Monthly Archives: October 2015

My feeble attempt at reconciliation between the OMA and the government

Well here we are. After ten months of posturing from the government and the OMA, we’ve reached the inevitable. Today, the OMA filed a challenge under the Canadian Charter of Rights and Freedoms against the Ontario government. The doctors of Ontario with no option but to take the government to court to achieve a binding dispute resolution mechanism.

Everything both sides have done to this point has been sadly predictable. The government was never going to back down from their arbitrary global cap. With the terms of the Representation Rights Agreement (RRA), they never needed to. The prospect of big clawbacks in April 2016 would have been difficult to justify to the public, so they elected to make interim cuts in October 2015 to attempt to mask the impact. They’ve taken the pound of financial flesh from Ontario physicians that they always planned to. During this time, the OMA has predictably objected to the unilateral cuts, and refused to provide the government with any input related to implementing the cuts. They have done their due diligence to ensure that a legal action will have its greatest chance of being successful, to the point that many members have criticized the general snail’s pace of action from the OMA.

But no one has any predictable moves left. The legal challenge has been filed. After months of clamouring for a legal challenge, where do we go from here?

I would gently point out to both the OMA and the government that neither can afford this dispute to last until the resolution of the legal challenge, years from now.

To the government: Be prepared for another 2.5 years until the next election with physicians pointing out every single flaw in our health care system. And putting those flaws squarely at the feet of government. Family medicine residents fleeing the province. Physicians retiring. What physician will come to a province where the medical association has taken the province to court? And every single complaint our patients have about wait times (which is an hourly event for some of us), we’ll happily tell them who is to blame. Physicians can be a terrific ally for any government, and a vocal enemy for a stubborn regime.

To the OMA: Quiet diplomacy has worked for many years during peacetime, but physician unrest continues to grow. You can’t place the future of bargaining solely at the feet of the result of the legal challenge. Patience is waning, and I can imagine that splinter groups will pick up further momentum as the court case drags along.

Neither side can afford to allow this debacle to continue for another few years. Both have ample incentive to come to an agreement. But both have political barriers they are finding difficult to overcome. For the government, it’s the financial constraints set by the Treasury Board and their golden ticket of the RRA. The don’t want to willingly give the OMA binding arbitration unless forced by a judge. They don’t want to spend a dime more than they’ve offered. The OMA cannot agree to any deal with the government that includes a firm cap on billings (cannot be held responsible for all increased utilization), nor a deal that doesn’t include binding arbitration with all future negotiations. Ontario MDs are insisting on those terms. But binding arbitration will eventually be granted to Ontario physicians, so rather than waste millions on legal costs on an inevitable result, is there a solution that gets the demands of both parties met?

As Deb Matthews said in the W5 documentary, “Now we have to think.”

Here’s my feeble attempt at a plan that may placate both parties. A lot of give and take, but better than the alternative of an indefinite stalemate. (No judging until you’ve read the entire proposal).

  1. The OMA and government agree to begin negotiations at the budget limits proposed by the government in their January 2015 unilateral action, with 1.25% yearly growth from 2015-2018. However, this will not be a strict cap, but will be a guideline. Both parties will agree to targeted elimination or reduction of low-value physician services that are agreed to have a high likelihood of meeting the government’s budget targets. These will be taken from the proposals provided to the ministry by each OMA medical specialty ahead of the 2014 provincial election. Other mechanisms may include FHO reform, continuing a portion of the current across-the-board cuts, and accountability measures that are mutually agreed upon. Both parties will agree that the plan has an equal likelihood of coming in over or under budget.
  • Rationale for OMA: If they don’t agree to a plan with the government, the government will continue to unilaterally impose their will until the legal action is completed. Which may be years away. The OMA wants some sort of agreement now, but can’t take the political step of “agreeing to implement the cuts”. Physicians would revolt. This provides them a more politically-appealing method of moving forward.
  • Rationale for government: They achieve an extremely high likelihood of achieving their fiscal targets, and even have a chance of coming in under budget. They also get the chance to reshape the Physicians’ Services Agreement, with many of the reform proposals they have wanted to implement for years. Keep in mind, they are implementing these proposals now already, and examples like the NGEP shows that they need physicians’ expertise, and we need to inform their decision-making.

2. Government agrees to grant the OMA a binding dispute resolution mechanism for the negotiations period that will lead to the contract that will begin April 1, 2018. A binding dispute resolution will be part of every future negotiations between the OMA and the MOHLTC.

  • Rationale for OMA: Assuming these negotiations begin in late 2016 or early 2017, it will include a resolution mechanism, which is well before a legal case would typically be expected to conclude.
  • Rationale for government: They will go into the 2018 election with a stable contract with physicians, and can present to voters that they have been fair to physicians, yet fiscally sound. They avoid the inevitable political fallout of going into an election with vocal physician opposition.

3. Government and OMA agree to urgently develop plan to address volatility of methadone maintenance programs, ensuring that patients achieve access to stable care that is not dependent on the financial situation of prescribing physicians or clinic owners. The program will reimburse physicians in a manner that rewards quality care, and provides no perverse incentive for over-testing.

  • No rationale needed, I hope. These patients desperately need a solution. Everyone knows this.

 

The alternative to an agreement is another 2+ years of exactly what we’ve experienced over the past 10 months. It’s draining emotionally for physicians, and it’s draining the government of political capital.

My parting message to the OMA and the government: please be creative, understand the other’s position, and there may be a solution to be had somewhere in this mess. We need stability and predictability in our system. Right now, we have neither.

Why the New Graduate Entry Program is a non-offer

Every single Ontario physician who saw the recently-released New Graduate Entry Program (NGEP) for new family doctors had the same thought. “Is the government serious?” (If the link doesn’t work, keep trying. It works eventually.)

Unfortunately, they are very serious, and this is exhibit A of what happens when unilateral action is imposed without physician consultation. You get a short-sighted plan.

Let me first address what likely led to this proposal. The government was being widely criticized for limiting new family physicians from joining FHOs in non-underserviced areas. The 416 and 905 are vote-rich areas, and are largely not considered underserviced. The messaging that doctors could not start practices in these areas was likely having some political traction, and the ministry needed to do something to rebut this. They can spin this as being at least an option for new grads, as terrible as the conditions are.

The second issue that likely led to the NGEP was the ministry’s frustration with new grads not committing to starting up practice and sticking with that practice. From my experience here in London, we have had a number of physicians start up practice and leave the area within their first 3 years. That revolving door is frustrating for patients, and is not conducive to a quality patient-physician relationship.  Rewarding physicians for providing continuity was likely part of the ministry’s plan.

But this plan was clearly drawn up by bureaucrats.

The limits set on billings outside of the FHO/FHN group is the most detrimental to patient care. The cap on year 1 outside billings at $0 is likely intended to discourage new grads from moonlighting in walk-in clinics and other clinical areas not related to their patient care (concierge clinics, marijuana clinics, etc.). But what they have failed to realize is that by setting a $0 cap, they are completely limiting new grads from benefitting financially from providing any non-FHO high value services, like house calls, or focused practice work in palliative care, obstetrics, psychotherapy, inpatient care, or ER work. Frankly I have no problem with physicians doing other part-time work, as long as they are meeting the FTE commitments that they have with their FHO (more on that later). I understand if the ministry wants to set some sort of reasonable cap on non-FHO work to ensure physicians are doing the necessary FHO work, but a $0 cap is absurd.

The proposed compensation schedule is a complete non-starter. The income proposed for year 1 will barely cover overhead for physicians in major urban centres. If the ministry is truly interested in having a serious dialogue about this plan, then they must adjust the proposed annual compensation levels for all three years. The issue of internal relativity and whether novice physicians should be subject to lower compensation is an issue to be debated amongst physicians, but this level of discrepancy between family physicians is completely unacceptable under any circumstances.

As for the “Practice Improvement Plans” suggested in the NGEP…I began to write my thoughts on this, but this quickly devolved into an essay unto itself on the relative merits on pay-for-performance programs in Ontario. I will post this essay later this week. In short, of course we need some metrics that look at measures like access and quality of care. And tying some element of physician funding to those measures is not unreasonable. But what the ministry has proposed in the NGEP is draconian. Patient experience surveys? To how many patients? By what means are they being surveyed? What are they asking patients? What will the cut-offs be for deeming success? Are they not aware of the literature showing that giving financial incentives to reward “increased patient satisfaction” also leads to increase hospitalizations, increased opioid and antibiotic prescribing, and to increased utilization of lab and radiology services? I’ll go into detail in my next piece about potential solutions that would actually work for accountability measures, but what the ministry has proposed is baffling, and will create a litany of unintended consequences.

Let me give a bit of praise where deserved. I do actually like the idea of establishing a 40-hour work week as 1.0 FTE, and having the physician declare their FTE commitment as part of their contract. We all know that there are a minority of physicians in FHOs who are being paid as full-time physicians, but spending only part-time hours in their clinic. This needs to be addressed, and I don’t think the ministry is entirely unreasonable for having some expectation that FHO capitation payments will be paid roughly according to how much time is spent in the clinic. And I am definitely in favour of the ministry enforcing that FHO physicians deliver the after-hours care that they are contracted to provide. The FTE commitments and after-hours enforcement should be implemented both for new grads and for established FHO physicians. Throw in a maximum number of holiday weeks a year for FHO physicians, beyond which those vacation weeks will be paid at a markedly reduced base compensation rate.

The number of patients proposed to be rostered per year is not unreasonable. Although I will concede that if two part-time physicians want to join forces to split 1.0 FTE and a targeted roster number, I think that should definitely be accommodated. Also, I like the general idea of the mentorship program, although far more details are needed before it can be endorsed.

But on its whole, this program cannot be endorsed to graduating family physicians. It has far too many flaws, has too many gaps in potential interpretations, and given how trustworthy the ministry has been to date, this is not a contract that new family physicians should be signing. The worst thing for the ministry is that this will do nothing to keep graduating family physicians in Ontario.

Will Ontario Liberals set cap on total MPP compensation budget?

As most of you know, the Ontario Liberal government has set an arbitrary cap on total physician payments, with clawbacks and cuts imposed unilaterally. If physician services exceeds their cap, due to increased utilization by the public, an aging population, or unforeseen epidemics, the government will enforce further cuts to recoup anything above the cap.

It’s irrational, short-sighted, and will drive physicians out of our province.

But I have a proposal.

For the 2018 Ontario provincial election, the number of MPPs will be increasing from 107 to 122, to account for increasing population growth…the same growth that the province refuses to fund for physician services. So right now, 107 MPPs each make a base salary of $116,500 (ministers and the premier make more, but I’ll keep the calculations simple). Following the government’s “net-zero” mandate, the $12,465,500 (107×116,500) that MPPs earn collectively cannot be increased. Dividing that amongst 122 MPPs, their new salary will be $102,176, which still puts them all comfortably on the Sunshine List.

But the MPPs will argue “Why should our pay be decreased 12.3% when we are doing the same amount of work for the people of Ontario?”

That’s exactly what physicians are asking you about our situation.