Recently I had a discussion with some physician colleagues about the Ontario Medical Association (OMA) campaign and specifically the principle of communicating non-neutral, political information to our patients. The campaign to which I am referring is that seeking to solicit the support of Ontario patients for physicians who are trying to get the government back to the bargaining table, because the process of negotiating changes to the OHIP fee schedule has stalled. The Ontario government has walked away from the table after presenting a revised schedule of fees which amounts to pay cuts for doctors, and it is unwilling as of this writing to continue the discussion.
One of the core principles of collective bargaining is good faith negotiating and there are a number of strategies for bargaining agents such as the OMA to utilize in a situation such as this. Mounting a public information campaign to gain support and apply pressure to the “employer” for lack of a better term is one of them – fair enough. Where I think this situation gets ethically problematic is here: well paid health care providers are asking patients, who are dependent on us for things that are important to them and who cannot just “go get another provider” very easily, certainly not in medically underserviced areas, to support their campaign to not have income cuts. Many of these patients have experienced job loss and pension cuts and drastic reductions in their social assistance income. Considering the cost of living and inflation, social assistance payments have been reduced by 60% since 1995, which is not only shameful but utterly myopic since poverty equals illness equals expensive health care system – but, I digress.
The proposed cuts to physician payments are presented by the OMA’s public relations people as equivalent to reduced access to health care. Now, if physician payments go down, some doctors may choose to lay off staff rather than take a pay cut, which will reduce the services they can provide (injections, wound care, maybe seeing fewer patients because of having less help, etc.) and some doctors may choose to re-locate to other jurisdictions. Clearly those consequences would reduce people’s access to health care.
But are there really only two options? Maintain the status quo or ruin the health care system? Where in this debate is anyone talking about alternative health system funding models? What about doing away with fee for service? What about expanding the community health centre model? What about consideration of the regional contractual model used in the UK (groups of physicians become responsible for a bigger chunk of the regional budget but have to use these finite resources for their group of patients)? There are many other interesting options to consider. Most never get talked about.
I do not necessarily agree with all the cuts the province has tabled vis a vis the OHIP fee schedule. But I also think Ontario’s health care system is a very, very expensive system and despite colossal wads of money there are many parts that do not work well. Almost half of the Ontario budget is spent on the health care system. When I started nursing in 1987 it was about one third. Today this is a whopping $48 billion dollars, $11 billion of which pays physicians.
An ICES report released earlier this year illustrated that historically, payments to Ontario doctors stayed more or less in line with the rate of inflation. This changed around 2005 when payments started to increase sharply upwards by about 10% per year, while inflation has only increased by about 2%. This is largely due to prevention bonuses, like those received for vaccinating elders against the flu or performing colon cancer screening. With the exception of colon cancer screening, uptake rates of these prevention activities have not improved appreciably. So, for example, the rates of people over age 65 getting the flu shot have not increased significantly, likely because primary care providers were already targeting this group, or because those over 65 who want the flu shot ensure they get it themselves without having to be recalled, and recalling those who don’t want it does not significantly increase the uptake for those people.
I do not support broad-based public sector cuts as the way to solve Ontario’s deficit problem. I support increased revenue through higher taxation for corporations. I am adamantly against the continued and accelerated transfer of wealth from poor people to rich people. The wealthiest Ontarians pay half the tax they did in 1980, while social assistance recipients will not get their promised $100 increase in Child Tax Benefit and starting next year will lose the Community Start Up benefits which is the money people use to be able to move from one crappy rental unit to another slightly less crappy one, or the money that allows women to leave violent situations. This will all end up costing the health care system more and more money – see myopia comment above.
But I also think it is disingenuous to imply that reducing physician payments must necessarily result in a compromised health care system without a discussion of alternative visions of a health care system (although I understand in the context of bargaining why a discussion of alternatives would be omitted). Further, I think it is inappropriate for health care providers to ask patients to support this position, because some patients will feel obliged to do so, not because they understand the bigger issues or agree with the position, but because their doctor is asking them to.