It’s about funding, not income: Why Ontario’s doctors should vote no
Ontario physicians have long cared for their patients, guided by long-standing physician services agreements negotiated with the government and revisited every three to four years. To look at these agreements, certainly over the course of my career, is to see times when the public sector is flush with resources and others when it is not. These contracts have little to do with whether there is a Liberal or Conservative government in power.
If casually following the occasional headline, many in the public will only see a battle that pits seemingly affluent, self-serving physicians against a government that is championing the cause of the taxpayer.
The reality, however, is that doctors are pushing back against chronically inadequate health care funding in general and increased expectations for care, and that doctors have borne the brunt of this gap. Since 2012, physicians have continued to deliver care to their patients, despite the absence of a physician service agreement. During this time, the Ministry of Health has rolled back physician compensation by about 7%. Given that Ontario’s population continues to grow and age, that funding deficit will inevitably spiral upwards.
Last month, a six page summary of a tentative deal between the Ontario Medical Association (OMA) and the Ontario government was quickly released for membership review. The OMA has endorsed it and recommended ratification so that physicians are not subject to further unilateral reductions at the discretion of the Ministry.
The argument is that we will be allowed to be partners in reforming the system as we move forward with promises to look for efficiencies and modernize the fee schedule. However, some have complained that the six page report is not long enough or filled with enough detail to make an informed decision; that it is too vague and incomplete. There has been a lot of debate about what the numbers mean and whether the health care system will be adequately funded into the future.
In my mind however, I didn’t need to read past the first few lines of the agreement. To accept the proposed agreement requires doctors to accept that the approximately 7% clawback to physician earnings that were put in place to slowdown the growth in spending on health care, remains intact. In my opinion, the profession cannot agree to this on principle.
It is not for me to know whether physicians get paid too much or not enough. Perhaps we should be paid less. I just don’t know. However, what I do know is that if as a society we all value good public health care, then I think we all own a share of that responsibility when resources are inadequate to fund that system. Accepting this agreement establishes as fact that a funding shortfall for the care that physicians provided their patients existed in Ontario between 2012 and 2016 and that physicians have agreed to accept sole responsibility to make up the difference in that gap. That is a dangerous precedent.
For most of my 20-year career, health care managers and providers have been trying to streamline healthcare. The relative cost of technology continues to rise as do patient expectations, as they quite rightfully demand the best. Hospitals such as mine have nobly continued to balance their budget despite not being provided enough to fund the care that is necessary. Operating room time has been reduced or operating rooms have been closed for years across many, many hospitals in the province. These maneuvers predate the post 2008 fiscal crisis by many years. Up until now, the work always seemingly gets done. Hospital administrators, doctors, nurses and others tirelessly triage the most important tasks like cancer care. Other treatments get pushed down the road a little further every year. However, I have long said that 2016 is the year that things might come to a head. Budgets are no longer so easy to balance.
It begs the question, then, that if everyone within the system is seriously trying to address the funding gap by trying to improve efficiencies to make sure patients are cared for, should we not expect the same level of commitment from government? After four years of 0% hospital budget increases – despite an aging and growing population, and despite increasing costs of new technologies and inflation – this past February, this government announced that it was “investing” in hospital care. It released this banal tweet that amounts to 1% in new funding for hospitals relative to the prior year:
If Ontario physicians accept this current offer then we are basically agreeing to be the only ones to disproportionately reconcile any funding deficit. That is a very big problem. The profession is an easy target as certainly we do ‘well enough’. The populist strategy has its merits. We would declare that we are willing to make up the difference while decisions made with an eye to the next election will continue to propagate the myth of a well-funded healthcare system into the future.
Yes, we need to tighten our belts. Perhaps we do need to roll back the fee schedule, but this has to be done in true partnership with government. The tentative agreement is too vague on how decisions will be made about health care resource allocations. Anything less than that will eventually still lead to the demise of the public system over time. You can only kick the can down the road so far. The current course is not sustainable. Good public healthcare, its stewardship through difficult times and its long term health is a social contract that binds us all.
It is time for all parties to get serious about what our health care system will look like in the future, well beyond election cycles. It is time to move forward with broad consultation, mutual respect and in good faith.
Rajiv Singal is a urologic surgeon at Michael Garron Hospital and professor at the University of Toronto. This post is a version of an article that appeared on his blog.