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Is the OMA an appropriate vehicle for negotiating doctors’ fees?


In the wake of the recent agreement between the Government of Ontario and the Ontario Medical Association, it is time to reevaluate the appropriateness of the OMA as the bargaining agent for Ontario physicians. I will spend most of this opinion piece using ophthalmology as an example since that is the specialty that I practice. Similar analyses and analogies can be made by other sections.

The physicians of Ontario are a diverse group with widely varying practice patterns. These include doctors who are hospital based vs. community based, capitated vs. fee for service, urban vs. rural, academic vs. non-academic, group practice vs. solo practice, surgeons vs. non-surgeons, acute care vs. on-going care, and high overhead vs. low overhead.

Also in the mix are students. According to the OMA there were 7,413 Medical Students, Interns and Residents issued votes for the recent agreement with the government. This is about 20% of the 38,587 total votes issued. The Student vote overwhelms every other section’s voting power except for General and Family Practice. For Students to have so much influence over the fiscal issues of practicing physicians is totally unreasonable. They have no overhead. It is inappropriate for those not directly affected by the agreement to have more influence on its acceptance than the groups that are profoundly affected by it.

The vast majority of ophthalmologists bill fee-for-service and have private offices for which they pay all the expenses. I recently had discussions with several solo ophthalmologists in private practice about the costs of running their offices. The following are some of their comments:

  • “3 secretaries, a technician, 3 ophthalmic assistants, a bookkeeper/typist and an office manager. Half-million dollars in equipment.”
  • “I have 1 full time secretary and one part time. I have one full time tech and one part time. I have a bookkeeper and a biller both who come in once a week. My overhead comes to about $250,000.”
  • “3 full time employees and 1 part time.”
  • “I have 3 ½ staff. An office manager who does assisting, reception and billing as well. An ophthalmic assistant and a visual field technician who also does reception. 1 part-timer phoning test results and filing charts.”
  • All rent space varying from 1000 square feet to 2700 square feet.

But not every OMA section has overhead expenses like this. To illustrate the varying overheads between sections I present the following table to compare the types of expenses of a hospital-based emergency physician to those of an office-based ophthalmologist.

Emergency Room Doctor

Expense paid by HOSPITAL

Ophthalmologist

Expense paid by DOCTOR

Triage Nurse

Ophthalmic Assistant

IV Technician

Visual Field Technician

EKG Technician

OCT Technician

Nurse

Ophthalmic Assistant

Head of Emergency Department

Office Manager

Reception        

Reception

Admitting Staff

Operating room booking

Outgoing Correspondence

Typist

Supplies, sutures, instruments

Supplies, sutures, instruments

CME for Nurses & other Staff 

CME for Staff

Cleaning staff   

Cleaning staff

Working Space

Working Space Rental

All of the expenses paid by the ophthalmologist come out of their billings, whereas most of an emergency room doctors’ expenses are paid by their hospital. Can one bargaining organization really represent these two very different doctors fairly?

I acknowledge the hard work of the OMA’s negotiation team, but an analysis of information supplied by the OMA suggests that this team was not representative of the physicians of Ontario. The OMA negotiations team included 3 family doctors, an adolescent psychiatrist, an emergency physician and a vascular surgeon. It included a lawyer, the CEO of the OMA (a former deputy minister of health), a senior director of the OMA and staff in the OMA negotiation department.

Only one representative of the negotiating committee was a member of the 20 highest billing sections of the OMA. The negotiating committee was not a representative sample of the doctors of Ontario. No one on the negotiating team seems to have experience with the overhead of running a modern state-of-the-art radiology, cardiology or ophthalmology office.

Of the seven sections with above average cuts to their billings, only one had a representative on the negotiating committee. Is it really legitimate that the hardest-hit specialties were barely represented on the negotiating committee?

The OMA seems to have erroneously accepted the popularly held misconception that High Billings equals High Earnings. Equating high billings to high earnings was a major part of the public propaganda campaign by the Health Minister during the recent negotiations. The OMA negotiators seem to have been sucked in by the Health Minister’s ploy of equating billings to earnings. The OMA negotiators apparently do not understand, or chose to ignore, the effect of overhead.

A recent study on physician income adjusted for overhead costs confirms that billings do not equal earnings. This study found that “overhead ranged from 12.5% in emergency medicine to 42.5% in ophthalmology.” Furthermore it found that “ophthalmologists were ranked second [in income] when only public payments were considered but eighth [in income] when overhead was included.”

These finding make it clear to me that a large and diverse organization like the OMA cannot adequately understand the workings of the various specialties within it. The result after factoring in overhead is that the average decrease in earnings for ophthalmologists in Ontario will be 16.5%. That is average. Some will be less than this amount and those with higher overheads will be much higher.

It is my belief that cuts of this magnitude will make it impossible for ophthalmic care to remain at the same quality and availability. It will make modern state-of-the-art ophthalmology care nonviable economically. A number of my colleagues have already begun to retire early or are leaving for other jurisdictions. These negative effects will continue. As newer technologies are invented and become available, Ontario’s ophthalmologists will not be able to afford them, and the eye care Ontarians receive will begin to lag behind other regions.

A prime example is Optical Coherence Tomography (OCT), which has been alluded to frequently during recent discussions. Advances in this imaging have evolved rapidly in the last 5 years as newer higher definition models have continued to come out. With cuts to fees it is now economically impossible to justify spending $90,000 every few years to keep up with state-of-the art OCT imaging and interpretation. As a result of the OMA’s recent agreement with the Government, patient care will suffer as those with high overhead will be unable to provide the best possible medical care that will be available in the world of medicine.

Other specialties have their own issues with the OMA’s recent agreement with the Ontario government. I have only used my section of Ophthalmology to illustrate that the OMA may well be a suitable organization for things like group benefits in insurance, car rental and hotel discounts, as well as its Physician Health Program, but because of its size it cannot comprehend or react properly while taking into account the heterogeneous needs of Ontario physicians. It is no longer the appropriate agency for negotiating or making the fee schedule for physicians as it is no longer able to serve the diverse needs of Ontario physicians and their patients.

Gerald I. Goldlist is an Ophthalmologist in North Toronto. Follow Gerry on Twitter @gerrybuddy

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52 comments

  1. Birinder Singh

    Even as a family physician (the group for whom invariably the OMA provides the greatest protection based on sheer numbers of members), I find the new development of the OMA as our de-facto representative bargaining unit a bit strange. I am also a lawyer, so seeing the OMA being given sole negotiator status for Ontario’s doctors without having an in-depth conversation as to whether this is appropriate for our members is a little unsettling. This is a major development in the latest agreement that was overlooked for the most part. The agreement almost sets us up as a union of sorts, which definitely has it’s benefits, but we need to look further as to whether we now need to re-examine the structure of the OMA and the negotiations team we structure. I do feel the OMA does a good job negotiating on our behalf, but I also wonder if this development simply provides the OMA much more power without appropriate consideration by its members.

  2. Scott Wooder

    This is an important and necessary discussion. I’d like to respond to 3 areas: representation, overhead and student voting.

    No Section of the OMA and no specialty is represented at the negotiations table. Members of the negotiations committee have a fiduciary duty to represent all OMA members fairly and in good faith.

    Family Doctors may bring some special knowledge of family medicine issues when they served on the Negotiations Committee, but they certainly do not represent family physicians. The Executive of that Section is consulted, as are other Sections, on matters that directly affect them. Each OMA Section can present information to the Negotiations team prior to negotiations starting and the Committee seeks out advice as the process proceeds.

    The fact that there were no members on the Committee from Ophthalmology, Cardiology and Diagnostic Imaging may be related to the fact that members of those Sections did not apply to join the Committee.

    The point made about overhead is excellent. That is why the Negotiating committee uses ANDI, average net daily income, when comparing incomes for different Sections. This methodology takes overhead into account when a Section’s economic interests are considered. The Committee does not arbitrarily use ANDI. That is a policy that is made by OMA Council which includes representative if each and every OMA Section.

    Students vote and they turn out in great numbers. Why shouldn’t they? Decisions made about their futures during negotiations will affect them in their careers for up to four decades. One could argue that decisions made during negotiations will have a much greater impact on students and their futures than they will on physicians in the last few year of practice.

    The OMA has negotiated for all of our members dating back to the introduction of medicare. It is not new and it has served our members and our patients well. Doing anything different would be new. That’s not to say that we shouldn’t think about the process and re-examine it from time to time. But let’s do so with a clear understanding of the facts.

    Don’t forget that 81% of our members voted in favour of the last agreement. That agreement clearly identified the OMA as the sole representative for physicians when negotiating with the Province of Ontario.

    Scott Wooder, MD
    Co-Chair OMA 2012 Negotiations Committee

    • Helen Robertson

      Seeing the OMA renewal come in again makes me feel physically sick. I have worked in Canada for the last 30 years and Ontario for the last 15 years. During most of that time I have worked for DND or other organisations . I have rarely billed the OMA , but I am required to pay your exorbitant fees.

      How dare you say that you represent me ! I totally disagree with the OMA’s mandate
      “Ontario Medical Association (OMA) represents the political, clinical and economic interests of the province’s medical profession. Practicing physicians, residents, and students enrolled in any of the six Ontario faculties of medicine are eligible for OMA members.”

      Over the past 30 years I have worked in five provinces and witnessed the decline of Medicare. It is no surprise that Canada continues to fall in the ONEC ratings for Health Care . “Canada” as an effective entity for delivering Health Care does not exist. The CMA ,which I gladly support, should be a representative body for Canadian physicians driving innvovation and excellence like National Medical Organisations in other countries. Instead it is an anemic, toothless shadow organization. Why ? Because we are not required to join our National Organisation. Meanwhile the bloated greedy self aggrandized Provincial Medical Associations are presiding over the demise of socialized medicine in Canada. But I guess that is okay because they negotiate our fees?
      I did not become a Doctor to fight over fees and get rich. I became a Doctor to look after sick people and work in system that delivers reasonable health care to patients.

      It seems I now work in the wrong country.

      Finally if anyone has the energy and knowhow to take legal action against the OMA for misrepresentation of physicians in it’s mandate. Please let me know.

  3. Mark D

    I was also thoroughly disgusted that the OMA received sole negotiator status as part of the ‘deal’. If I had a choice, I would not be paying my OMA dues. I’m not a lawyer, but think that at some point, hopefully sooner than later, there will be a legal case against both the OMA and the government for how things have and are playing out.

  4. Mark D

    Re: medical students having a vote: I'm 100% against this as well. I understand that this is their future; however, they are not yet in practice, and have nowhere near the same understanding of how any 'deal' will affect us (or them, once they are in practice). In fact, I would go so far as to say that they have NO CLUE whatsoever about how a deal will affect them once in practice.

    Why not give undergraduate students who call themselves 'pre-med' the right to vote as well?

    They'll be in practice even longer than med students… I have to say, I've lost essentially all faith in the OMA. And now we're heading into another round of 'negotiations'.

    • TapOff, M.Sc. Epi

      It seems from this discussion as though the many disciplines and practices only know their own “burden” (and perhaps also **believe** they understand the burden of [all] patients).
      Given this discussion, I surmise that at least the OMA did provide collective bargaining yet the organization does what any institution does once entrenched; speak for the institution’s preservation and **status quo** rather than promotion a system wide reform for the good of a healthy population.

      • Gerald I. Goldlist, MD

        Very well said, TapOff. “The organization does what any institution does once entrenched; speak for the institution’s preservation.”

        The recent deal is an excellent example of two bureaucratic organizations agreeing to a deal that was in the best interests of the institutions themselves. The following part of the agreement shows this well:

        “The MOHLTC recognizes the OMA as the exclusive representative of the physicians practicing in Ontario for the purposes of these negotiations.”

  5. Pamela Velos

    “81% voted in favour” means the majority of voters (20 % of whom were students) were not as adversely affected by the agreement as the 20% against (which included whole sections – the high overhead specialties of Cardiology, Diagnostic imaging, and Ophthalmology).

    The reason Gov’t returned to negotiating table was because the above sections increased public awareness of unintended consequences of unilateral MOH decisions. Unintended consequences were not addressed in agreement and continue to be a problem.

    Disappointing that Dr Wooder does not acknowledge that there is a problem when whole sections and their patients are adversely affected by an agreement

  6. Toronto Doc

    Great Article Dr. Goldlist. I think you have very precisely put your finger on the reason why more and more specialists have completely lost faith in the OMA.

    Dr. Wooder,

    In regards to your points

    1) Your assertion that the negotiating committee is looking after the best interests of all members is simply not true. Cardiology, Ophthalmology and DI were “thrown under the bus”. Some specialists have taken a 50%, that’s correct a 50% cut in their net income after overhead. How can any negotiating committee accept an agreement where some physicians are taking a 50% reduction in their net income. How does it come to 50%? Previously a doctor was billing $100 with overhead of $40 therefore net income is $60. This doctor is in a group seen as a “high biller”. Billings have now been cut from $100 to $70. Overhead remains at $40. Net income is now $70-$40= $30. That is a 50% percent reduction in net income. I honestly have no faith that anyone on the negotiating team or on the OMA board has a grasp of this simple math. What was the net income reduction for other specialties such as Emergency medicine and Anesthesia where there is no overhead….likely low single digits for most docs.

    The fact that medical students, interns or residents who do not have an MD or have never practiced in the real word, should have the largest voice (after family practice) in the outcome of the negotiations is simply absurd. They should have their own contract that they can vote on. Justifying it by saying that the contract will influence them for many decades is ridiculous, as contracts are negotiated every 4 years, or perhaps in our case every year. Once a medical student or intern becomes a practicing physician, they should only then be allowed to vote. If we use your logic, then babies, infants, kids and adolescents should be allowed to vote in our national and provincial elections as decisions made by the government will certainly influence them more than a 90 year old.

    Finally, you state that ANDI is used to make decisions regarding incomes of physicians. This may take into account overhead, but there is no way it can take into account the intensity of running ones own practice. In a high overhead private office, one will go bankrupt if they work at the pace of most salaried physicians. As an example take Physician A and B in the same specialty. Physician A decides to work from 7 am to 6pm. He takes minimal or no lunch break etc. He works diligently and efficiently and sees 6 patients per hour. Physician B works from 9 to 3, and in between patients takes a 5-10min break to write notes, discuss the case at length with others around him/her, have a coffee and then see the next patient. In summary Patient A has worked 11 hours seeing 6 patients per hour =66 patients. Physician B has worked 6 hours seeing 3 patients per hour=18 patients. Assuming all else is equal, Physician A is 3 to 4 times more productive than Physician B. It is obvious that physician A will bill OHIP 3-4 times that of Physician B. Does ANDI take these scenarios into account, and if yes please describe the methodology used to arrive at the numbers. Even if ANDI was an accurate reflection of “the work done”, can you please post ANDI amount for each specialty and % cut taken by each specialty in the last agreement. As you know there are many specialties that have much less overhead and higher NET incomes, that should have taken a larger cut, with less dramatic cuts to Cardiology, Radiology and Ophthalmology.

  7. Pesky Medical Student

    This opinion piece is very misguided. A) The author places significant blame on learners. While the utility of learners having a vote in negotiations that affect them (loan forgiveness, clerkship stipend, near-future practice compensation) can be debated, I suppose, the author provides no substantial data on how many learners actually voted or what the vote breakdown was. Without these data he is simply scapegoating the future of the profession, which is…pretty disgusting. Should learners count as 3/5 of a person for a vote, perhaps? A cursory look finds that the actual number of votes cast overall is significantly lower than the total issued. In actuality – without revealing confidential information – learners appear to be responsible for, in absolute numbers, 13% of the yes vote. An overwhelming majority would still have ratified the agreement. Let’s not let facts get in the way of animus, however. There are clearly other sections that are more responsible for the result, but I suppose it is easier to blame more powerless groups within the association. B) The author points out the many differences between ER Medicine and Ophthalmology (cherry-picking his comparison, but let’s ignore that for the moment). Fair enough. But he shows zero evidence that these differences were not taken into account. Relative fee parity and negotiations are very complicated and there are intricate, continually optimized formulae and rubrics used for this evaluation. I should add that these methods have previously favoured ophthalmology quite handsomely. C) Differences between practice dynamics, location, and overhead aside, the basic reason why the OMA should negotiate for the entirety of physicians is bargaining power. The OMA is, simply put, a better bargainer than any combination of specialty interest groups could be. They have more to offer and more to withhold. We need only look to Quebec for evidence of the detrimental effects of dividing the vote. If your goal is ultimately to let the MOHLTC unilaterally determine your practice characteristics and take-home pay, perhaps you are on to something.

    If you are unhappy with how the OMA has represented you, the solution is to get active within your section and encourage changes for the next round. Perhaps you can also consider sparing learners from your unprofessional wrath.

    • Collin

      In response to the med student:

      I understand how you may feel somewhat insulted and sympathize; however, I think that your response is itself misguided.

      You seem to imply that you have significant understanding of how negotiations play out, what’s involved, etc. There is no medical student in Ontario who has direct and significant involvement with negotiations. Many of us, on the other hand, do. Please do not pretend that you have some sort of unique insight into negotiations as a med student.

      You also imply that you have knowledge of practice costs (you state that the original author ‘cherry picked’ his comparisons between ER and ophthalmology). Excuse me, but have you ever practiced in either field? You haven’t.

      The original author’s point, or one of them, if I can put words in his mouth, is that medical students have more voting power than entire sections. This does not make sense. No offence, but you have no clue about practice, negotiations, or their impact. How could you – you have never practiced obviously. In case it’s brought up – having a parent who’s a physician does not give you qualified insight.

      You mention that not all who could have voted, did vote. I’m not sure what your point is. This is the case with any essentially election ever held.

      Again, I sympathize if you felt offended. However, the author makes a very valid point. Once you’ve finished med school, residency, fellowship, and then been in practice and have had to set up your own office, pay your staff, pay for your equipment, your overhead and office space, your CME costs, PR/advertising in some cases, etc, I think that you might start to understand what the author was trying to say.

      PS: What percentage of each section that voted yes or no is not confidential. This information is open to those who wish to know it. The OMA has broken down the numbers in multiple ways.

    • Clinician

      I don’t think that Dr. Goldlist is ‘blaming’ medical students for how the vote turned out. Simply that it’s not fair that medical students have such great voting power.

      I would agree entirely with him.

      Why not give undergraduate ‘pre-med’ students the power to vote in that case?

  8. Community Cardiologist

    Statistics from the OMA contract vote:

    Diagnostic imaging: 81% voted “no” (512/633)
    Neuroradiology: 79% voted “no” (37/47)
    Nuclear Medicine: 72% voted “no” (38/53)
    Ophthalmology: 71% voted “no” (235/329)
    Cardiology: 62% voted “no” (192/310)
    Radiation oncology: 52% voted “no” (62/109)
    Total # of “no” votes/ total voters for all above sections: = 1076/1481 (73%)

    Why doesn’t Dr Wooder address this in his comment? He sadly seems to almost blame Cardiology/ Ophthalmology/ Radiology for not being on the council, rather than acknowledging their engagement in the voting process and their legitimate concerns. He wrote “The OMA has negotiated for all of our members … [the] agreement clearly identified the OMA as the sole representative for physicians.” This highly misleading comment ignores how these sections voted.

    Also, on the subject of medical students – it is interesting to note that the vote from this single section more than offsets all the votes from the above 6 sections:

    Medical students: 95% voted yes = (1166/1228)

    Am I convinced, as Dr Wooder seems to be, that the OMA is the true “sole representative for all physicians”? Of course not. I’m only convinced of one thing – we need to find better representation!

    • academic md

      I couldn’t agree more with the above comment. The OMA did a great job at the start of keeping all MDs together. We all (including myself) supported the OMA. It made sense.

      Then things changed. The OMA touted a ‘deal’ that wasn’t particularly better than what was going to be opposed on us. The OMA sold out a number of specialties.

      We should have kept on with the lawsuit.

  9. KS

    I agree with the community cardiologist. I think that there’s one more chance to get things right (the next negotiations). If that goes like the last one, some of us will begin to leave the province for another, or to the US.

  10. Gerald I. Goldlist, MD

    In reply to Pesky Medical Student.

    He uses the terms “blame”, “scapegoating”, “animus” and “unprofessional wrath”. I don’t believe that there were any of these in my opinion piece. My opinion piece was about the OMA’s being an appropriate vehicle for negotiating doctors’ fees.

    He says that I provided “no substantial data on how many learners actually voted or what the vote count was.” This information was sent out to OMA members a few months ago.

    He suggests that I have cherry picked the comparison between ER Medicine and Ophthalmology. The table comparing expenses of the two sections is clearly meant to show differences in expenses between a hospital-based physician and an office-based physician. I said at the beginning of the piece that “I will spend most of this opinion piece using ophthalmology as an example since that is the specialty that I practice.” An emergency department is an obvious example of a hospital-based setting. Many internists and surgeons who work in a hospital also have private offices and to use them as examples would have made the comparison confusing.

    Re: “Relative fee parity and negotiations are very complicated and there are intricate, continually optimized formulae and rubrics used for this evaluation.”

    Not that it matters to my argument, but I can’t help but wonder if these words are really the words of a medical student.

    Re: “These methods have previously favoured ophthalmology quite handsomely.”

    Were these words really written by a medical student?

    In any case, does “Pesky Medical Student” have any proof for his statement? Does the fact that cataract fees have been lowered 3 times in the last 5 years make a difference? In fact, if what he says is true, it helps make my point that the OMA is not an appropriate vehicle for negotiating doctors fees?

    Re: “Differences between practice dynamics, location, and overhead aside”

    This cannot be put aside. OMA’s lack of understanding of these issues is the main point of my opinion piece.

    Re: “If you are unhappy with how the OMA has represented you, the solution is to get active within your section and encourage changes for the next round.”

    Many of us have been active within our sections. The smaller high-overhead sections have been very active in getting the problems with the government-imposed settlement out to the public. Nevertheless, the OMA accepted an agreement without significant changes to the items affecting the smaller high-overhead sections. The OMA has shown that being active and supporting the OMA has not been successful in promoting the interests of their sections.

  11. Academic physician

    What would I have rather seen instead? A fair deal obviously, come to by a fair process.

    This was neither.

    (your vague, open ended question deserved a similar response, sorry).

    • Gerald I. Goldlist, MD

      Matthew, you have chosen to interpret my words in a way that suits your own conclusion on a different topic. My opinion piece was done to point out a defective bargaining process that has harmed patient care as well as the physicians of Ontario.

      If you want to discuss the fiscal realities of the health care system in Ontario and Canada then you should go ahead and write an opinion piece on that topic.

      • Gerald I. Goldlist, MD

        Matthew, “fairer” is a relative term and depends on the perspective of the stakeholder. There are many stakeholders and thus multiple opinions on what is fair.

        If you got the impression that the dissatisfaction stems from the outcome then your impression is wrong.

      • Gerald I. Goldlist, MD

        Matthew, “Fair Deal” is a relative term and depends on whose perspective we look at it from. I will answer from the point of view of a patient. A fair deal would be one in which the patient can get state-of-the-art health care now and in the future.

    • community

      I was pretty upset with the process. As physicians, we cannot strike. I understand this.

      However, because we have essentially a single-payer system, we are (or were supposedly) guaranteed to have a fair negotiation process. What happened was anything but a fair process. A new schedule was imposed on physicians. The OMA begged the MOH to come back to the bargaining table…at which point the OMA was brow-beaten into accepting a deal, which was little better than what was to be imposed originally.

      Regardless of the outcome, and regardless of fiscal realties, necessary cuts, etc., this is bullying by the Liberal government, and should not have occurred.

  12. Gerald I. Goldlist, MD

    Toronto Doc made some comments about ANDI (Average Net Daily Income) that are very important since “ANDI is used to make decisions regarding incomes of physicians.” Absolutely. This is confirmed as the minutes of the OMA Council Meeting of May 5 – May 6, 2012 show that a motion carried “that the principle of relativity be applied to negative allocations.”

    Toronto Doc also wants to know if hours of work are factored into the ANDI data. The minutes of the OMA Council meeting of May 2012 state that the “CANDI Relativity Implementation Committee recommended ‘an INTRODUCTION of the hours of work modifier using PwC data.’”

    Without the hours of work modifier, the use of the relativity data is preposterous.

  13. Patient

    Regarding Pesky Medical Student:

    Why are you using such rhetoric, including calling a colleague “disgusting” when commenting here? Is it because you are anonymous?

    “Perhaps you can also consider sparing learners from your unprofessional wrath.”

    Some introspection may be needed. Dr. Goldlist’s piece was far from unprofessional and certainly did not evoke wrath. I would worry more about sparing patients from your attitude than I would about Dr. Goldlist’s commentary.

    • Oshawa

      Totally agree with the response above by Patient.

      First, I’m not entirely sure that ‘pesky med student’ is in fact a medical student.

      If it is (or isn’t), calling your (future?) colleague disgusting is entirely unprofessional.

  14. Dr. James Lannister

    Physicians should be banding together to denounce any fee cuts to any specialties or to general practitioners.

    It is an unfortunate state of affairs when the highly-compensated fields have their fees cut, supposedly out of a presumed envy of the panelists in charge of recommending such cuts. As you had mentioned above, the panel is comprised of predominantly underpaid physicians like family doctors and psychiatrists. Rather than try to increase billings to their own professions, which we all agree are underpaid, they are ok with making drastic, fairly arbitrary cuts to the highest billers.

    This outcome would have been prevented had physicians stood together as a cohesive unit. That means ophthalmologists, radiologists and cardiologists would be standing with the family doctors and psychiatrists to demand that they be paid more from the public purse. The provincial government says there is no money, but when the McGuinty cabinet ministers all received large bonuses for reelection, I found that statement hard to believe.

    The fact of the matter is that the medical profession is fractured down income lines. Rather than write about how the cuts hurt the bottom line of your profession, Dr. Goldlist, you should also include how the underpay of the other professions that had allowed this axe to fall contributes to poorer patient care, and that they deserve more. Though it might be a bit late for those words to have any effect in this instance. Still, its better to start somewhere than never start at all.

    We are all in this together, yet we stand apart. I am saddened.

    • Gerald I. Goldlist, MD

      I agree with you. Physicians in other fields on medicine should be letting their patients know how the recent cuts affect their personal health care.

  15. Bill Evans

    Lets be honest here, the fee schedule at present is out of date for ophthalmology. Tech advancements have significantly reduced the time and risk required in eye surgery, yet the fee schedule has not reflected this change. An update has long been overdue.

    You mention a colleague who has overhead of 250,000 dollars. This number is meaningless without including the profit margin.

    • Tim Hillson

      Um, Bill, taking into account inflation, cataract surgery is now reimbursed at 50% the rate it was in the 1980s. The fee has been reduced three times in the last three years. Ontario now has the lowest paid cataract surgeons in Canada except for Quebec. What kind of a reduction beyond that were you thinking is needed?

  16. dr merrilee fullerton

    This Province’s “fiscal reality” is not going to change any time soon…not for years and possibly not for decades. We need a better approach and more open minds about broader health care changes that are needed rather than trying to squeeze MDs for the next 30 yrs.

    In other words, we need to be preparing for a Hybrid system rather than blaming MDs.

    • TapOff, M.Sc. Epi

      How do you define “Hybrid System” and are you aware of the concept of Zombie Arguments related to this issue?

  17. Pamela Velos

    Bill Evans, Risk of going blind is significant material risk, ask any patient, and not much lower than it was 30 years ago. Everything in the practice of medicine is better than it was 30 years ago – certain specialties are supposed to subsidize these advances more than other MDs?

    Real problem with the OMA agreement is that is does not reverse unintended consequences of government imposed cuts – ie only 4 OCTs will be paid in one year when evidence shows they are needed monthly to treat Age Related Macular Degeneration. Agreement does not support state of the art care.

    As a patient you should be concerned. Things are going to get a lot worse for patients.

  18. Bill Evans

    Inflation has reduced the reimbursement of all fields’ billings.

    In the 80s, cataract surgery was more complex and risky. Now its relatively simpler.

    The 50% reduction sounds steep, as does the reduction thrice in the past three years. However, what is the $/hour of the procedure and what % is kept by the ophthalmologist as profit? This is the most important factor determining whether a slash is justified.

    To Pamela Velos: lots of things are risky in medicine. Emergencies are probably the riskiest of situations. Smoking is still a major problem that, if family doctors were remunerated fairly for working on smoking cessation, could prevent so much disease that the risk of age related macular degeneration pales in comparison.

    Long story short, ophthalmologists are overpaid. No physician can work ophthalmology hours (which on average are far less than those of say a general surgeon), bill millions a year, and call it fair.

    • Gerald I. Goldlist, MD

      Bill Evans said: “Long story short, ophthalmologists are overpaid. No physician can work ophthalmology hours (which on average are far less than those of say a general surgeon), bill millions a year, and call it fair.”

      I prefer to stick my topic of the OMA’s ability to represent all physicians. Nevertheless…

      Dr. Evan’s statement once again shows that one section does not understand the workings of another .Ophthalmology is not just a surgical specialty. I guess you do not know that over 50% of Ophthalmology is practiced in the office and not in the hospital. You do not know that about 30-40% of ophthalmologists practice only what is called medical ophthalmology and do not do surgery.

      Dr. Evans, you have no data to support your wild claims on hours and billings. You are just making that stuff up.

      • Bill Evans

        If I am making it up, then perhaps you would be able to direct me to information that negates my claim? I can only extrapolate via the surgical ophthalmologists boards at the hospital I work at combined with the information gleaned from the schedule of benefits. Combined they make for an obscene amount of money. Again, please provide me with data refuting my claim.

        The ophthalmologists that perform medical ophthalmology are not the group I am referring to. Nor am I referring to ophthalmologists that perform private procedures paid for out-of-pocket by patients, such as LASIK. I am merely referring to publically-billing surgical ophthalmologists that, because of swift advancements in technology, have had their surgeries made essentially automatic, yet are still remunerated as if it were the 80s before these technologies existed. It’s a problem because the public is paying for it. By accepting this, you are suggesting that ophthalmology is the most important, most complex, field in medicine, and deserves the biggest slice of the pie to the detriment of other fields, which I disagree with. We have family doc and psych shortages, incompetent pathologists and radiologists, and surgeons without work; that money could really be used to repair the ailments in those fields.

        As for your main point: maybe the OMA is representing what most physicians support. The only physicians who think that ophthalmologists fees should not be cut are ophthalmologists, it seems.

        • Chris MD

          The data that the MOH used, from ICES, directly refute your claim. The averages that were given, were certainly not ‘millions a year’. A high school student can look it up. You made the claim ‘millions a year’ – it’s up to you to provide your data. If you do want a link, try this:

          http://www.longwoods.com/content/23135

          Btw, I somehow doubt that the ophtho board at your hospital provides you with their personal incomes (particularly as you seem to have some sort of weird axe to grind…).

          You said that there are ‘incompetent radiologists and pathologists’. I’m beginning to understand your tactic better – make broad, stereotyped, inflammatory generalizations. There are MDs in every field of medicine who are incompetent. I don’t understand your point here.

          I could just as easily say that academic oncologists are grossly overpaid. With oodles of academic time to talk to pharma companies and wrangle free dinners and honoraria, walk around the hospital all day, teach, and perform research, and with med students, residents, and fellows to do the actual clinical work that you’re billing for, how much time is actually spent caring for patients? Canadian patients care more about being seen than about how many free dinners you can wrangle from pharma companies. (See – it’s not nice or particularly useful to overgeneralize. I don’t believe the above btw – I think that all physicians, gps and specialists bust their backsides to help patients and do a phenomenal job at it).

          You said that we could use some of the ophtho’s income to ‘solve’ the problem of ‘surgeons without work’? Wow. We should elect you to be health minister. You’re clearly so full of brilliant ideas!

        • Gerald I. Goldlist, MD

          Response to Dr. Bill Evans

          2300 years ago the Greek philosopher Aristotle could have taught several logic lessons based on the February 22, 2013 posts of Dr. Bill Evans. It may also be appropriate for Dr. Evans to introspect as to why he would make an intemperate digression from my opinion piece about the OMA as an Appropriate Vehicle for Negotiating Doctors’ Fees”. I cannot help but wonder if there is some personal agenda or vendetta against Ophthalmology.

          You say that you “can only extrapolate via the surgical ophthalmologists boards at the hospital I work at combined with the information gleaned from the schedule of benefits.” From your limited data base you have inferred that the ophthalmologists of Ontario “make an obscene amount of money.” This is a form of the Logical Fallacy of False Generalization.

          You state that today’s surgeries are “essentially automatic”.
          I graduated ophthalmology in 1976. I did cataract surgery into the mid-1980s. I have not done surgery since then but I have watched numerous cataract surgeries. I believe that, although results for patients are much better, the actual cataract surgery itself is much more difficult than it was in the 1980s. It is certainly not “automatic”. Cataract surgery has evolved rapidly requiring lots of continuing medical education and increased skill to keep up with the advances and deliver state-of-the-art care.

          You have stated that I am “suggesting that ophthalmology is the most important, most complex, field in medicine, and deserves the biggest slice of the pie to the detriment of other fields, which I disagree with.”

          I have never and will never say that any one field of medicine is “the most important, most complex, field in medicine.”

          You used the Red Herring statement: “We have family doc and psych shortages, incompetent pathologists and radiologists, and surgeons without work; that money could really be used to repair the ailments in those fields.”

          A Red Herring is a fallacy in which an irrelevant topic is presented in order to divert attention from the original issue. The basic idea is to “win” an argument by leading attention away from the argument to another topic.

          Dr. Evans, if as you imply the “OMA is representing with most physician support” you use the Ad Populum Argument and add weight to my opinion piece that the OMA “is no longer the appropriate agency for negotiating or making the fee schedule for physicians as it is no longer able to serve the diverse needs of Ontario physicians and their patients.”

          You make the statement “They make an obscene amount of money. Again, please provide me with data refuting my claim.” You go on to: “If I am making it up, then perhaps you would be able to direct me to information that negates my claim? “

          Here you use another form of false argument which basically states that specific belief is true because we don’t know that it isn’t true. This type of false argument is appropriately called Argumentum Ad Ignorantiam.

      • Bill Evans

        For your main point: maybe the OMA is representing what most physicians support. The only physicians who think that ophthalmologists fees should not be cut are ophthalmologists, it seems.

        If I am making it up, then perhaps you would be able to direct me to information that negates my claim? I can only extrapolate via the surgical ophthalmologists boards at the hospital I work at combined with the information gleaned from the schedule of benefits. Combined they make for an obscene amount of money. Again, please provide me with data refuting my claim.

        The ophthalmologists that perform medical ophthalmology are not the group I am referring to. Nor am I referring to ophthalmologists that perform private procedures paid for out-of-pocket by patients, such as LASIK. I am merely referring to publically-billing surgical ophthalmologists that, because of swift advancements in technology, have had their surgeries made essentially automatic, yet are still remunerated as if it were the 80s before these technologies existed. It’s a problem because the public is paying for it. By accepting this, you are suggesting that ophthalmology is the most important, most complex, field in medicine, and deserves the biggest slice of the pie to the detriment of other fields, which I disagree with. We have family doc and psych shortages, incompetent pathologists and radiologists, and surgeons without work; that money could really be used to repair the ailments in those fields.

    • Chris MD

      Dr. Evan’s response is absolutely absurd. ‘Bill millions a year’. What tripe. Even the inflated numbers the government was touting during the so-called ‘negotiations’ weren’t this high.

      I’m sorry, but what crap. Ophthalmologists, or any other group, do not on average ‘bill millions a year’.

      It’s these sorts of guys that are a problem during these discussions – they make this garbage up.

      Bill Evans is in academics. Well, let me tell you, Dr. Evans, those of us in the community are not able to spend the majority of our time on non-clinicial ventures (talking at meetings, talking to pharma companies, research, etc). At the end of the day, patients have to be seen – and this is what we do.

      It’s funny – those who are speaking so loudly against the targeted fields, on some sort of MOH or government committee, tend to be in academic centres, with a majority of their time spent doing everything but seeing patients (and when they do, they have medical students, residents, and fellows…). Cataract surgery has become less complex? I’d love to know – how many cataracts have you done yourself?

      I think that this is indeed off-topic however. Dr. Goldlist’s piece was about the OMA’s representation.

  19. Gerald I. Goldlist, MD

    I would like to respond to DR. SCOTT WOODER’S February 11th comments.

    In his positions as President-elect of the OMA and co-chair of the OMA Negotiating Committee I am confident of his dedication and sincerity and that he serves with the best intentions for his colleagues. Nevertheless, I disagree with many of his points.

    Re: “Members of the negotiations committee have a fiduciary duty to represent all OMA members fairly and in good faith.

    The negotiations committee may have a fiduciary duty and act in good faith but that does not mean that they have the information to act in an appropriate manner.

    Re: “The fact that there no members on the Committee from Ophthalmology, Cardiology and Diagnostic Imaging may be related to the fact that members of those Sections did not apply to join the Committee.”

    Whether or not members of those sections applied to join the committee is not relevant to my argument. Ophthalmology does not understand the workings of Cardiology and Diagnostic Imaging does not understand the workings of Ophthalmology. None of these groups is knowledgeable of the running of a family practice. My argument is that the OMA Negotiating Team does not have the necessary information to represent all groups of physicians properly.

    Re: “The Negotiating committee uses ANDI, average net daily income, when comparing incomes for different Sections.”

    The fact that ANDI is used to make decisions regarding incomes of physicians is confirmed by a motion passed at the OMA Council meeting of May 2012 “that the principle of relativity be applied to negative allocations.”

    The minutes of the OMA Council meeting of May 2012 also state on page 6-7 that the “CANDI Relativity Implementation Committee recommended ‘an INTRODUCTION of the hours of work modifier using PwC data.’”

    So the hours of work modifier WILL BE introduced and is not in the current ANDI. Using the relativity data without the hours of work modifier is unwarranted and frankly ludicrous.

    Re: “Policy that is made by OMA Council which includes representative of each and every OMA Section.”

    Being represented does not mean having influence. In a letter to its members dated January 14, 2013 the Ontario Association of Radiologists states that:

    “Evidence uncovered following a detailed review of diagnostic radiology section priorities submitted and discussed with previous OMA negotiating teams [shows] that none of [Diagnostic Imaging] negotiating priorities have ever made their way into a final OMA/MOH agreement.”

    I repeat: NONE OF RADIOLOGY’S NEGOTIATING PRIORITIES HAVE EVER MADE THEIR WAY INTO A FINAL OMA/MOH AGREEMENT.

    Re: “Students vote and they turn out in great numbers. Why shouldn’t they?”

    They shouldn’t vote on fee agreements because:

    ● Their current income is not affected by current physician agreements.
    ● They do not pay for their offices and understand overhead.
    ● They may never even become practicing physicians.
    ● Even if they graduate they may never practice in Ontario.

    The OMA, in their analysis of the agreement, did not even list an impact on medical students and residents. It is also ridiculous that even some retired physicians have the right to vote.

    Re: “The OMA has negotiated for all of our members dating back to the introduction of medicare. It is not new and it has served our members and our patients well.”

    This is not serving Ontario doctors well:

    ● When the GST was implemented the OMA did not get a fee increase to cover this increase in expenses for physicians.
    ● OMA dues have increased faster than the OHIP fee schedule that the OMA negotiated on behalf of physicians.
    ● Since the 1970’s the fees negotiated by the OMA have not kept up with inflation.
    ● In about 1985 the OMA negotiated a zero per cent increase as inflation soared to 10%.
    ● In the 1980’s the OHIP fee schedule was 90% of the OMA fee schedule. Now it is only 50%!

    To call this “serving our members well” is simply breathtaking.

    Re: “Don’t forget that 81% of our members voted in favour of the last agreement.”

    The smaller high overhead sections who voted against the agreement were stymied by the larger number of votes of those with dissimilar situations.

    During the bargaining process prior to the recent agreement, the Health Minister tried to bypass the OMA and negotiate directly with some individual sections. The smaller high overhead sections stuck with the OMA. In retrospect they should have negotiated directly with the Health Minister. In order to have their interests addressed in future negotiations direct negotiations with The Ministry of Health may well be the route they should take.

  20. eye md

    In response to Dr Evans:

    Irrespective of Dr Evans’ sophisticated analysis of determining an ophthalmologist’s income based on glancing at surgical lists, let’s look at some real data, as he suggests. If he had taken the time to read Dr Goldlist’s article, he would have noticed that the income data is actually mentioned within the article itself. For net income, Ophthalmology ranks 8th when accounting for overhead – source, as referenced in the article: http://www.longwoods.com/content/23135. So much for making “obscene” amounts of money. The only thing “obscene” is how confrontational and judgmental Dr Evans’ overstated and egregious hyperbole is. Why not make the effort to learn, engage and understand each other and the situation at hand? As Dr Lannister has eloquently written in the comments below, it is a sad state of affairs when fellow MD’s attack one other frivolously.

    Funny enough, Dr Evans’ misinformed and underhanded comments have unwittingly and paradoxically proved the crux of Dr Goldlist’s paper – many physician groups are misunderstood, and therefore, a single negotiating group such as the OMA cannot adequately represent the needs of all of Ontario’s physicians.

  21. Jason McDonald

    In general I agree with Dr. Goldlist. However, like most people expressing an opinion, Dr Goldlist has his blinders on about how much money Opthalmologists really make relative to others.

    At the OMA annual meeting this year, many of us had access to data about how much doctors bill…so much data it was really overwhelming. Average age, average income for those billing about 75K, 100K. etc.

    The 95 percentile ophthalmologist billed the government just a few thousand shy of 2 million. Meaning 16 ophthalmologists billed more than 2 mill in the provice. The average amount billed for those billing at least 75 K was close to a million. And most of the ophthalmologists I know have between 125-200K in expenses at most (some of it including things like cars and computers that are also for personal use). My close friend purchased, in cash, a Bentley within 1 yr of working (in another jurisdiction out west i concede), and the opthalmogists in my town live in the 3 mill+ enclaves. A few eye docs in fields like glaucoma are probably unfairly hurting. And the high opthalmology averages INCLUDE docs that do non OHIP stuff too…like laser eye surgery, or elective oculoplastics.

  22. Dr. Sweeney

    The pie is limited, and to give to one is to take from another. Eye docs have a disproportionate piece of it, whereas family docs, psychiatrists and pathologists have too little. Until things are made more proportional, expect to see fam docs practicing everything but family medicine, psychiatrists in short supply, and pathologists being recruited from substandard foreign medical schools and making huge errors. Money attracts talent. Some fields need the money, to ensure patient care is up to snuff. We are failing on that.

  23. Paul Conte

    Interesting to review this 2 years later…after the sh*t has REALLY hit the fan.

    Now we really know that the OMA emperor, in 2012, had no clothes. Pretty hard to take an effective stand now, when the OMA already pushed us a contract with $850 million in ‘savings’. The stand should have been taken then but the OMA was to preoccupied with looking after itself and the government needs at that point.

    • Gerry Goldlist

      Thanks, Paul, for commenting about my opinion piece a few years after. Tough to be like Cassandra and predict the future but and not be believed.

      Let’s hope the OMA does better for doctors and patients in 2015.

  24. Nick Cuberovic

    Well said Gerald.
    This is why I closed my family practice in 2001 and work full time ER. The only way family doctors can now afford to work is in a group that shares expenses.
    I have slowly reduced clinical work paid for by OHIP over the years. I am a Coroner paid for by a different Ministry, an Ontario Race Physician paid by independent race car organizations (Indy, NASCAR etc.), paid to teach by MUMC, and paid by the hospital as the ER Medical Director. Good clinical work is at risk once again.
    I just removed myself from providing OHIP enucleation services. The pay is hardly worth the sacrifice to do those in the middle of the night. I had been doing it because of the good it brings our patients. Doing good only goes so far with the Government.
    The OMA has always been conciliatory with government and it has hurt us badly. ER doctors who were never in private practice often don’t get it. I know and have worked with all the heads of the OMA ER section. Great guys who are trying their best to get me the most money possible, but they are constantly in battle with the an entrenched OMA board. I’ve always said we need more of a “union” mind frame.

    • Gerry Goldlist

      Thanks, Nick. It is great for me to see comments on my blog piece years later.

  25. concerned

    research has shown that ophthalmologists bring home nearly 500K/year after accounting for overhead. they bill ohip over 1 million on average. this is not accounting for the millions ophthalmologists bring in through lasik and other procedures not covered by the government. their training is not longer and is in fact shorter than several specialties. the residency curriculum is less strenuous than most surgical specialties. and yet, they make 4-5 times more after overheard than every other specialty with the exception of radiology, cardiology, and anesthesiology. as far as im concerned, the cuts of 2012 were not enough.

    • Gerry Goldlist

      A few questions:
      1. Why did you post that here?
      2. References?
      3. What’s your point?

      • Resident

        I came back to this conversation after the most recent vote. I was a mere medical student during the 2013 vote and didn’t participate because I didn’t feel my grasp on the system was complete enough.

        But now, I am a resident and much more engaged. I think Goldlist has made the points that I’ve heard from most specialists and they land somewhat reasonably with me – a to-be rural generalist. But, Dr. Goldlist, your response to “concerned” is reasonable on one count – “concerned” should post references*** – but rather dismissive and against the spirit of constructive discourse on the other two counts.
        1. “concerned” posted the comment there because it reflects the denominator of the gross income equation and you focused largely on the numerator. So, I would call the comment relevant.

        3. The point is a salient one. Ophthalmologists are doing well – less well than before – but still very well all while our health care system creaks toward collapse. We can’t afford mental health, even though the burden is extraordinary. We can’t afford rural health or Indigenous health. We are barely keeping the lid on the costs of comprehensive diabetes care. The physician services budget has to remain in touch with the overall cost of healthcare.

        I say this as the daughter of someone who has relied for his entire life on the care of good ophthalmologists and donor corneas to sustain his vision and his livelihood. What you do is remarkable and I am grateful this province** can pay for the continued evolution of your science. But at some point, enough billings are enough billings to live a good life while income inequality in this province swallows entire families whole. I do not think physicians should be part of that problem, I believe we are mandated to help solve it and that means accepting rational cuts*.

        *Not all cuts have been rational.
        **The province should, in good faith, pay for work already done.
        *** References for “Concerned”:
        http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3517870/
        https://www.cma.ca/Assets/assets-library/document/en/advocacy/profiles/ophthalmology-e.pdf

        • Gerald Goldlist

          It is amazing that there are still comments to this article. Thank you for taking the time to write. You say that you” believe we are mandated to help solve it and that means accepting rational cuts.”

          I don’t believe that.

  26. Ian MacLeod

    Gerald, Your article is fair and to the point. I am going to use points from it to combat the same assault taking place in Alberta. The situation is the same. The AMA ‘representing doctors’, but adopting the ANDI model for ‘income equality’ amongst practitioners that are most assuredly not equal under any parameter considered, and the ‘modifiers’ used to make things ‘equal’ are inaccurate, or arbitrary, or both.

    • Gerry Goldlist

      Ian,thank you. I am honoured that you think some my points are worth using.

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