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.