Opinion

The false dichotomy of fee cuts

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.

The comments section is closed.

4 Comments
  • Gerald I. Goldlist, MD says:

    I am sure that you are sincere in your beliefs but I also believe that you work on salary and do not have experience in the workings of a private doctor’s practice. I would like to respond to specific statements that you have made in your article titled “THE FALSE DICHOTOMY OF FEE CUTS” http://healthydebate.ca/opinions/4769
    Kathy Hardill

    Re:
    “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.”

    When I talk to my patients about the impact of the fee cuts I do not discuss my income. One of the things that I specifically tell my patients is the impact of the cut in payments for Optical Coherence Tomography imaging on the treatment of wet macular degeneration. I only discuss the impact on their care and not on my income. The discussion I have with my patients is not about doctors’ incomes but of patient access to medical care. It is only right that patients and voters know these facts.

    Re:
    “One of the core principles of collective bargaining is good faith negotiating…”

    The government offered a global fee cap as well as cuts to numerous fees. The OMA offered to freeze the OHIP schedule of fees for two years and also to find millions of dollars of savings for the Minister of Health without impacting patient care. The government was not willing to budge from its position of a global cap. Included in the global budget imposed by the Health Minister was the provision that future increases in utilization would not be accompanied by an increase in the global budget. As the population increases as well as ages, the number of services required for state-of-the-art medicine will increase. The Health Minister has imposed a fee structure that makes current physicians responsible for future increases in physician costs regardless of how many physicians there are and how many patients there are.

    Ontario needs about 700 more physicians. According to the government’s imposed settlement these 700 physicians are expected to be paid from the same global budget. There is no increase in the global budget to accommodate this increase in physician numbers. This would be like a hospital with 500 nurses hiring 100 more nurses without increasing the budget for hospital nurses. Thus the 500 current nurses would be expected to pay for the hundred new nurses hired.

    That is what the Health Minister has imposed. That is not good faith bargaining.

    Re:
    “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.”

    As you have stated this is not the issue at hand. It is for a more general discussion that society needs to have.

    Re:
    “The proposed cuts to physician payments are presented by the OMA’s public relations people as equivalent to reduced access to health care.”

    Reduced access to health care is not equivalent to, but was caused by the imposed cuts to total physician payments.

    Re:
    “But are there really only two options? … Most never get talked about.”

    That is correct but it is up to society and not physicians to decide how to deal with a limited budget and delivering state-of-the-art medical care. The decision should not be made by doctors nor should it be made by the Health Minister’s dictates. The patients and the voters need to consider the issues and make a reasonable decision. To do this they need to know the consequences of the Health Minister’s fee cuts to their health care.

    None of the other payment options for health care have ever been shown to be cheaper or more efficient for providing state-of-the-art health care.

    Most physicians would like to go on salary and let someone else look after the economic risks and responsibilities of running a practice. They would be happy to just deal with patients. They would be happy to give up the responsibilities for rent, insurance, equipment, computers, IT, pens and pencils. They would be happy to give up at the economic risk and responsibility of purchasing and repairing expensive equipment. They would be happy to not be responsible for heat, electricity, changing light bulbs, hiring cleaners and making sure phones are working. They would be delighted for an employer to pay for a payroll department and a human resources department to hire, fire, train their staff and to resolve staff disputes. They would be thrilled to have their employer provide and pay for internet costs, plumbers, electricians and all other costs for which salaried physicians are not responsible. I would love to go to work and just see patients.

    In the 1970s Stephen Lewis, leader of the Ontario NDP party, was asked why he didn’t put all physicians on salary. His answer was that he couldn’t afford to.

    Re: “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.”

    Forgotten in this discussion is that in 1987 the Ministry of Health budget did not include the Ministry of Long-Term Care budget. These two ministries were merged in 1999. Thus today’s Ministry of health and long-term care budget should be compared with the total of the 1987 budgets of the Ministry of Health PLUS that of the Ministry of Long-Term Care.

    Re:
    “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.”

    I doubt that the increase is largely due to prevention bonuses. You have ignored Ontario’s population increase of close to 10% since 2005. You also have ignored the fact that the early baby boomers started reaching their 60s at this time. Now the early boomers have advanced past 65 while more boomers are moving into their 60s. You also have not taken into account the waiting time initiatives brought in by the government. More OR time was made available and so ophthalmologists and orthopedic surgeons worked longer hours and treated more patients. The specialists who worked harder and longer were not given any prevention bonuses. But now the health minister has chosen to cut their fees.
    Re:
    “I do not support broad-based public sector cuts as the way to solve Ontario’s deficit problem.”

    This issue is for society as a whole. It is not the issue at hand.

    Re:
    “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.”
    Physicians have a duty to tell their patients when treatments that are not available in Ontario but are available elsewhere. What is going on now is an extension of that responsibility. What I discuss with my patients is how the changes to the global OHIP budget will affect THEIR HEALTH CARE not my income.

    I am a patient too. I am getting older. I am concerned about my health care, my family’s health care, my friends’ health as well as my patients’ health care.

    GERALD I. GOLDLIST, M.D.
    D.OPHTH.SC., F.R.C.S.(C), D.A.B.O.
    EYE PHYSICIAN

  • Ryan Herriot says:

    Thank you for this.

  • Tapoff says:

    Kathy Hardill has finally, concisely summarized the many issues that constructed the largest ELEPHANT of the Health Care Funding “crisis” currently being argued; at least in Ontario.
    No less than 5 different reimbursement models exist for Primary Care physicians in Ontario now because Physicians refuse to agree on letting go of a Fee For Service model. Consider the costly ADMINISTRATIVE nightmare, let alone the cost of bargaining all the “alternatives” . Enough evidence is available from the developed world that 2 or at most 3 modified serviceable models would be sufficient from Public Health to Tertiary Care.
    Cutting staff rather than adding to (externalizing) the burden for responsibly attending to our determinants health is of course playing directly into the rhetoric of the increasingly complex gaming around the relatively simple concept of “single payer Canada Health act”. I observe increasing Reports by executive Bank Economists who spin figures like all good Marketing consultant would. The results are panicked citizenry and bought politicians. The citizenry are *NOT* beneficiaries.
    The beneficiaries are insurance and other financial corporation who are drooling at the periphery of a for-profit-model and opens doors that may be extremely difficult to close.
    =Concierge medicine – diverting primary care to those with greater means to feel better about their families’ already good health outcomes.
    =”not medically necessary **eye care** ”
    =”not medially necessary mobility support services”
    =”not medically necessary oxygen therapy”
    =”not medically necessary physiotherapy”
    =”psychological services VS. RARE psychiatric services” Hmmm medication referral waiting lists???
    =”rural vs urban” access differential. . .
    =”Travel reimbursement “issues”

    BETTER to work to **improve** an OVERALL, HEALTHIER Approach to assuring EQUITABLE ACCESS to HEALTH CARE services, AND Folding in the PROMOTION & SUPPORT for EFFECTIVELY implementing the VAST KNOWLEDGE WE HAVE GAINED OVER THESE 50+ YEARS about health provision, health, the HEALTH OF A NATION and its CITIZENRY for the creativity and PROSPERITY of its future.

    I agree with Kathy. Work with a Community Health Model. Use the LIHN structure to re-work delivery models from Public Health through to Tertiary care, using the regional models and the basic infrastructure. Rummage through the basket, consider what might work given functional models from successful communities in ideal single payer systems.
    Re-distribute the rigid hierarchies and change the functional strategies to work for each of the different types of communities and their networks. USE EVIDENCE, integrate EVIDENCE. I encourage scientific health and health economics evidence and perhaps even critically thought out policy evidence.
    Kathy is accurate when she disagrees with the broad based public sector cuts. Tap the vast creative wealth within AND without the Ministries of Health rather than suppress it. Break out of the usual hierarchical reporting structures and models. This calls for extreme critical and creative thinking. Partner with the academic and civil communities. ***Actually*** problem solve. Appropriate structure will re-establish itself. It always does.
    Prevailing policy statements and reports support notions that the figures promoted by those who only look at one side of an equation, and use figures and indices that were never intended to measure or evaluate the true wealth and prosperity of a nation of human beings.
    They { (neo_insert party name here_) } increasingly ignore the remaining half of the equation that includes changes in taxation, and government revenue base/distribution/admin, and the fact that proportions of expenditures in social services have changed in much less proportion to the reporting of the single inappropriate GDP measure and associated corporate wealth transfer policy changes that have gutted the ability for a good social-safety-net to be integrated as an entire somewhat modular support system let alone RE-IMAGINED from the middle of the 20th to this not-so-new century and planned for as with many of better positioned nations from our developed world with better social programs integrated with simple taxation laws AND a Prosperous citizenry.

  • concerned Ontario citizen.... says:

    I remember when the nurses were cut and nurses flocked to the U.S. during that time, and also for years to come afterwards. I was one of them. Trained here but during my schooling I just assumed the only place to go was anywhere but Ontario. There is a huge chunk of knowledge lag in the nursing profession because of this. I’ve now lived in two other countries besides Canada and they offer MDs a much higher respect and income which continue to call our doctors overseas. When they leave, they don’t come back. (unlike me)
    There has been HUGE waste by this property …. $180 million just reported today over this Mississauga plant . Gone. Lets talk ORNGE or eHealth, all money wasted. In this day and age of computers there is no reason why a government paid organisation cannot be more accountable where their money is spent. Heavens me with school boards of budgets in the $190 Million per year (Ottawa public brd) with little oversight where money is spent. I recently was on the VIA RAIL website and I was so impressed how the CEO and VP both had FULL accountability as to the amount of money they have spent on travel/ hotel/ etc. for the entire year, unlike York district school board spent for OVERSEAS trips for their Trustees !! There is money, and it isn’t until we start to fully crack down on the government spending and more accountability will this government start to pay off their debt. How is it ok to build new schools and new hospitals and then cut MDs and teachers who fill those buildings ? WHY ? Because the Liberals knew that people would see something tangible like a building and think the Liberals are doing something good. No, you don’t build unless you have the money to spend.
    Give us the $180 million wasted on this Mississauga plant and that will fix up all this MD mess.

Author

Kathy Hardill

Contributor

Kathy Hardill is a Primary Care Nurse Practitioner at a clinic which includes patients whose health is made vulnerable through homelessness, poverty and other risk factors.

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