Perspective on payment negotiation for Ontario’s doctors
The Ontario Medical Association (OMA) and Ministry of Health and Long Term Care negotiate fee schedules on a four year basis.
This year, the process has garnered a great deal of attention as negotiations broke down, and the Ministry of Health unilaterally imposed fee reductions in some areas.
Understanding the history of bargaining between doctors and the government can create a context for current headlines.
In June 1986, Ontario’s doctors went on strike because of legislation introduced to outlaw extra billing. A research paper published two years later noted that the 23 day strike “not only failed to avert the ban on extra-billing, but it was widely viewed as a public relations disaster for physicians.”
The Politics of Paying Doctors
The vast majority of Ontario’s doctors bill for their services through a single public insurance program, the Ontario Health Insurance Plan (OHIP). Consultations, services, and procedures performed by doctors are listed in the Schedule of Benefits, which contains more than 8000 different fee codes. The Schedule of Benefits is updated every four years to reflect the adoption of new technologies and practice changes, through a negotiation process between the Ministry of Health and the OMA, who represent the interests of the more than 25,000 doctors in Ontario.
The negotiation process has been described by health policy researchers Tom Archibald and Colleen Flood as “quite private, shielded from public input and scrutiny, and one in which, for better or worse the medical profession continues to exert a significant control over the policy agenda and outcomes.”
The importance of the negotiation process is underscored by how central health care costs are to provincial governments. In Ontario, almost 50% of all public dollars are spent on health care. The Ontario government is estimating that it will spend $11 billion of Ontario’s nearly $48 billion health care budget on paying doctors in 2012/2013. Ontario’s doctors also have significant reach in influencing public opinions, given their daily personal contact with members of the public to whom they provide health care services.
The OMA Represents the Interests of Ontario’s Doctors
The mandate of the OMA is to “represent the political, economical and clinical interests of the province’s medical profession.” All practicing doctors in Ontario are required to pay membership dues to the OMA as a result of legislation passed in the 1990s, which recognizes the OMA as the only bargaining agent who can speak on behalf of Ontario’s doctors.
The OMA works to accommodate the interests of its’ membership through an extensive governance structure which includes a Council composed of over 290 delegates representing territorial divisions, as well as a smaller elected Board of Directors. The OMA has 62 sections for specialty groups of doctors who share an area of practice such as psychiatry or cardiology. These groups meet with government representatives to discuss issues related to payment and practice in their specialty.
The OMA website notes that “section activity has increased in recent years.” Stephen Brown, chair of the Anesthesiology section of the OMA from 2005 to 2008 says that it can be challenging to find common ground between each section, the OMA as a whole, and the Ministry of Health. However, “we are all stronger if we work together… and find shared goals to work towards.” For example, Brown notes that during his term as chair the Ministry of Health began to address lengthy wait times for surgical services, which required support from anesthesiologists. The section, OMA and Ministry of Health worked together to find creative, sustainable solutions that worked for all of the groups.
Within the OMA there is a history of conflict between sections, where one group, such as family doctors or radiologists, feels short changed because they believe they have suffered the brunt of trade offs made among sections during bargaining. David Peachey, a family doctor and Director of Professional Affairs for the OMA from 1985 to 1995 says “the real challenge for the OMA is holding together the many different subspecialties and groups, each of which has its own interests, concerns and goals.”
It is challenging for the OMA to effectively represent its various sections, while at the same time presenting a common front with government.
The History of Labour Disputes Between Ontario’s Government & Doctors
Alan Hudson, past lead of the Ontario Ministry of Health’s Access to Services and Wait Times initiative, notes that organized medical associations such as the OMA are established to look after the interests of their members, and that “the main interest of the OMA is to maintain the self interest of doctors, specifically their incomes.” Another informant suggested that in times of economic hardship, governments often look to restrict doctors’ incomes or curb costs associated with doctors’ fees.
The strongest lever available to doctors when their income is being threatened is to organize work slow downs, rotating job actions or outright strikes. However, in the past 30 years, Ontario doctors have only gone on strike twice, for one day in 1982, and for 23 days in 1986 . There was also some rotating job action in late 1996.
The first two of these job actions were in response to a federal commission in 1980 that set up the Canada Health Act. The commission recommended that doctors across Canada should no longer be able to carry out a practice known as ‘extra billing’ whereby they could charge patients for services through both provincial insurance programs and privately.
In 1986, the government introduced legislation that banned extra billing, and in response the OMA Council voted to strike. The June 1986 strike lasted for 23 days, with about half of Ontario’s doctors closing their offices, withdrawing hospital services, and canceling elective and non-emergency services. This strike also led to the rotating closure of emergency departments across the province. Issues regarding access to doctors’ and hospital services during this time were widely chronicled in the media. There was little public support for the strikes, and most doctors returned to work, or worked reduced hours, with the extra billing issue unresolved. The government held its position, passed a law banning extra billing, and the two parties returned to the negotiation table three months after the decision to strike.
Eric Meslin, a bioethicist, argued in a research paper that the OMA “failed to convince either the provincial government or the public of the soundness of its position.” Jackie Duffin, a medical historian and oncologist at Queens University argued that “doctors lost public credibility and public sympathy” as a result of the strike. Duffin suggested “when doctors go on strike, they lose. Even if they win on a monetary technicality, they lose public support.”
In 1996, as a response to earning caps put on certain specialist salaries, Ontario’s obstetricians expressed concerns that they were not being paid sufficiently for their services. The obstetricians were joined in a job action by orthopedic surgeons, some general surgeons and family doctors. The action resulted in 1 and 2 day withdrawal of services in some locations, and ended a few weeks later with the Ontario government agreeing to reduce salary restrictions on these specialists that had been put in place by the previous government. However, this also led to discontent among family doctors, whose pay remained static.
Doctors can also pursue legal action against their association, although this happens infrequently because it is in the best interest of specialist groups to maintain representation through their provincial associations. In 1998, claiming that they were unfairly bearing the brunt of $100 million in targeted savings in health care, a group representing Ontario’s radiologists launched a law suit against the OMA. There have been similar legal actions in BC, where groups of specialists have sued or distanced themselves from the BC Medical Association.
Disharmony between doctors and their associations is generally not in the best interests of the profession. David Peachey points out that “the Ontario Ministry of Health has rightfully not negotiated with groups that have attempted to be separate from the OMA in the past, in no small part due to the legislation mandating all physicians be pay dues to the OMA, in place since 1992.”
What Can Doctors do to Express Discontent?
Recent history in Ontario suggests that in times of government cut backs leading to reduced income growth, doctors have a number of options.
The first is to continue to bargain with the government and try to find a resolution. This can be a challenge with multiple stakeholders and many disparate groups and interests all under the OMA umbrella. The second is to mount strikes or job actions – however these can have negative consequences both in terms of reducing public access to health care and reducing public confidence and support for doctors. Finally, there is the potential for a lack of solidarity within the OMA, with various groups of doctors taking action against the OMA or launching targeted, unilateral job actions.
Alan Hudson says that doctors need to consider both “the economic context and public mood” when they negotiate over their salaries with the government and that “as much as the public respects doctors, there is little sympathy for doctors being exempted from cuts during these tough economic times.” Hudson argues that “all doctors are professionals, and taking out frustration with income problems on patient care is unprofessional.”
Given the various options available to doctors and government around negotiations, and the cost constraints facing Ontario’s health care system, many informants suggested that they are hopeful that in the present situation the government and OMA will return to the negotiation table to find a solution to the current impasse.