What the OMA needs to do now

The last nine months have been a stressful time for Ontario physicians, and has reached a boil over the past week with the announcement of further cuts by the Liberal government. Physicians have been active both in print and on social media in record numbers, and we are finally seeing the physician engagement on this issue that we have desperately needed for months.

As part of the vented frustration, the OMA has come under fire by many for a perceived lack of leadership in this crisis. The negotiating team from 2012 certainly deserves fair criticism for agreeing to a Representation Rights Agreement that allowed negotiations in 2015 to end with unilateral action. But I think we need to realize that in the short-term, the organizational muscle behind the OMA may still be our best bet to try and salvage something from this debacle. The OMA is a representation of the will of physicians. If enough physicians stand up and demand certain action from the OMA, they will have to act. With the number of splinter physician groups that are forming out of frustration with the system, the OMA is in a position where they must listen to membership, or risk becoming irrelevant.

One of the positives of this past week’s social media explosion has been the number of great ideas that have been put forward by physicians. Part of the downside of social media is that great ideas often drown under the wave of the next post by the next person, so here’s my summary of what the OMA needs to do immediately.

1) At the OMA Spring Council, Council agreed unanimously that “The Ontario Medical Association demand the Representation Rights Agreement be amended to add a binding dispute resolution mechanism”. The general understanding was that the window was three months for a response, and the details provided to membership by the OMA on this has been very disappointing. The OMA must provide both membership and the government with a clear timeline for when responses and resolution on this issue are expected, and need to follow through with legal action should expected deadlines from the government not be met. At this point, the government cannot be trusted as a reasonable partner, and they will stretch this out as long as possible. The OMA cannot allow this, and must use the immediate threat of legal action to create some urgency. Membership must be provided with very detailed and timely updates as to this process, perhaps even weekly.

2) Job action has been discussed by many physicians. Some ideas have been reasonable, others not so. The OMA must urgently provide its members with a “menu of options”, a list of detailed forms of job action that the OMA endorses. There has been great debate as to what the focus of these actions should be. Should they drive up non-physician expenditures to inconvenience the ministry? Should they be intended to inconvenience patients? Should they reduce non-urgent access for patients? (For the record, I think all three of those will hurt us in the long-run.). I know the OMA has been criticized for its reluctance to support any sort of job action, but this is an opportunity for it to provide membership with a list of approved actions to provide us with a united front. Rogue doctors reducing care will only disrupt their own physician-patient relationships, and will have very little impact on government policy.

3) The OMA must urgently create a publicly available database of physicians who have stopped working in Ontario since January 2015. The public will take notice of this growing list, and government will gradually feel the heat. I am tired of hearing the government boast about adding 700 doctors this year. Counter that with this list of the departed. Publicize the hell out of this list.

4) Along the same lines, many physicians have expressed interest in the leaving the province. The OMA should provide a form letter to its members, where physicians can sign a “Letter of Intent”, with the province or country they have inquired about moving to. This will not have any binding terms, but will provide the OMA with quantifiable data of the number of physicians who are considering moving. Again, putting numbers to this will make this situation very real for the ministry. Publicize the hell out of these numbers.

5) The OMA must urgently meet with family physicians in the Niagara, Guelph, and North York regions. They must inform those physicians that with the primary care reform being implemented by the ministry, obstructing that implementation temporarily is one of our few bargaining chips to push the government to binding arbitration. For those physicians who have yet to sign any contracts, the OMA must ask those physicians to refrain from doing so as a gesture of support for the rest of Ontario physicians.

6) Do not spend another dime on the #Carenotcuts campaign. It was a sensible campaign, but has failed to move the needle. Save that money for publicizing the threat of physicians leaving the province.

So there it is, OMA. There’s your blueprint. Please don’t wait for “physician consultation” and “road shows” to gauge physician sentiment. The last week has made things very clear. Physicians want action. Now.

More MOH secrecy: Patient Care Groups implemented behind the scenes

Many of us have been lamenting that the relationship between the Ontario government and Ontario physicians has deteriorated to a historic low.

It appears that we’ve gone from bad to worse.

I have learned from sources that the government has been working behind the scenes to implement the much-discussed Price Report, without any prior consultation of many key physician leaders and groups. Funding has already been secured for three pilot projects, and the province expects one third to one half of physician practices to be in Patient Care Groups (PCGs, also called Integrated Service Delivery Zones in some reports) within the next year. The Ontario Medical Association (OMA), the Section for General and Family Practice (SGFP), the Ontario College of Family Physicians (OCFP), and other physician groups have been intentionally kept completely in dark by the government until a leak emerged this past week.

What is the Price Report? What are Patient Care Groups?

In late 2013, the Ministry of Health and Long-Term Care (MOH) convened the Expert Advisory Committee on Strengthening Primary Health Care in Ontario to address current challenges in Ontario’s primary care system. The MOH identified four policy questions of particular interest: attaching all Ontarians to a primary care provider, ensuring all Ontarians can obtain services from an inter-professional care team, improving integration of care among providers, and ensuring access after business hours and on weekends.

This committee was chaired by Dr. David Price, Provincial Primary Care Lead and Chair of the Department of Family Medicine at McMaster University, and Elizabeth Baker, Provincial Nursing Lead. The final report from that committee was completed on November 13, 2014. It has still not been officially released to the public, ten months later.

The report recommended a complete redesign of Ontario’s primary care sector. The redesign would be a population-based model of primary care delivery, designed around Patient Care Groups (PCGs). PCGs are fund-holding organizations that are accountable to the MOH through the Local Health Integration Networks (LHINs). Citizens are assigned to a PCG based on geography, “akin to the assignment of public school students to the local school in their neighbourhood”. Funding to each PCG would be on a per capita basis, “reflecting the demographics, geographic rurality of the population, socio-economic status, and projected health needs of the catchment area”. The PCG then contracts with its local primary care providers, “honouring existing relationships and agreements currently in place”, to deliver primary care services. That would include physicians, nurses, and other health care professionals. “Provider groups and individual providers, who may be subcontracted to provider groups, earn the right, based on their ability to achieve quality benchmarks and any additional criteria/metrics captured in their accountability agreement, to participate in the system. The right to deliver service is not guaranteed but is performance-based.” Essentially Family Health Teams, Family Health Organizations, Family Health Groups, fee for service physicians, Community Health Centres, Community Care Access Centres, and Nurse-Practitioner-led Clinics would all fall under the banner of the PCG. The PCG, for example, would have the ability to decide whether a particular physician could work in a specific region governed by the PCG.

Each PCG would have a community-based board of directors. Each PCG holds an accountability agreement with the LHIN, renewed annually and monitored by the PCG’s board, subject to certain metrics (percentage of patients attached, avoidable ED usage, after-hours accessibility, etc.). Each PCG board has its own Executive Director, who develops a leadership team (existing hospital committees, Health Links structures, CHC staff, FHO/FHT staff, etc).

“Physicians will be paid through the contract between the PCG and their delivery model (FHG, FHO, etc.). Similar to the process to implement Alternative Funding Agreements for hospital-based physician (eg. E.D.), funds would be transferred to the PCG by OHIP then allocated to each physician group according to the terms of the contract. These would likely follow the existing terms of the model agreement but then could evolve over time.” What this evolution would mean for future physician compensation agreements, no one seems to know.

It’s a 34-page report, so I won’t go through every point in detail, but suffice it to say, it would completely transform Ontario’s primary care system.

I obtained a copy of the report from a source back in late February 2015. Many physician leaders have read leaked copies of the report since it was completed in November, but as the months have passed, it was assumed that the silence from the MOH indicated that they were not prepared to act on it. After all, it is a radical change, and would take years of planning and consultation to implement properly.

I learned this week that not only was the government prepared to act on the report, but they had been working on implementation for months behind the scenes. The OMA and SGFP were completely in the dark. Same for the OCFP. Most highly-connected physicians I spoke to this week had no idea that the Price Report implementation was in motion.

Three PCGs have already been formed with funding arranged, for North York, Guelph, and a group led by Dr. Price. Susan Fitzpatrick, Associate Deputy Minister, has left the MOH to become LHIN CEO, and the primary care branch of the MOH has been largely dismantled. LHINs are scrambling to create PCGs, with legislation expected to be passed in January to rubber stamp this primary care system reform. Those within many LHINs admit privately that they currently lack the organizational maturity for an undertaking of this magnitude.

Many of us will be working within this new transformed primary care system for the next decades of our careers, and it is incredibly arrogant of the government to believe that they alone have the necessary ideas and beliefs to guide Ontario primary care reform. Rubber stamping of projects is not the way to lead system reform.

I have a few simple requests for the Ontario government.

First, release the Price Report to the public. Second, be completely transparent about any ongoing implementation, meeting with physician leaders and physician groups to address concerns and seek input. We can simply look to the NHS system in the UK to see how complex a centrally-planned primary care system is to manage, and to exclude physicians from the planning process is incredibly naïve and short-sighted. The NHS has experienced decades of growing pains, and continues to experience significant short-comings, and we need to learn from their mistakes in shaping our own system.

Physicians need to be looked to for input on this program, including FHT, FHO, FHG and fee-for-service physicians at the planning table. Too much is being changed too quickly, and since patient access is still the biggest hurdle for patients, primary care physicians need to be involved in any decision-making. Leaving physicians out of any system planning will end up being a complete fiasco for this government, and for future governments that are left with layers of expensive bureaucracy that cannot be undone. Implementation has to be done thoughtfully, not in a clandestine manner without physician input. Resources need to be distributed equitably, with strong, evidence-based planning.

The report itself stated the following: “It must be noted that as of the writing of this document, the deliberations had not yet moved beyond the Committee; stakeholders will be engaged when appropriate to refine the initial model described below and help set the stage for implementation”. That sounds pretty clear to me. Stakeholders need to be engaged BEFORE implementation. The report also outlined in its Vision section that “in three years, the design elements necessary for Ontario to have an effective primary care system to improve population health outcomes will be in place.” Three years. Not overnight. The report also included an entire section entitled “Issues needing further discussion and investigation”. I will not include details here, but they are major hurdles to overcome. Finally, section 5.0 of the report is entitled “Proposed Implementation”. It includes a 12-point plan for implementation, the first two of which are “Engagement and consultation with patients, providers and other stakeholders in design development” and “Articulation of clear benefits to citizens, providers and communities”. Neither of these have occurred to date. Our LHIN (the Southwest LHIN) has not been given any marching orders from the government, and at the present time lacks the infrastructure to enact what the government is proposing.

I am not advocating for years of endless debate on the merits of the proposed system. Dozens of previous primary care reports have collected dust for years, and certainly we don’t need another report to add to the pile. But there needs to be public discussion on this system before widespread implementation. I am sure the government is wary of allowing outspoken dissenting voices with ideological opposition to central planning into the debate, but no system will be embraced by everyone, there will always be dissenters, and that cannot allow implementation to be done in the shadows.

Lift the veil of secrecy on the Price Report and primary care reform, before we end up with a dysfunctional, costly system that doesn’t serve our patients.

Medical testing for students and retirement home patients: the need for standardization

Most family physicians can relate to the same avalanche of forms and requests coming through the office.

Patient X is planning to move to a local retirement home, and requires a detailed physical, a chest x-ray, proof of immunizations, and a whole host of bloodwork.

Patient Y is starting a nursing course in the fall, and requires a physical to confirm that they “are free of any significant disease”, immunization records to fulfill their specific criteria, as well as blood work to confirm that they are immune to specific diseases.

What is most striking about these forms is how different the requests are, depending on the organization or facility that is requesting the information. Two retirement homes with similar set-ups often ask for completely different information. Similarly, schools offering the same program can widely vary in what medical information they require of their students.

Also notable is that a lot of the information that they ask for is not evidence-based. Tests without utility have significant costs, and these costs are downloaded onto our public system.

An ideal solution to this issue is for local public health departments to set evidence-based standards for what should be asked for by retirement homes, schools, and employers. This will set a baseline for what our public system should cover, and make it very clear that any additional requests are unnecessary, and would then have to be paid for by the requesting individual or the patient.

Let me attempt to provide some specific guidance. First I will address the pre-retirement home assessments that have become commonplace. We know that a physical examination in a patient without significant disease has no utility. It should not be required, requested, or offered. Screening bloodwork? This should be done in keeping with primary care guidelines, and not on the retirement home’s timeline. They demand a chest x-ray of every patient to rule out TB. Where is the evidence for this? If their concern is picking up rare latent cases of TB, shouldn’t we also be screening for TB in the community? Or in hospitals? The answers to these hypotheticals is a resounding no, and our public health units need to be fiscally responsible and make recommendations to stop these requests. Whether Tamiflu prophylaxis is effective is an article unto itself, but certainly the wisdom in ordering yearly creatinine levels in all retirement home patients to dose Tamiflu needs to be questioned. It’s an expensive program, with highly questionable benefits.

For school and employment requests for immunization information, this process needs to be standardized. Most organizations make reasonable requests for tetanus, diphtheria, polio, and pertussis information, but many make non-evidence based requests for serology for measles, mumps, and rubella, requesting re-immunization even for patients who have received 2 doses of MMR, lack antibody-mediated immunity, but likely possess cell-mediated immunity.

These assessments and requests from private organizations place an incredible financial burden on our strained health care system, and health units can help to alleviate some of this strain by providing evidence-based templates that these organizations and facilities are bound to comply with.