You Can’t Always Get What You Want: An Assessment of the Tentative 2016 Physician Services Agreement


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  1. Andrew Appleton

    Thank you for your pragmatic view on the TPSA issue. After reviewing the recent legal ruling on the petition, general members meeting and proxies, I am convinced that the dissenting group is less focused on the actual content of the TPSA, and more angry about being left out of the negotiations process. In essence, they feel betrayed. The OMA could have been more forthcoming about what was going on in the spring and certainly should have done a better job with including all resolutions named in the petition on the proxy votes. However, in order to move forward, it must be recognized that the deal before us is far more positive for the profession and health care system as a whole, than it is negative. It’s not easy for those in a position of privilege to succumb to the notion that in a negotiation, you can’t get everything you want. Yes, we should have binding arbitration. But, realistically, it will take time. The OMA is going about it the best way they can, via the courts. In the meantime, we need stability as a profession, and as a province, to achieve the best future together.

    • Jordan Weinstein

      No Andrew. You clearly have no understanding of the COD’s position and at best a naive view of the TPSA. People in the COD have generally no interest in the being involved in the negotiations, for the most part. They are predominantly unhappy mainly about endorsing a fixed maximum for the PSB. It is not within our power to curb utilization. Period. Attempting to make us responsible is a recipe for disaster.

      Getting back to your rather insulting commentary on those in the No camp; it seems far more likely that those in the Yes camp are in fact themselves aligning with what has become a fairly corrupt OMA and more interested to insert themselves in to the discussion simply for the sake of being involved (i.e. bureaucrats).

      I don’t dispute that a No vote will be disruptive in the short term but believing that the TPSA is in any way stabilizing to health care is a pipe dream being peddled by an OMA which is largely responsible for the predicament we are in. And which is being swallowed hook line and sinker by the likes of many in the Yes camp.

      • Mario Elia

        Jordan I would caution you against referring to a colleague’s opinion as naive. You are correct that most members of COD may have had no interest in being directly involved in negotiations, as that would involve actual work and compromise, not just complaining on social media. How you have managed to perceive Dr. Appleton’s balanced take as some “insulting commentary” is just another example of how absurdly partisan many have been in this debate.

        • Mikael Lavigne

          It’s also quite interesting that someone can ask a colleague to be more respectful and then in the very next sentence, imply that members of COD are lazy and despise work and compromise. The fact is, people on both sides of the argument have spent countless hours having arguments on social media in 140 characters about this issue, and remaining civil is always a challenge in that situation. It highlights one of the challenges that we face in this era with trying to have civilized discourse.

  2. Brooke Saunders

    One point of clarification in an otherwise well reasoned article. You talk about the $200 million in permanent cuts as “providing a cushion against budget overrun” and the annual lump sum payments as a carrot offered to doctors if they stay within the budget. However the OMA’s own economic analysis agrees that these are in fact necessary to have any hope of staying within the 2.5% budget increase (since the historical 15yr average increase is 3.2%). In fact these “carrots” are really camouflage for the fact that the government is under funding physician services based on the historical increase in demand. The reason the agreement is structured this way is simply to provide political cover to the government (so that they can argue they “held the line” on union negotiations and limit any wage increases in contracts negotiated with other unions). It is truly political doublespeak at its best, and forces doctors to be complicit in rationing care to their patients. Furthermore, many feel it creates a conflict of interest for front line physicians, as instead of asking “does this patient require a given test/procedure/consult” we might be unconsciously asking “can our budget afford this test/procedure/consult.” The agreement provides a clear financial incentive for physicians to deny care to patients (in the form of the annual lump sum payments).

  3. Jordan

    The point about the 200m in savings acting as a cushion to budget over-run is warped.

    It is a pre-emptive cut to avoid a future cut. Not sure how this escapes advocates of the deal.

    Jordan

  4. Hamilton Doctor

    This column, like every other column supporting the PSA completely misses the reason for the no vote (of course it does create several strawmen to attack). The TPSA makes individual physicians responsible for overages in the global provincial budget. Once physicians in Ontario agree to be responsible for overages in the budget, that will never change. Many physicians voting no would prefer a fee cut to agreeing that somehow billings can be clawed back retroactively from individual doctors if a global budget is exceeded.

  5. Marlon

    Interpreting the proposed agreement with your experience, I am surprised your calculation of a $200M cut in fees is wrong. Verified by the OMA Economic team, the total cuts add to $400M.( No cuts year 1 , $100m cuts each year 2 and 3 , $200m year 4) To quote misleading information as a former legal advisor for prior negotiations is surprising.

    • Marlon

      And as a current legal advisor to PARO at a bare minimum get the facts straight before advising medical residents

  6. London Doc

    The notion of making individual physicians responsible for an overrun of the overall physician services budget is fundamentally flawed and must not ever be a part of any agreement. Let’s look at an analogy: A factory makes 100 widgets per day using 10 employees. The demand for widgets increases, so the factory hires 2 more employees to increase production. However, management decides that all 12 employees have to share the salary of the original 10 in an effort to keep costs down. The 12 employees then form a bargaining unit but are told that it is illegal to take job action because the widgets are an essential product that everyone needs.

    MDs in Ontario are essentially being put in that exact position. Where this analogy falls flat is that the factory likely makes a profit, but the province only continues to lose money. That is the nature of government-funded health care. Either we choose to accept this as a premise or we allow for-profit health care to take root and grow. That is the elephant in the room that few people want to address. If we, as a society, do not want to accept for-profit health care, then we need to accept the Canada Health Act as a firm guideline and fully fund health care for all Canadians.

    • Kitchener Doc

      I find it quite clear that the bullying of physicians is the government’s chicken game in getting us to make the first move in establishing a more robust private system. Let’s face it, it already is a multi-tiered system. Patients of family health teams get publicly funded services like psych counselling, chiropody etc … that other other people have to cover privately. Both physicians and members of government (at every level) jump the queue daily. Why continue the charade of a publicly funded system when the government has so poorly governed with a litany of unacceptable scandals/blunders/fiascos, that they can no longer afford to run a system that properly services Ontarians? Just like Brian Day in BC who opened a private orthopaedic surgery clinic or MedCan which is already established in Toronto, the government may balk and call us greedy publicly, but would breathe a big sigh of relief behind closed doors. Time to just call a spade a spade.

  7. Chris

    Can the author, the OMA, or the MOHLTC provide an example of another jurisdiction that applies a cap to physician services in an already under-funded system? Or an example of any other profession this is applied to? I just can’t imagine agreeing to a deal where my pay will be cut unexpectedly based on factors outside my control.

    • Kitchener Doc

      I too would like to know the sacrifices the members of the Ontario Liberals have had to make to pay for their own inexcusable mistakes. Pay cuts? Loss of luxuries like travel stipends?

  8. Beantown

    There are two issues: the agreement and confidence in OMA. While the agreement can be debated, many will vote no as a vote of non confidence for the OMA who have been deceitful in their approach to negotiating and promoting the agreement.

    It is a shame that the two cannot be separated. While a yes vote may be pragmatic, it is very difficult to trust the OMA and this secret deal with no details that is being aggressively pushed. Seems like Dr Wallace is a used car salesman. Maybe she has a government job or compensation waiting if she pushes through the deal?

  9. Mikael Lavigne

    This article repeats many of the arguments that the OMA itself is using to spread fear among its members. Indeed, many of the main argument seems to be that “things could get better, but they could also get far worse”. By floating the specter of a scorched earth approach to cuts by the government, this writer continues the use of these tactics. In addition, to imply that a No vote would lead to a “splintered profession and a neutered OMA” is incorrect. The very nature of the system gives all physicians a vote, and at the end of the day, the OMA will have to accept the will of its members and move forward with that position. Isn’t that the very cornerstone of credible and effective representation?

  10. Winston Bharat, MD

    There does not seem to be a need for the Charter challenge as bj sing arbitration was provided for in 1984 under s.12.2(b) of the. Canada Health Act. The tPSA is in violation of the CHA to the extent that it does not provide for the OMA to choose between BA and conciliation in the event of disputes on compensation.

    Similarly, the recognition of clawbacks, which literally download the cost of every penny of PSB overages o private citizens (physicians) and MPCs appears to be in violation of s9 of the CHA which mandates that OHIP fund 100% of all insured services.

    I have attempted to contact the OMA about these issues on multiple occasions and have been met with silence.

    The tPSA additional ally functions as an insurance policy for the government in the event of overages to the PSB in a very literal sense. It provides for one party (physicians) furnishing money to the other party (government) if an event transpires (overuse of physician services anticipated or real beyond the PSB).
    This would additionally appear to violate the Health Insurance Act which states that all other forms of insurance for insured services are prohibited and that individuals cannot benefit from any services provided under any alternative insurance.

    There are serious grievances that many opposed to the tPSA have beyond those raised in the above post and they are not in the slightest bit trivial. The third party needing to account for “value to patients” will ensure that MDs lose in such binding decisions whenever the government presents an alternative use of monies other than for the PSB itself.

    The merits of the current FFS environment are up for debate and have been debated. However, such an environment exists at this time, as do the pieces of legislation above. Absent a cap on utilization, a tPSA cannot legally introduce a global cap on payment for utilization in this environment.

  11. Gerald Goldlist

    In the face of what the OMA has been doing to promote this agreement, I am sure that I am not the only who resents your calling those of us who have been pointing out the downside of a Yes vote as using “over blown rhetoric”.

    You say that “the deal contains a larger measure of stability, a greater degree of financial protection, and a formal role for the OMA in co-management of the physician services budget?”

    In other forums, many have pointed out that the stability and financial protection is for the government and not for physicians and not even for patients. Many have also said that: co-management of physicians services by the OMA is being complicit in continuing rationing of health care and that the current agreement is unacceptable for this reason alone.

    I believe that the court case should not be a major bargaining tool at all. To promote the court case as the major hope for Ontario physicians gaining binding arbitration is, in my opinion, a long shot. A very experienced corporate lawyer said that even in ironclad litigation cases you still only win 80% of the time. As well, according to The Canada Health Act and Justice Emmett Hall, binding arbitration should be a given and not a bargaining chip.

    I do not believe that strike action is at all necessary to a achieve significant gains for Ontario physicians. The retirement, leaving Ontario and changing practice patterns has already shown the effects of the government’s imposed cuts. Exposing the rationing of health care that is being going on and will continue under the proposed agreement is what we can continue to do to pressure the government, especially as a by-election is occurring in a couple of weeks and a general election is not far away.

    The agreement “commits both parties to find$100 million in permanent reductions to fees or physician payments.” All physician services have already been cut drastically. This Fall the OMA released a study showing the loss of earning power of Ontario physicians between 2011 and 2017. The earning power of family physicians has been cut 29%. 28.5% was the average loss in earning power from 2011 to 2017 for Ontario physicians. The cuts range from a low of 17% to one section to a high of 60% to another section. Are you suggesting that Ontario physicians vote yes to accept these losses and further losses as more patients come into the system and inflation continues?

    The COD has a wide cross-section of members, many of whom would rather have the government impose cuts rather than the cuts being given legitimacy by the OMA’s participation.

    You say that “those opposed to the agreement – on the basis that it lacks a guarantee of binding arbitration – should be reminded that, when the Government and OMA last agreed to binding arbitration (from 1991 to 1995), the compensation arrangements provided not only for a cap on overall physician expenditures, but also on individual physician incomes ($400,000 a year).”

    There is no reason for Ontario physicians to accept that binding arbitration must be tied to capping of OHIP Billings; in fact, with binding arbitration a cap should be next to impossible for the government to enforce. A very experienced lawyer with experience in corporate litigation and as an arbitrator himself said to me after after I told him about the the 2012 government OMA agreement, “What idiot lawyer would let his client sign a nonbinding arbitration agreement?”

    “Ultimately, amid all of the debate over the merits of the tentative agreement, there is one thing that seems relatively clear: if the vote on August 14 is no, we will see a splintered profession and a neutered OMA, casting serious doubt on its ability – or for that matter the capacity of any physician organization – to credibly and effectively represent physicians collectively in dealings with government on compensation and other matters affecting health policy.”

    With regard to a “neutered OMA”, when the GST was implemented the OMA did not get a fee increase to cover this increase in expenses for physicians. OMA dues have increased faster than the OHIP fee schedule that the OMA negotiated on behalf of physicians. Since the 1970’s the fees negotiated by the OMA have not kept up with inflation. In about 1985 the OMA negotiated a zero per cent increase as inflation soared to 10%. In the 1980’s the OHIP fee schedule was 90% of the OMA fee schedule. Now it is less than 50%! A “neutered OMA” could not possibly do any worse than that.

    According to a recent survey done by the OMA, two out of three physicians would opt out of the OMA and also felt that the OMA was doing a poor job in negotiations. The rest of the survey is also damning.

    Dr. Michael Howcroft was very active in OMA politics in the late 1980’s and early 1990’s. From your credits at the end of the opinion piece, it appears that you were working for the OMA at the same time that Dr. Howcroft was a director of the OMA. He is aware of what has been going here in Ontario and sent this email:

    Just to give you some history, the last time there was a general meeting was 1991.
    I was section chair at the time and we were faced with a PSA which would
    result in physician “income caps” (350K for family docs and 400K for
    specialists) and would give the OMA representation rights for all MD’s and
    allow them to invoke the rand formula (mandatory dues). In the meantime, we worked hard to drum up opposition to the agreement and I did multiple media interviews regarding the issue. In the end, the president of the OMA (I think it might have been Mike Wyman) showed up with several thousand proxy votes and the agreement was ratified.

    I served the board in a number of capacities, including as a member of the 1992
    Negotiating committee We worked with the OMA labour law firm
    in negotiating an agreement with the Bob Rae NDP government (remember the
    “social contract “?). We developed a complex agreement that
    included “delisting” a number of medical services and a provision for
    incorporation by MD’s. AFTER RATIFICATION, THE GOVERNMENT SIMPLY DECIDED
    NOT TO CARRY THROUGH ON MANY OF ITS COMMITMENTS BUT HELD US RESPONSIBLE FOR OURS.

    If I had a vote, I would definitely vote no. Given their past experience, it’s
    surprising that the OMA continues to negotiate with this government.

    Michael Howcroft, MD. former OMA Board of Directors Member

      • No Way

        And for all your ranting historical nonsense – I will tell you that doctors do not service Ontario – they ignore Northern Ontario – and you think your so special – to have increases above all other Ontarians – I frankly think your over paid in the first place and welcome you to leave Ontario.

  12. Kenneth Lai

    This article unfortunately misses the point and is grotesquely misguided. You make the unjustified assumption that physicians actually have some control over the utilization of health care in our system.
    As has been referenced elsewhere, using this argument, we should be able to ration government funded services everywhere and fix the Liberals problems in no time.
    Teachers should be responsible for rationing education no matter how many students; police can control the cost of crime; firemen can be responsible for the cost of fires; bureaucrats should be responsible for controlling the cost of red tape!
    Maybe grocers can become responsible for controlling the amount and cost of food eaten in the province!
    Predictability and stability for everyone!

  13. Dr. T. Weinberger

    You clearly miss the point.
    The OMA is suggesting to it’s membership to accept the coercion that if we don’t agree this flawed document, that worse will be done to us. This is like a bully (the government) saying that unless we agree to being beaten up slightly every year then we won’t get a severe beating.
    While the OMA states that it’s members won’t en mass enter a job action, it fails to provide the leadership to stand up to the abuse promised by the MOHLTC.
    If we accept this tentative agreement, then in fact we agree that we should be paid less each year for the next four years and have no cause to complain. The decrease in payment is guaranteed as yet unnamed fee reduction and saving will occur.
    Having said that, I believe that some fee corrections, changes and practice patterns do need alteration.
    There is only one way to vote, and that is a resounding “NO”.

  14. Ray Fredette

    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.

  15. Adam Smith

    Concerned Ontario Doctors … Acronym is C.O.D. … It should mean Cash On Demand … I’m struck by those opposing the deal .. Too often the commentary is of a self satisfied entitled bunch of well paid rich one percenters who don’t seem to realize that the rest of us earn far less, are dealing with tough economic times and can’t afford to pay more.

  16. Merrilee Fullerton

    Suggestion: How about the MDs who support the deal agree to the terms and be subjected to the terms?

    It seems many of them have other income.

    Please, go ahead…

  17. Get Real

    These Ontario doctors are out of their minds – trying to hold the province of Ontario at bay – I say tell them all to go work in Northern Ontario – and play their bluff – because they think they are so special. The reality is that I have met more poor doctors in Ontario then good ones – and they deserve no increase above any other Ontario worker. They think they are so special – I would welcome them to service Northern Ontario – or move out of the province all together. British Columbia has way better heath care then Ontario.

  18. k jablonowski

    With all due respect to Mr. Barrett here is what you don’t know ….
    1. We as doctors can’t control expenditures. I know that goes against everything the Liberals have told you but guess what….I don’t see people frivously to make money. Maybe a small number do. Most of us try to discourage overuse. And get college complaints that are taken seriously over it. Or yelled at. Or called repeatedly. If your clients tell you what to do and you do your best to give them good advice but they don’t listen are your billable hours docked? I won’t even include the hours of unpaid work we do that no lawyer would ever agree to. When you work you are paid. We are not unless the patient is there. Change that and we can save you money. Until then please feel free to do 2 hours of unpaid work daily for 11 years and get back to me about how this offer feels to you.
    2. The highest paid specialists lose 10%. GPS get incentives. What do the low paid front line specialists get. Most specifically with the focus on improving our third world level mental health system and providing for our aging population. I want a specific deal. With terms not empty promises. You are a lawyer. I wouldn’t sign a rental agreement this vague. Yes it’s to be discussed you will say. Ok then don’t approach us till it’s a detailed contract and let us decide based on fact not fairytales.
    3. Stop using fear to make a deal. This isn’t the Price is Right and if I try for the car I may lose my year supply of RiceORoni. I’m earning so little as a community psychiatrist I’m already closing my doors. When you have already lost being respected, paid, supported and appreciated whatever the Liberals do next would have to be less than zero. Come spend a week doing what I do. Then see my income. Then tell me I should have gone to law school like all my friends and had my Fridays off in University. I already know how bad it is. I see suffering patients every day. I wish I could help them more. But I’m not the problem. And until Minister Hoskins realizes that and shakes my hand and looks me in the eye and says thank you for your work I don’t really feel in the mood to agree to anything he has to say. Negotiating in good faith I believe we call it. Not under duress.
    Sincerely,
    Just a doctor trying to do their job.

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