The public squabble between the Ontario Medical Association and the Ontario government about tweaking physician payments is to be expected: no one likes cuts to their income. But in this case the cuts are concentrated in a few sub-specialties, so the pain is concentrated, prompting a particularly loud response.
So what’s it about? There’s an immediate issue of course: the public response to reductions in fees for ophthalmologists, radiologists and cardiologists. The fee schedule reflects relative priorities and typically fee schedules over-compensate procedural specialties and under-compensate the more ‘cognitive’ specialties. Technological change can exacerbate the problem. Ophthalmologists, in particular, have been previously targeted for fee reductions in Ontario (though they have been successful in staving that off in some provinces). Cataract operations, for example, can be done more quickly now than in the past (by orders of magnitude); more can be done in a day, so the effective hourly rate for these operations has dramatically escalated. This is about how the gains of technological advances should be shared – so should ophthalmologists accrue all the benefits of this or should the taxpayer expect some return?
But there is another issue at play here. “Who gets what?” is the stuff of politics, and so payment policy could be expected to be highly contentious. The founding bargain of Canadian Medicare had as its objective “to find a way of combining publicly supported universal coverage with the true essentials of professional freedom.” “Professional freedom” came to mean that distribution of fee increases within medical specialties was generally left for the provincial medical associations to sort out internally. But the interests of the ophthalmologists, radiologists, cardiologists and others in the medical profession and the interests of government/health system/public are not necessarily the same.
Payment structure is one of the critical policy levers that drives reform of publicly-funded health care systems. The Canadian situation, where use of this lever is dulled by passing through negotiations with physician organizations, potentially weakens and slows necessary system changes.
What we are seeing in Ontario is just a taste of what needs to happen in every province if governments are serious about controlling health care spending.