Are physicians responsible for only their individual patients, or do they also have a responsibility to help ensure that the health care system functions well?
To me, this is the question at the heart of the debate over the tentative Physician Services Agreement (PSA) that has been negotiated by the Ontario Ministry of Health and Long-Term Care and the Ontario Medical Association (OMA). The agreement has provoked a tremendous amount of discussion on social media and an extremely high level of rhetoric. There have also been challenges to the voting process. The OMA has been forced, by its own rules and by court judgments, to hold a general meeting and to amend the questions that are being asked of physicians. It seems like people are shouting a whole lot more than with previous agreements, which is unfortunate, because it can detract from the kind of careful deliberation that is needed to assess a nuanced and complex proposal.
Others have discussed whether the proposed increases in spending are what can be realistically expected (I think they are given the province’s financial situation) and whether the process was transparent (I think this is where the OMA has performed badly; they reportedly did not fully involve their own Negotiations Advisory Committee and their messages and online voting system have been accused of being biased). These are essential questions, but I would like to discuss two important points that I think are being lost amid the heated discussion.
First, I think the PSA represents a significant shift towards a system-level perspective, primarily by setting a limit on total physician expenditures – how much the government spends on doctors in aggregate – rather than focusing on the fees that physicians bill for specific procedures or placing caps on how much an individual physician can bill in a year. Fee negotiations, caps, and other mechanisms will be used to control total expenditures. These will be negotiated throughout the four-year term of the agreement by the Ministry and the OMA as part of a process to meet system-level targets. Importantly, these are tools to meet a larger objective, rather than the focus of the PSA as in previous agreements. That is, the agreement starts with a specified outcome (limited growth in total physician expenditures) and establishes a process to reach that goal rather than starting with fees and caps and hoping for a reduction in total expenditures, an approach that has not worked very well.
Focusing on cutting fee codes (as the Ministry has done, sometimes with and, more recently, without the OMA’s agreement) doesn’t seem to work to limit physician billings. The fee schedule is complicated and, perhaps to an extent not widely appreciated, somewhat discretionary. Some doctors respond to cuts in fees by working more; others by billing aggressively, for example by defining more patients as complex and thus billing higher rates. A cap on individual physicians’ salaries might result in some high-billing doctors taking long extended vacations once they reach their cap. Billings may fall but so will access to care. And while the 2012 PSA agreement established mechanisms to encourage evidence-based approaches to spend less on low-value care, my impression is that the impact from those initiatives has been limited, perhaps in part because that agreement was announced in December 2012 and expired in March 2014 – too short a time to realize significant change (the new PSA covers four years).
Some say that managing the health care budget is not the job of physicians. I disagree and so does the Royal College of Physicians and Surgeons of Canada, which states that a core competency of physicians is to “engage in the stewardship of health care resources.” The PSA explicitly says that physicians should “co-manage,” with the Ministry, how much is spent from the public purse on physician billings. A very large argument in favour of this agreement is that it offers the best framework to date to fulfill physicians’ stewardship role and to shift thinking to perspectives broader than those that focus solely on individual doctors’ billings.
Second, the PSA includes an innovative incentive structure that deserves to be tested. In essence, physicians will get bonuses (what the agreement calls “One-time payment increases”) if total physician expenditures remain within target ranges. If actual expenditures exceed the targets, the one-time payment for that fiscal year will be reduced by the excess amount. Starting in 2017, further excesses would be addressed by reducing future payments and other mechanisms to limit fees.
Behavioural economists and cognitive psychologists have studied how behaviour is influenced by the design and delivery of incentives. For example, “mental accounting” is the principle that incentives are stronger if they are given separately from regular payments. “Loss aversion” suggests that once a bonus has been given, people will work hard to keep that bonus in subsequent years. It is important to note that “for Fiscal Year 2016-2017, there will be no reconciliation of the overage [amount in excess] past the one-time payment reduction [withholding the bonus].” In plain English, physicians’ fees are protected from clawbacks in the first year, which behavioural economics predicts will motivate them to avoid such losses in subsequent years. I don’t think incorporating such incentives should be seen as duplicitous or underhanded. The point of such structures is to capitalize on human psychology to bring about desired changes. However, such incentives are complex and do not always work – they may conflict with other motivations or may be too small to lead to behaviour change. The one-time payment model should be rigorously evaluated to see if it works. But it nevertheless represents a novel approach to changing physician behaviour and deserves to be tried.
The OMA has a mandate to advocate for physicians but now, more clearly than ever, it will also have a mandate to ensure that physicians are partners in working towards a sustainable health care system. The PSA is hardly revolutionary. Still, it contains significant shifts in thinking about the roles of physicians as a group and innovative methods to try to control costs that make it well worth supporting.
Read more about this issue.
Rajiv Singal, a urologic surgeon at Michael Garron Hospital and professor at the University of Toronto, writes It’s about funding, not income: Why Ontario’s doctors should vote no
For another perspective on the deal, labour lawyer Steven Barrett writes, You Can’t Always Get What You Want: An Assessment of the Tentative 2016 Physician Services Agreement
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What is in the agreement that outlines the extent to which a Physician is liable for their individual quality of service ? The link to the ‘tentative document” is a dead link.
Thank You
Karl
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What about patient and caregiver responsibility? The medical consumer should contribute in some measure to responsible use of available resources. The current “free credit card” for medical care is not sustainable.
The coalition charges that the agreement is confusing and vague, yet the coalition itself details precise statistics to support its position. All members have access to the terms and time to analyse. It may not be to the coalition’s liking but it is not confusing or vague. The coalition complains that the OMA is promoting the ratification of the agreement yet, as bargaining agents, the OMA is duty and honour bound to do so within the definition of two-party negotiations who have a tentative agreement. The coalition needs to brush up on labour law and negotiations procedures and should not build straw men to obfuscate the actual content of the deal.
I am not sure that the Oma is duty bound to promote the deal, but even if it were, spending millions of membership dollars to influence the vote, denying access to membership contact information and presenting a manipulative proxy arrangement is scandalous. And I don’t have to be a labour lawyer or even a brain surgeon to see that
So your complaints are related to internal politics and procedures, likely legitimate, not the content of the agreement.
The OMA’s tactics in pushing this deal are despicable.
I have explained why I vote No in my reply to Steven Barrett’s recent opinion piece.
Dr. Faulds,
Many thousands of docs are not “leaders in the health care system locally,regionally,nationaly and globally”as you say. They are the ones who are seeing your patients at 4 am,and weekends,sacrificing their health and families,who are too busy or not in a position to teach or have an academic or government role,and who are literally keeping this system (which CLEARLY can no longer fund itself) afloat while you read medico-sociological fluff pieces like the one you quote. They are older,worn out,seeing elderly and increased immigrant populations (which take much more time), in high volume,dangerous FFS situations (which also keeps this system afloat- the line ups would be even more brutal if it was all salary and AFA). They have been rewarded with over a decade of income decreases as a reward for their decades of experience,dedication and lousy hours,then told they all have to work as a teammate with the Liberals because everyone knows its patient interests that drive their decision making,and academics like you,from your comfortable desk, think this is a good thing. Another speech from the Hazelton Lanes politburo. Membership has its privelages…
Read the comments after i made my first…I see another academic has chimed in as a follow up to her Huffington Post propaganda column… who has bought real estate in a cheaper area, during cushy times, and makes income not based on lousy hours and FFS nightmare line ups, and also happens to be part of the Hazelton Lanes funded cafe life,feels a 6 page agreement,which will float for 5 -6 years ,with no details of any kind, thinks making a little less money wont hurt her now well established life but will keep her and her OMA buddies feeling important…sorry,just telling it like it is…
Another terrible argument from a university academic who is not working to see 40 people at 2 in the morning…likely salaried and loving the pace…
The CanMEDS Leader Role describes the
engagement of all physicians in shared decisionmaking
for the operation and ongoing evolution of
the health care system. As a societal expectation,
physicians demonstrate collaborative leadership
and management within the health care system.
At a system level, physicians contribute to the
development and delivery of continuously improving
health care and engage with others in working
toward this goal. Physicians integrate their personal
lives with their clinical, administrative, scholarly,
and teaching responsibilities. They function as
individual care providers, as members of teams, and
as participants and leaders in the health care system
locally, regionally, nationally, and globally
I don’t believe that the CanMEDS leadership program envisioned that the reckless spending of the Ontario government would result in MDs being forced to shoulder the debt costs of government mismanagement.
That’s not what leadership in medicine or health care should be.
Physician leaders can advocate for patients and a resilient system. They should not be leading the profession to be a scapegoat.
‘Physicians integrate their personal lives with their clinical, administrative, scholarly,and teaching responsibilities.”
I believe that I speak for most of us who spend the majority of our lives in clinical practice treating patients, when I say that we wish the OMA would spend more of our hard earned RANDED dollars to advocate for the physicians of Ontario gand less on being Social Justice Warriors.
Thank you for this piece. Your first question; “Are physicians responsible for only their individual patients, or do they also have a responsibility to help ensure that the health care system functions well?” can be answered not only by the CPSO but also by the CANMEDS roles. We have a manager role that is clearly defined as “contributing to the effectiveness of the healthcare system” http://www.educationforhealth.net/publishedarticles/article367_13.gif. I do not see that we can separate ourselves from the advocacy we do for patients and the management of the system in which we work.
This is a major cultural change for many in our profession and has not been easily digested nor the opportunity easily appreciated.
Teaching the physician manager role is now an important aspect of many residency programs. This reference is concerning the psychiatry program at U of T. http://staticcontent.springer.com/lookinside/art%3A10.1176%2Fappi.ap.33.2.125/000.png
In response to Dr Faulds: Physicians being made solely responsible for cost overruns creates a terrible OMA-MOH manufactured conflict of interest. This distorts the Trust that is integral to the patient-physician relationship.
The deal is poorly thought out, lacks details and worst of all it damages trust. The medical profession would be wise to toss it out and start again.
“Management” isn’t and should not be at the heart of the patient-physician relationship.
Dr Bayoumi, *how* are physicians expected to change their behaviour to keep from going over budget? The only possibility is to see fewer patients, and you know that. And most of us find that completely unethical.
We literally can not change our behaviour to fit this fantasy outcome the OMA has dreamed up. And they know that. So their plan is simply to cut physician fees as we approach the budget ceiling every year (this is the “co-management” part).
There are lots of ways to “engage in the stewardship of health care resources” but this unpredictable nightmare is not an acceptable one.
It becomes an issue of divided loyalty and bias.
If preserving the system is the priority rather than serving the patient, what recourse does a patient have?
If the government wants a “Patients First” system, why does it appear to put them secondary? Perhaps the legislation should be called “System First”.
If physicians are required to be accountable gatekeepers, who are they accountable to—-their patients or the government?
The Ontario government has chosen to spend tens of billions of tax payer $ on projects that have demonstrated minimal to no value and on projects that have overcharged Ontario tax payers by over 37 billion dollars according to the Ontario Auditor General.
Now the Ontario government wants the province’s physicians to carry the burden it created.
The Ontario government wants MDs to be accountable for rationing care yet it is not accountable for its wasteful spending that has driven up provincial debt dramatically and caused a billion dollars a month to be spent on servicing its debt—a billion dollars a month that could have gone to health care or other areas that create opportunity and positive potential.
It’s interesting to note that many MDs who earn significant amounts of income through work other than patient care speak in support of the deal that will affect the ability of others to provide patient services.
It’s unsettling.
”Lovers of Medicare legislation love Medicare more than patient care” –Shawn Whatley http://shawnwhatley.com/ #cdnhealth #cdnpoli
Your talk of rhetoric is breathtaking in the face of the lack of transparency by the OMA. The duly elected representatives of the patients created this health care system. Physicians are not responsible for it, but just doing the best we can.