Patients lose in showdown between doctors and ministry

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.

The comments section is closed.

  • Nicholas Leyland says:

    It has been interesting to observe the on going debate and discussion regarding physician payment and the current impasse between the OMA and the Ontario Government.
    The fee for service provider payment system is in a large part the root cause of the problem as is the antiquated distribution of fees to the various medical special interest groups.
    The OMA and the Ministry of Health and Long Term care must be prepared to address this serious block to the provision of effective care to Ontarians.
    There is no ideal way to commensate providers that does not have some drawback. However, the most likely sucessful approach is to have multiple models depending on the specialty, location of services, etc. Capitation, blended salary- fee for service for deliverables, fee for service for after hours services, etc all can be utilised depending on the circumstances and appropriateness.
    The goal should be fair compensation for providers to recognise and remunerate them for their professional service and their overhead costs that are to some degree beyond their control.
    The “deliverables” have to be aligned with the needs of the patients. This is care commensurate with the highest quality. Remember, quality is composed of effective, efficient, safe, timely, patient centered care. Providers must be called upon to demonstrate all of these components for the system to work.
    Unfortunately the present impasse and the strategic direction of the OMA is not moving us any closer to a satisfactory solution to this very important issue.

    • Ryan Herriot says:

      Yup. What’s odd is that everyone who knows anything about health care seems (at least in person) to be more or less on board with this idea, and yet the institutional inertia holding this kind of change back is immense. Very frustrating.

  • Mark MacLeod says:

    Sounds much like an agency directed model I’ve talked about for a while. The biggest problem with the system right now is that it is too politicized.

    I’m not sure I understand anymore what people mean by patient led, patient centred and so on? Which patients? The ones who vote most? The ones who have the best media campaigns or media advisors? The ones who have the most emotional laden issues?

    I don’t think the advice should be from patients at all, it should be from society at a larger level as, in the end, it is their tax dollars that we spend as providers and we use as patients. Patient voices are no less political than any others in the current arena of yelling voices. Decisions do need to be made from real evidence with an independent panel to judge how good that evidence is (and most of it isn’t), and need to be made after appropriate input from all groups, and then need to be made dispassionately without fear of reprisal.


    • Ryan Herriot says:

      Doesn’t representation from “society at a larger level” come back to representation from elected officials? I think that the same way that all research on HIV-positive people includes input from HIV-positive people, all health care institutions should include more patient input. Which patients? I’m not sure it matters. Ones who are available to volunteer their time, most likely. Ones that have had a shitty time with the health care system and who care enough to try to make it better. Put them on your independent panel, along with physicians, other health care workers, people with Masters in publich health or health economics, etc., etc.

      • Mark MacLeod says:

        I have lost complete trust in politicians and in particular the political class. They have become the new masters in our contemporary feudal system. I don’t beleive that elected officials have the content knowledge or the wisdom to do this work. It used to be that the bureaucrats were the defacto impartial agency but since the NDP government in Ontario, change in government has also seen substantive high level, ideologically driven changes in the bureaucracy

  • Ryan Herriot says:

    Great idea! This would resolve all of my concerns about the current public relations battle, especially if such an entity were patient-led.

  • Scott Wooder says:

    In 2004 the MOH and the OMA agreed to appoint a Physician Services Payment Committee (PSPC). Each side would nominate members to sit on the Committee and advice regarding changes to the Schedule of Benefits would be made to the Minster of Health.
    The OMA nominated members, living up to their side of the agreement. The MOH never nominated any members and although there is a legislative framework to support the PSPC, the MOH has not activated this committee.
    This has been very dissapointing to the OMA.



Hsien Seow


Hsien Seow is an Assistant Professor at McMaster University, Department of Oncology and the Cancer Care Ontario Research Chair in Health Services Research. His views are independent of either institution.

Deanna Bryant


Deanna Bryant is a research coordinator at McMaster University, Department of Oncology, with interests in chronic disease prevention and management.

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