Like most Ontario physicians, I’ve spent the past few days trying to digest our failed negotiations with the Ministry of Health and Long-Term Care (MOHLTC).
I don’t typically consider myself to be someone who is particularly passionate about matters of remuneration. I generally feel I’m paid adequately for the services I provide, and I think most physicians would agree with that sentiment. When the negotiations fell apart in 2012 and a 0.5% clawback on our fees was unilaterally imposed by the government, I didn’t feel too aggrieved. I understood that our economy and the provincial coffers were in tatters, and that some degree of austerity would be expected from public sector workers. Perhaps naively I assumed that as a result of the 2012 negotiations that the province would feel the urgency to craft a sustainable strategy that ensured no further cuts to physician compensation and adequate patient access to care. Clearly, I was wrong.
As frustrating as the proposed cuts are, I am infinitely more irritated at the spin that Health Minister Dr. Eric Hoskins has been weaving both in interviews and on social media. I understand that in any labour negotiation, his job is to craft a message to the public to put the government in a good light. He has inherited an absolute mess from his predecessors, and I don’t envy him in the least. But I expect honesty from him. He has repeated his mantra of the “average physician making $360,000″, knowing full well that the public will interpret this as a net pay and not understand the weighty overhead expenses and other fees that physicians pay. And that physicians receive no pension or benefits. He has asserted that overall compensation to physicians will be unchanged, again glossing over the fact that the users within the system will continue to increase. He is intentionally confusing the public by conflating overall physician compensation with individual compensation.
One of his other favourite criticisms is that physician compensation has increased 60% since 2003. Again the obvious deceit in this is that he is describing overall compensation (which accounts for more users) while knowing the public will interpret this as individual compensation. I would actually prefer that he come right out and say who he blames for the increases. Is it physicians in FHOs? (Disclosure: I am a fee-for-service physician). Is it ophthalmologists? Other specialists? Lumping all physicians into one group of fat cats muddies an already messy situation. He mentioned in a Tweet that in the negotiations, “We wanted to focus more on high earners. OMA did not accept.” This seems to be directed at high-income specialists, but he didn’t provide any further clarification.
The OMA is in a tricky position representing many group of physicians with varying financial interests, and understandably will not criticize any specific group of members, while trying to appease everyone. It is then incumbent on the Ministry to be crystal clear in communicating to the public and to physicians where they identify the remuneration problems to be. For instance, even as a family physician, I have no idea how the Ministry views the sustainability of FHOs/FHTs. Their sound bites frequently describe their commitment to these groups, but they then complain about exponential growth in physician income. Clarity is much needed.
The Ministry started off in the negotiations looking for $740 million in savings. That’s one heck of a jumping off point. I won’t veer off track by criticizing other provincial scandals in other sectors, but trying to recoup that magnitude of funds in one fell swoop sure as hell better be supported by a great plan moving forward.
Having reviewed the proposal from the Ministry, I don’t necessarily disagree with all of their proposals. Their argument that they shouldn’t be funding Continuing Medical Education for only certain groups of physicians is a logical one, and if they were to provide a framework for more evidence-based CME (similar to their Low Back Pain Strategy), that would be a positive development. Their proposal to eliminate patient enrollment bonuses has been criticized as being unfair to new grads, but I think at the very least physicians should be obligated to be responsible to those patients for a minimum period (5-10 years) to retain those bonuses.
But here’s my question to the ministry. Let’s assume that the OMA accepts the proposal from the MOHLTC including all cuts, with a total savings of $650 million. What happens in 2017? Inevitably utilization of health care will increase, and the deficit will still be a major issue for the government. So more cuts to fees? What is the end game? That’s the part I struggle with the most. There has been no strategy communicated from the Ministry for how they plan on funding health care moving forward. They will likely point to the proposed “Task Force on the Future of Physician Services in Ontario” and the “Minister’s Roundtable on Health System Transformation” from Judge Winkler as the solution to our system’s ills. And while both of those initiatives are badly needed, the Ministry is asking physicians to sacrifice financially in the short-term, and asking us to trust that they will be able to solve things by 2017. Colour me skeptical.
Physicians are desperate to be part of the solution in our health care system. We see how poorly it functions, and we are in the best position to aid in the recovery. It’s part of our nature as healers to want to help. And I fear that the stance taken from the MOHLTC will embolden some physicians to withdraw from roles where they can help our system. I sincerely hope that this controversy prompts physicians to become more engaged in local system improvements, as clearly our government is sorely missing any top-down solution in the near future.
The comments section is closed.
Collectively the MDs need to go on strike — like the Teachers. Do it organized and well and it will make a statement.
GET on it.
MDs can’t strike for multiple reasons: they are not unionized, they are not salaried (except the pathologists, who SHOULD strike), and they have a duty to provide care that goes beyond contracts. The government is taking advantage of their absolute unwillingness and inability to strike, and that is a low blow.
The MDs are approaching this from the wrong angle. Nobody cares if doctor pay gets cut. In some cases, their pay (radiologists, ophthalmologists and cardiologists) is obscenely inflated.
Instead, the government has not answered the following questions and should be held to task:
1. Why are physician fees, of all things, the target of cuts?
2. What else within the health care system is overfunded and can be cut?
3. What will the savings be used for?
In the midst of this impasse, nobody from the OMA has focused on the salary raises and bonuses that the ministers have given themselves, nor the scandal of ORNGE, nor other corrupt government actions. It is clear from the past actions of the Liberal party that they cannot be trusted with money management, particularly not the health care system. The OMA should go on the offensive regarding these things.
Thank you Dr. Elia for an articulate and accurate assessment of the present state of the health care “system” in Ontario. I agree with your skepticism.
The fundamental problem with our present “system” is that the strategy for the future is being orchestrated by politicians whose goals for change are limited to short term political windows. They simply will not make the difficult choices required to repair our system because, for them, it will be political suicide.
A few years ago a former Assistant Deputy Minister of Health had indicated in a discussion with me over dinner that this portfolio should be managed by an entity that would function at arms length (as independently as possible) from the politicos.
That way we could look at all options for the system including the many in Europe and other jurisdictions that have significantly better health metrics than we achieve here in Canada.
Our system ranks very poorly in comparison to many other systems save the one in the USA. Change in our approach does not have to mean the adoption of their system at all.
The following was written in 1985 by an Ontario physician. The situation for patients is worse now than in 1985 but the gist of this still rings true.
Gerry Goldlist:
Our society thought that:
-that everyone has a right to unlimited free health care (or worry care e.g. “My eyes get red when I take a shower”)
-they could insist on a patient’s bill of rights with unlimited right to a second opinion
-doctors who work hard must be crooks and so have to be stopped
-doctors make a lot of money and so should work for free
-doctors are born rich and so should work for free
-doctors were born doctors and so never had to work their asses off in school and now in practice and so should work for free
-doctors are lucky to be doctors (see previous item) and so should work for free
-doctors think they know a lot about medicine because they went to medical school. Therefore they should not be trusted. Those who own health food stores etc. and sell wonderful products etc, should be trusted with health needs
-medical associations that warned governments about doctor shortages in the mid-70’s were self-serving. The facts presented years ago concerning: aging population, lower productivity of younger physicians, more female physicians who looked after their children, retiring physicians were all considered bunk by the elected representatives of society.
-doctors and nurses went into medicine because they want to hurt patients. That is why they brought in the time- and money-wasting Patient Advocate Legislation.
-doctors should spend more and more time dealing with political crises in medicine than with the day to day running of their practices.
-doctors should spend more and more time reading edicts from OHIP, drug benefit rules, hospital rules etc than on continuing medical education.
-doctors have done so little continuing medical education that they know less than health food managers about health care and so now should have MANDATORY CME on top of reading the edicts mentioned above
-doctors enjoy hearing themselves tarred with the same brush as the doctors who are unethical and criminal in their behaviour
-doctors love to hear what bastards and crooks they are in the media. When they complain about the unfair depiction, the doctors are told if they don’t like it, they can leave….Many did and will continue to do so.
-doctors are thrilled to take on the extra work of those doctors who have left the country or retired or gone into cosmetic practice. In fact, those that are working harder than they already want to, may add to the list of those retiring, leaving etc.
AND SO MORE DOCTORS
-have retired
-gone into cosmetics
-gone into other careers, related to medicine or otherwise
-moved south and west
-got sick (they thought bastards like us would not do this)
-died (they thought bastards like us would not do this)
and…
now…
there is a shortage of medical care and it is getting worse.
Have a nice day, Ontario. Don’t get sick.
As a frequent reader of the healthy debate it is encouraging to see the compassion and commitment of each physicians to their profession, and despite the struggles there in, an ongoing willingness to look to the future and hope for solutions.
Nevertheless it would appear from this article, the word-press original, and the comments connected that the most significant deterrent to a sustainable health system maybe the inability of the physicians themselves to work along side and as a cohesive group of professionals.
Yes blame can be forwarded to a representative body or a governing system. However when all is said and done, the examples put forth in comments and commentary demonstrates a culture of resentment between skills sets and environment of gratuitous suspicion.
Moreover, while physicians themselves may have advanced education, expert training, and scholastic knowledge, these attributes are of pointless value if as group they are unable to function as a working example.
Dear Robert: Amen
I am deeply disappointed by the public representation provided by the OMA. I believe that their public relations present our professional community as greedy, self-interested and bearing no accountability for the cost and sustainability of our healthcare system.
I absolutely want to work in a sustainable system that delivers high quality care and in which I am compensated fairly for the work that I do. I agree with the author that most grassroots physicians are desperate to be involved in improving the provision of care and the responsible remediation of our health system. The byzantine bureaucracy of the MOHLTC and LHIN system stifles most of our input and we receive little advocacy or help in this regard from the OMA. This must change. The difference between the projected growth and increase in MOHTLC envelope can be found in these savings. And is it also often good for our patinets.
The biggest problem facing the OMA is pay inequality across its ranks. Support for the OMA will never be unanimous while it steadfastly refuses to address the blatant inequities in the fee-for-service fee schedule which perpetuate a caste system within our membership. The fee schedule is rife with fees that incentivize care which is highly remunerative but often of low value to the health of Ontarians. Meanwhile comprehensive care is dependent on pride, duty of care and remunerated atrociously. As has been noted in preceding comments, previous attempts to focus reductions in the fee schedule to these high earning specialties were re-negotiated by the OMA until the cuts were distributed across all physicians. What greedy, self-interested and unfair representation!
The author is also rightfully frustrated with some of the tactics and sound bites from the MOHLTC. The government’s credibility has indeed been undermined by repeated spending scandals. But for the first time in more than a generation we have a minister and deputy who are both physicians and have a true understanding of medicine. They understand the inequality in out fee schedule and the contempt and resentment felt across specialties and sections of the OMA. Fiscal restraint is a reality. But responsible and fair remuneration across the fee schedule is our responsibility – and one which the OMA has failed to advance fairly.
Engage doctors and find savings.
Society should pay doctors fairly for work that has real value to people.
Stop paying exorbitant rates for specialized, low value and procedure-centric work.
What I do not understand is that, with the huge number of family doctors in the province, why they do not lobby aggressively like their specialist counterparts. Their lack of organization makes them target for paycuts, as you can see. Nothing worth having is without fighting for, so fight!
OI, If you want to fight for doctors and patients health care, maybe you should join this coalition of Family Doctors and Specialists
http://www.doctorsontario.ca/?page_id=41
I am a doctor who works in Ontario. Sadly, the OMA has lost a lot of credibility with ME over the years. They trot out the “patients will suffer” line for every eventuality. Their ad campaigns are embarrassing and self-serving. How many other doctors in Ontario feel the way I do, but don’t think they have enough voice or power to change the way things work?
You got it! I feel like its the hyper-specialists warning the public that, should their overpriced fees be cut, that they’re gonna leave and everyone will die!
As a social worker, I have not had a pay increase in 5 years. Other health care providers, who “work hard” (which has been the defense from Physicians) have had their salaries frozen with no hope of additional renumeration no matter how hard they worked. It is the same old discussion from MDs when it comes to their earnings, their salaries etc. But we all bear the burden in healthcare and allied health services, which are no less valuable, have seen this for many years. So I say, stop taking advantage of the system doctors, work together, put the patient at the centre and if this is not where your heart lies – go to wall street.
Emile,
I too am a social worker just outside Port Dover, Ontario and while I understand your sentiments, I am afraid you are misinformed. I was originally on the side of the government in this, but now I realized that the docs have got it right…
I’ve read the latest stats and the what the Ministry of Health has committed to funding. It is LESS than half the growth/demand of health care in this province. That’s just irresponsible. They’re also threatening to penalize doctors who see more patients and provide health services over a certain limit that the government just came up with. What do they tell a patient who’s really sick and needs to see them? “Sorry, the gov’t says I can only provide a certain number of services or else I’ll get a violate my contract, my bad”
What does that mean for my doctor who is one of the only doctors in my small town in South Western Ontario? She can’t see me once she’s hit her quota? That’s unfair.
Secondly, social workers do work hard, and yes the job is thankless. But we’re hired by social services agencies, schools, government and we get a salary (and benefits if we’re lucky). We don’t have to run our own business and pay overhead to keep our clinics running. I was shocked when I learned that docs pay at a minimum 30% in overhead, sometimes 60% depending on what they practice.
Take a look. #’s are pretty shocking.
http://www.ontariosdoctors.com/wp-content/uploads/2015/01/Overhead_BillingsvsSalary_infographic.pdf
http://www.ontariosdoctors.com/wp-content/uploads/2015/01/DemandforFundingIncreases.pdf
This comment contain a factual error: physicians do not pay a minimum of 30% overhead – doctors in Ontario pay an average of 28% overhead. For a complete breakdown of overhead paid by specialty, please see: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3517870/
With all due respect, you’ve fallen for the government’s tired old talking points and blatant mistruths hook, line and sinker.
No matter how you slice it, that $740 million in savings is simply $740 of medical services that Ontario patients will need and won’t be getting. And without a private option, don’t even have the ability to pay for themselves.
You have had salary freezes while physicians are having fees cuts. The OMA asked for a fee freeze. The current CUT imposed on physicians is 2.65%I For a physician with 40% overhead that translated to a 4.4% pay CUT. For a physician with 60% overhead, and there are many, the fee cut translates to a pay CUT of 6.625%.
Can anyone shed light on the fact that Fee For Service groups will be subject to a 2.65% clawback beginning in February 2015, whilst the FHO groups will be clawed back several months later. Why the inequity?
To change fees in the schedule of benefits, they just need to re-write a regulation
To change elements of FHO or other contracts, contracts they need to give notice, usually 60 days, and then re-issue the contracts.
No favourites here. All GPs equally effected. What might be surprising is that GPs get bigger cuts than do specialists. New Grads and Rural physicians are the hardest hit of all.
how ironic…I am a fee for service doc, so that means if I don’t see pts. I dont’ get paid. However, in the capitation model, you are paid whether you see the pt. or not…hummm? where is the logic in that?
There really does need to be a cut to ophthalmology and radiology. Tech has made their volume and speed increase.
Why do fam docs always get shafted?
Because we are idiots for going into family medicine and will be continually punished for this cardinal sin for the rest of eternity.
A lot of myths exist about doctors’ fees in general and some specialties. OI, you appear to be misinformed about the history of fee cuts in Ontario. The biggest cuts last time were for the specialties you mentioned.
Ophthalmologists have been buying equipment that hospitals, because of their own budgets, do not buy. I had to spend $35,000, pay my own technician,buy supplies and a $2000/year service contract since my hospital, to save money, shut down its field machine. The hospital had been offering this service for many years but then could not or would not pay the salary of the technician and also would not pay for repairs needed to the machine.
Ophthalmologists have bought $100,000 OCT machines that were originally paid at a fee of $70 then cut to $67 and in the last contract the fee was cut to $25. And don’t forget the 0.5% clawback on top of that. When this same test is done by an optometrist it not OHIP-insured. The usual fee for reimbursement by a private insurance company is $125.
With advances in technology and wear and tear these machines will soon become obsolete. How do you propose to have state of the art medicine for Ontarians without paying for state of the art equipment?
You have implied that ophthalmologists fees are too high. Taking into account inflation, cataract surgery is now reimbursed at 50% the rate it was in the 1980s. The fee has been reduced three times in the last five years. Ontario now has the lowest paid cataract surgeons in Canada except for Quebec. What kind of a reduction beyond that were you thinking is needed?
You implied that specialities like ophthalmology are getting a good deal from the OMA. That is incorrect. I refer you to my Healthy Debate article that was published two years ago.
http://healthydebate.ca/opinions/is-the-oma-an-appropriate-vehicle-for-negotiating-doctors-fees
Maybe we’re all getting bad deals. But I can assure you that family docs, psychiatrists pediatricians and pathologists are getting worse deals than ophthalmologists. How is that fair?
Fair to whom? Fair is determined by perspective.
I have a very long term perspective on this. Many do not understand that shuffling the chairs on the Titanic would not have saved it from sinking. Shuffling money from one pocket to another will not help patient care.
It might. Who knows?
In a perfect world I’d argue that the fees for the high-billers are appropriate – its the low-fees that are undervalued.
Unfortunately, money doesn’t grow on trees and balance is long overdue.
Nobody can say with a straight face that an ophthalmologic procedure is “worth” more than managing an octogenarian’s multiple medical comorbidities and polypharmaceutical complications, or more valuable than resecting a ruptured appendix. Yet that’s what we have.
The methods of valuation of services are unclear and opaque, which fuels the discontent and gives government free reign to change fees arbitrarily. If it can be justified that such high valuation is appropriate using data, then one can concede and argue against cuts. But so far I’ve not seen anything concrete that justifies such discrepancies in fees.
I know someone who is an ophthalmologist. He works less than 20 hours a week. Plays golf 3 days a week. I can’t comment on fees and such all that I can say is that he lives in a multimillion dollar home, gets paid an obscene amount, and barely works. His education and now his lifestyle are covered by my tax dollars. An artificially created supply constraint and an inefficient system have created this anomaly. There is a long line of foreign trained doctors who will happily and adequately do his job at a still very generous half the cost. Clearly something is broken if you can make hundreds of thousands of dollars, claim every expense and pay minimal taxes, and only have to work a handful of hours. Doctors have such an unbelievable sense of entitlement.
Opthos fees are too high. The US rightsized optho fees years ago. Canada should do the same. Redistribute the excess to other underpaid docs like pediatricians and psychiatrist.
This is what happens when a few bad apples spoil it for everyone.
If I recall correctly the high-earners were in line to have their fees reduced by approximately 10% a few years back. Pressure from their professional groups (ophthalmologists, radiologists and cardiologists) caused the cuts to be spread across everyone at 0.5% rather than solely directed at them. This gives the government a precedent to cut everyone across the board even more.
%featured%Excellent piece. I share your major disappointment in the aftermath of this round (and I was at the table!)%featured% If I felt these cuts led to a more sustainable system in the future, I would have recommended the membership vote for the deal.
In 2012 the Ontario Medical Association and the Government of Ontario reached agreement on a Physician Services Agreement. The agreement included $850 million in savings. The two parties worked hard to find savings that were informed by the best available evidence. They were designed to eliminate or minimize the effects on patient care.
Examples included saving around elimination of annual health exams for healthy adults aged 19-64. It was the opinion of the parties that the evidence supported eliminating this annual exam. Frequency of cervical cancer screening was also changed to reflect current evidence.
The OMA spent a lot of time and resources explaining these savings to our members and supporting the changes to the public. We did this because we were convinced that the system needed reform and that we had to stop spending resources doing things that did not improve patient care.
In 2015 the parties have not been able to come to an agreement. I was not involved in the discussion but I do believe that failure to come to an agreement was not for lack of trying.
In response the Government has imposed significant cuts to the Physician Services Budget. These cuts are just that, changes designed to save money. No pretence has been made that any of the cuts are informed by evidence.
In fact some of the specific changes are troublesome.
New Family Medicine graduates will have a very limited opportunity to join non-Fee-for-Service team based models. They will in effect, be forced to practice in fee-for-service. This is contrary to the policy direction of 2 decades of primary care reform.
Continuing Medical Education subsidies for rural and remote physicians are being eliminated. This is one of the only useful recruiting incentives that under serviced areas have for attracting new recruits. Do we really want to eliminate that subsidy now? What is the policy behind that change?
These are only a few of the implications that seem to be either poorly thought out or are signalling new and disturbing Government policy directions.
%featured%The doctors of the Province of Ontario have a long history of finding evidence informed savings by working in collaboration with their government colleagues. Unilateral cuts that are bound to have disruptive patient care implications are not the way to go.%featured%
Disappointing that a physician who is now Health Minister, after such a short time in his portfolio, talks just like a politician, toeing his party’s line to cut spending without any regard for intelligent planning or forethought.
Absolutely. I wasn’t expecting a bag man, but it is dispiriting how fast people, including our supposed colleagues, sell out.
“Physicians are desperate to be part of the solution in our health care system. ”
I’m curious to know: why do so few family physicians use Advanced Access scheduling (same day booking) for patient appointments? This would fundamentally change our healthcare system, increasing salaries of fee-for-service family physicians (by eliminating no-shows); decrease doctor, staff & patient stress: significantly reduce non-emergency visits to the ER; treat illness early; and save millions.
Great summary and analysis, Scott. If it is not possible to make evidence-based shared decisions in Ontario now as happened in 2012, would it not help if the Ontario Medical Association made fee adjustments to achieve greater inter-sectional equity as the Alberta Medical Association has done? This act of principled internal stewardship of public resources seems to have spared docs in Alberta the trauma of blunt government cuts.
If the MOHLTC were to identify where they thought the specific remuneration problems with (i.e. with which group or groups of physicians), then would not the OMA have to then respond to that? And what is the likelihood that the OMA might concede that ‘yes, that group can and should have its remuneration constrained’. As the author says, the OMA has to keep its diverse constituency happy and it does that by defending all elements of that constituency in all circumstances.
While I sympathize with the author’s frustration with the MOHLTC’s lack of specificity with regard to where in the realm of remuneration it wants restraint, one should not let the OMA off the hook with the idea of ‘oh well, they have to defend everybody and that’s to be expected’.
The OMA has had contentious relations with every government of every political stripe for decades now. And yet, it seems, it bears no responsibility (according to the author) for any of the challenges faced by the system. %featured%I agree that the MOHLTC is prone to game playing and misdirection with regard to the stats, but the OMA is not much better in its consistent position that nothing doctors do is open to criticism or change.%featured%
You can’t put all of the blame for the current impasse on the MOHLTC. The OMA has to take its share of the responsibility as well.
Tom, have you ever done a shift in a hospital…I will tell you where the problems are and where money needs to be saved, but no one listens to us…MOHLTC sure does not understand the system! As an overworked hospitalist, I tried desperately to make real changes but met with ridiculous rules and administrative garbage mostly from the LHIN’s (god knows whose idea that was!). Our system is broken and $650 million saved by hammering the doctor’s billings is not going to solve anything. As the article says, we know how to make this better, but we are not given a voice other than OMA.
I’m not a physician, but I’m in an allied health profession.
The cost drivers are the decisions made by the province over the last ten years to save pennies on the front end and offload the cost down the line. Now they are scrambling to make up the difference.
Physician compensation has remained grossly stagnated for the last five years while cost of living has increased. Average physician salary in Ontario is 360,000 before taxes at 42% (avg)
so
$208,800
with
-no pension, except self paid
-no benefits, except self paid
-overhead costs paid by the physician (office, staffing, utilities)
-costs of registration paid by physician
However, aging infrastructure ignored by the MOHLTC in favour of burgeoning top heavy office positions are the main issue. Locally our three hospitals were merged into single health sciences centre, which resulted in closures of roughly 60 beds. Now, we have been over capacity by 40-80 people almost every day for the last two years. The problem with that is people get sicker in the ER waiting for a bed and end up costing more.
The LHIN are nothing more than a layer to prevent the Province taking responsibility for the choices they make while still continuing to force their mandate down onto the providers.
Unfortunately, I believe that the OMA may not have as an emotional media presence a my own provincial professional body