamiliar with the numbers, but I feel that this would ultimately increase the spending figures.

    I fail to see accountability and transparency of this government. Look at eHealth. Look at ORNGE. Look at the ridiculousness of enforced resignations with simultaneous astronomical severence packages. Hell; look at how all the hospitals have replaced whiteboards with LCD TV’s and Smartboards with 20x the replacement cost, one-quarter of the service life, and actually requires power (hence money) to run. Best thing is? Half the time, the LCD TV’s are off, and people still use the white boards (that have now been moved to a different wall usually).

    The inefficiencies of this system is mind-boggling, but what’s truly disgusting is the blind-eye and complacency with which the upper echelon spends and wastes. It’s not like I don’t want to care; it’s that I can’t. The system strain’s trickled down to us front-liners, and I’m overworked and undersatisfied. How do I even have mental room to provide the policymakers with feedback that their decisions are nonsensical? Further bad decisions are made, the system strained more, and the cycle repeats.

    Here’s a thought. Refund the glorified white boards. Get our money back from ridiculous severence packages. Hell; KEEP the 2.65% pay cut. Use all that money you save, buy some binoculars, and start looking forward. I didn’t go into this job to be rich. If I do want to be rich now, I’d switch jobs.

    But guess what, I DID go into this job to serve and be appreciated. Sadly, if I do want to serve appreciated now, I feel like I ALSO have to switch jobs.

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  5. Gerald I. Goldlist, MD

    I would like to quote and respond to some of Dr. Weiss’s statements.

    “leaves us in the top 1% of the population.”

    For another perspective on this statement look at this comparison between Doctor and Teacher Earnings:
    http://www.bestmedicaldegrees.com/salary-of-doctors/

    Ed, you did not comment about this but I want to mention that many people talk about average doctor incomes. The doctors who are at the top of the gross income scale can be working as much as 60 hours per week and are not the average physician in Ontario. Those who work 35 hours per week (plus studying and paperwork) do not make anywhere near the averages they allude to.

    “ Are we really in a position to grouse about a relatively small absolute decrease in our income?”

    I see that you do not understand the overhead issue. The Ministry of Health has imposed a 2.65% decrease in fees on BILLINGS not EARNINGS . For those on salary this is a 2.65% decrease in earnings. With inflation currently running at 2%, this is a 4.65% decrease in earning power.

    For those who work on a fee for service basis, the decrease imposed by the Ministry of Health is much more onerous. You may quibble about average overheads but there are always those above and below average. There are a huge number of physicians with overheads as follows. Someone with an overhead of 40% will be having their net income (which is more comparable to salary) cut by 4.42%. That is a pretty large cut in income. Adding inflation, this is a loss of earning power of about 6.42% This is not as you have said “a relatively small absolute decrease in income”.

    There are many doctors who have overhead of 50% and for them the decrease in net income is 5.3%. You may not be aware of this but there are numerous doctors who have even higher overhead of 60% (I am one of them). For those with a 60% overhead the decrease in “salary” is 6.625%. I suspect that even you would consider that a hefty cut in “salary”. Adding inflation for these physicians, their earning power is decreased by 8.262%

    The absolute decrease in income is large and not “relatively small” as you have said.

    You say that we have “ heavily subsidized extended health insurance”. That is nonsense. I chose not to get this insurance because it is so expensive and confusing.

    “We may not have paid sick leave, but we can easily get locums to cover extended absences.”

    What is your point? Locums don’t pay our incomes. They just take over seeing our practices. When a doctor is sick and doesn’t work, he takes time off but does not get paid.

    “I’ve encountered a number of situations in which potentially illegal block fees were being charged .”

    This has nothing to do with fee agreements with the government. If some doctors charge illegal fees then you should call the police not lower the fees for all physicians.

    Gerry Goldlist

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    1. Ed Weiss

      Gerry, I think we might be talking past each other a bit. Let me try to address some of your critiques.

      For another perspective on this statement look at this comparison between Doctor and Teacher Earnings:
      http://www.bestmedicaldegrees.com/salary-of-doctors/

      I’ve seen that chart, and I think it hardly captures the reality of the situation. First off, the numbers are based on training in the US, not in Canada. Second, the numbers don’t quite add up. As an example: I’m speaking for myself, but I didn’t spend 15,360 hours actively studying in medical school (it would equal 73 hours a week for all four years). Third, although it tries hard to say that our average pay is the same a teacher’s, there’s a vast difference between what we make at the beginning of our career vs. as we are more established and further from residency. Honestly, what proportion of teachers do you see living in expensive houses and driving expensive cars compared to the percentage of doctors who do the same? Add to that tax-sheltering through incorporation, etc, and the difference become much more stark.

      Ed, you did not comment about this but I want to mention that many people talk about average doctor incomes. The doctors who are at the top of the gross income scale can be working as much as 60 hours per week and are not the average physician in Ontario. Those who work 35 hours per week (plus studying and paperwork) do not make anywhere near the averages they allude to.

      Fair enough, but can you deny that even the lowest-paid full-time physician still grosses more than $150,000 per year? That’s at least in the top 10%, if not the top 1%.

      I see that you do not understand the overhead issue. The Ministry of Health has imposed a 2.65% decrease in fees on BILLINGS not EARNINGS . For those on salary this is a 2.65% decrease in earnings. With inflation currently running at 2%, this is a 4.65% decrease in earning power.

      I fully understand the overhead issues, and I stand by my opinion. If a physician grosses $250,000 before this cut, the 2.65% = $6625. If we assume 30% overhead as a minimum, we’re left with about $170,000 before tax, vs $175,000 before the cut. Is that really so much? Those with greater overheads also tend to have higher gross incomes; I won’t go through the same calculation but I imagine the absolute difference is similar in scale.

      You say that we have “ heavily subsidized extended health insurance”. That is nonsense. I chose not to get this insurance because it is so expensive and confusing.

      I pay $175 a year for basic extended health coverage through OPIP, and I’ve chosen to add more coverage for a bit more. I’m not sure what’s expensive or confusing about it.

      Locums don’t pay our incomes. They just take over seeing our practices. When a doctor is sick and doesn’t work, he takes time off but does not get paid.

      True, but they make sure we have a job to come back to when and if we recover. And I’m sure intelligent physicians such as ourselves have decent disability coverage in the event of illness. Many people in the workforce don’t have the luxury of either.

      If some doctors charge illegal fees then you should call the police not lower the fees for all physicians.

      I didn’t say that this was related; I was only commenting on one of Mario’s points, that block fees are charged by a small minority of physicians. I certainly encourage people who come across these illegal block fees to report them to OHIP.

      Anyway, Gerry, I think we’re just coming at this from different angles. Maybe i’m just a naive young new graduate, but I’m happy to have a job, to have a job that I enjoy, and to have a job that I enjoy and that pays extremely well compared to 99% of the population. I would certainly work for less money, though I can see how it would be difficult for those who are used to a certain level of income to do the same, even the difference in income is, I believe, relatively small. I do agree that the current climate set by the government is not productive, but as in the past, I’m sure we’ll all get through it intact, and the cycle will continue.

      Regards,

      Ed

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    2. Ed Weiss

      I apologize, I just realized I did my math wrong regarding the overhead calculations. It depends on whether one assumes overhead costs are fixed or tied to billings (the latter would be the case in a number of managed family medicine clinics)

      If one assumes that overhead costs are fixed, than according to my calculations, one gets the following (using $250,000 and 30% overhead, and $500,000 and 50% overhead):

      For $250,000 in pre-cut billings, one would go from $175,000 after 30% overhead to $168,000. For $500,000 in pre-cut billings, one would go from $250,000 after 50% overhead to $237,000.

      I still stand by my opinion that, in the grand scheme of things, those who have the privilege of making this amount of income, and are still doing better than 99% of the population after these cuts, are not really in a position to complain.

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  6. Darren Larsen

    Mario, spectacular job analyzing this situation.
    We need more balanced, articulate points of views like yours out there.
    So happy you were published in the Medical Post.

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  7. Pingback: Ontario’s Doctors In the News | Ontario’s Doctors

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