The current negotiation process between the Ministry of Health (MOH) and the Ontario Medical Association (OMA) is deeply flawed. Currently, the negotiations focus primarily on physician pay and not on the best interests of the patients. The broader issue lies not in the details of which physician services received fee cuts and by how much, but the several flaws in the negotiation process itself. First, the structures of the two organizations prevent them from putting patients and evidence as their sole interest. Understandably, they must balance multiple stakeholder interests. Of note, sometimes the interests of one physician sub-speciality conflicts with another. Second, only the government and physicians are represented during the negotiation: the party missing is patients. Third, the details of the negotiations are private and not for public debate. As a result, the public becomes unclear if fee changes are based on politics or evidence about improved quality. Fourth, the negotiations happen once every four years, but technological advances and evidence on best clinical practices change more frequently. Consequently, changes to fee schedules lack timeliness, are high-stakes, and more drastic.
In order to avoid these four-year “showdowns,” the MOH should develop an independent advisory committee that proposes changes to the physician fee schedule. Specifically, the MOH should follow the model used in the US—the Medicare Payment Advisory Commission, which advises the US federal government on a wide range of healthcare payment issues ranging from insurance reimbursement to physician fee changes—all of which impact patient access and quality of care. The Commission is comprised of over a dozen part-time members, with diverse expertise ranging from health care financing and delivery of services. The members have staggered, 3 year terms. Supporting the members is a staff of analysts, who typically have backgrounds in economic, health policy, public health, and medicine. The Commission meets publicly to discuss policy issues, considering results of staff research, presentations by policy experts, and comments from interested parties, such as physician groups. They also seek input from government, health care researchers, providers, and patient advocates. Typically, the Commission produces 2 reports each year summarizing their recommendations for the government to enact.
Creating a similar independent advisory committee in Ontario would benefit all parties involved and address the current process’ flaws.
• One, evidence. This new structure prioritizes emerging evidence about quality, cost-effectiveness, and patient benefits as the primary driver of fee changes, increases included. This benefits physicians by de-politicizing their incomes. As well, experts are reviewing the evidence.
• Second, public discussion. This process considers how potential recommendations might affect a broad range of stakeholder groups, such as patients, community services, and care settings. These groups also include multiple physician sub-specialties, such as how fee changes in one specialty might affect other sub-specialties. Moreover, the committee not only focuses on the payment itself, but also on accountability to ensure patients receive quality care.
• Third, transparency. Although evidence may be used by the MOH in currently proposed fee changes, with this new process, issues and evidence are transparently reported and clearly linked to fee changes. This structure strengthens the MOH’s ability to implement changes, free from real or perceived political agendas. The process and recommendations are clear, open, and transparent for all parties to participate in and review.
• Fourth, yearly recommendations. The committee would make on-going, year-round, recommendations to the fee schedule, thus being more responsive to emerging evidence, technological advances, and clinical practice changes. Moreover, more timely updates facilitate more gradual fee changes, with less drastic impacts to physician salaries and practices.
In conclusion, developing an independent advisory committee in Ontario puts best evidence and the patient at the center of any proposed reimbursement changes, which is the missing common ground for these current negotiations.