Dean On Campus Blog

OMA and government reach potential agreement

I’m very pleased that after what seemed like an eternity (but was probably more like two years) without an agreement, the Province of Ontario and the Ontario Medical Association (OMA) are tabling a potential agreement. The tentative agreement is now being communicated out to the OMA’s 33,000 member physicians who will vote on whether to ratify it in the coming weeks. This is a long time coming, and is a very welcome turn of events. oma-logoTo say that the relationship between the OMA and the government over the last two years has been frosty is an understatement. It’s critical for our patients and for our health system that strong relationships characterized by open lines of communication exist between these two entities.

ontario@2x-printSome of the highlights of the tentative agreement are:

  1. A 2.5% increase in funding per year for the remainder of the contract (4 years).
  2. One-time payments ranging from $50M to $120M per year, with the caveat that those dollars cannot be used if the total physician compensation budget is exceeded.
  3. The OMA and the government will work together to identify $100M of savings in each of the years 2017 and 2019 based on a hard look at the fee schedule.
  4. There will be co-management of the agreement which includes a co-management process looking at health human resources.*

*The Deans have clarified with the OMA that they will be consulted during any HHR discussions.

From the vantage point of Queen’s, where we have a comprehensive alternate funding plan (AFP), exactly how these elements will be reflected in the AFP has not yet been clarified. However, one anticipates that it’s likely that payment to physicians in an AFP will echo the general arrangements that are being proposed in the agreement.

Of particular significance is the agreement to look at the two planned $100M carve-outs from the fee schedule. I predict this is going to be done largely based on the issue of relativity. Relativity, simply defined, is the issue of the tremendous variability we have in our fee schedule with respect to how we financially reward different types of specialists. For example, a young trainee who goes through three years of internal medicine training followed by two years of training in a subspecialty, will earn significantly more if he or she chooses a subspecialty in the areas of cardiology or nephrology as compared to geriatrics or rheumatology. The training times for those four subspecialties are the same, and yet the swing in income between the higher and lower can be hundreds of thousands of dollars. These discrepancies are largely an Doctor-and-man-in-suit-shaking-hands-2000-x-1335-pxartifact of a historical fee schedule that really hasn’t changed with the times and does not recognize that changing technologies has impacted significantly on the time that is necessary for certain procedures. In the same vein, some of the fees within the surgical specialties were set for procedures that used to take several hours, yet now take just a fraction of the time.

I’m hopeful that the agreement will be ratified by the OMA membership. In my own personal view, it’s important that we move on from the chill that we’ve experienced in the last few years, to a more constructive relationship between the OMA, which represents our physicians and our government, which is responsible for the overall health of our population. Once the issue of physician compensation is addressed and an agreement is ratified, we can shift our attention to the challenges that our healthcare system faces with an aging demographic that’s requiring more demands for services and new technologies emerging that might materially improve the lives of our patients.

Please share your thoughts on the tentative agreement by commenting on the blog, or better yet, drop by the Macklem House… my door is always open.

 

Richard

29 Responses to OMA and government reach potential agreement

  1. Charles Scott says:

    Richard, the tentative PSA being promoted by the OMA would certainly bring the OMA closer to the MOHLTC but I’m not sure that’s a good thing for physicians or our patients. Your recap of the OMA highlights fails to note that it enshrines the recent unilateral cuts as a starting point, and underfunds physician compensation further relative to recent historical averages. Accounting for inflation and even conservative estimates for growth in utilization, AFP and FFS funding will be cut over the term of this (long) 4-year agreement. The “carve-outs” you mention are unlikely to be granted since we will surely exceed the small growth allowed under the deal, and should not be thought of as a funding promise. In any case, they will be gone in 4 years, at which point we will be well behind where we started 2 years ago. The most egregious part of the deal is the hard cap on the budget, meaning the government abrogates its responsibility to fund physician care for patients under single-payer universal healthcare. Cost certainty for government, but troubling uncertainty for physicians, AFP or otherwise. You may see steady SEAMO funding, but it will not keep up with the demand for clinical output of your physicians. That’s a cut, not growth.

    Ratification of this agreement will set a dangerous precedent that physicians will now bear the financial burden of growth in health care needs beyond a certain point. Maybe we should get a fair agreement first before shaking hands over a deal that is light on specifics, leaves all the power in the hands of the bureaucracy and will spread to other provinces once it becomes clear physicians are willing to be complicit in the dismantling of our once-cherished status as independent consultants with professional autonomy.

    Charles Scott
    Dept of Radiology @ Queen’s

    • reznickr says:

      Charles, thanks for your comments.

      You bring up some very important points and I certainly understand that there is a sentiment that expresses great concern about this potential arrangement. That said, the current situation and status quo of a tremendous chill between the OMA and the ministry is in my opinion quite unsettling. The other material issue here is that the charter challenge will likely take 4 to 5 years to work its way through the courts. I believe the current arrangement is preferable to a situation where government carries on with its precedent of unilateral action.

      Richard

  2. Charles Scott says:

    The cuts only become “bilateral” if we agree to be a party to the clawbacks that will inevitably follow from this agreement. It’s a distinction without a difference, except for the terrible precedent it sets. Let the government take the blame for gutting the funding. Many physicians want no part of it. SEAMO will not be immune to the clawbacks, and I think the promise of funding stability which is probably what sells you on the deal, is a false one. Your members should be very wary. They will be asked to do more for less compensation either way.

    • reznickr says:

      Thanks Charles. I appreciate your perspective. I do not, however, having participated in a number of phone calls in the last few weeks, anticipate any funding reductions in the next few years.

  3. Charles Scott says:

    Insufficient growth in funding is a net cut in my books. While demand marches on, real funding allowing for inflation will fall behind and wait lists will continue to lengthen. If the AFPs are being offered some sort of exemption from SOB adjustments to maintain the hard cap, that would be a troubling inequity that should be declared prospectively in the interest of transparency.

  4. Hans Hundt MD FRCSC says:

    As a Queen’s medicine alumni (2006) I would have hoped for a less bias presentation of the tentative physician service agreement.
    My constructive and honest advice to trainees would be write your usmle to keep your options open. If you can secure a job outside Ontario, do it. The future of healthcare practice is bleek in Ontario.

    • reznickr says:

      Dear Dr. Hundt,

      Thanks for your perspective. I would say, the purpose of my blog is to highlight current issues that are of importance to our circle of colleagues. In doing so, I have always found it helpful to be declarative of my views. In so doing, I always welcome alternate views, such as yours. I hope that ends up with readers getting all perspectives.

      Richard

  5. EveryDoc says:

    All this agreement “enshrines” is that MOH will no longer need to take unilateral action because OMA will do it for them.

    The OMA has failed in its duty to represent physicians and is focussed on self-preservation as an institution.

    It is time for physicians to take a stand and vote NO.

  6. Victor Tron says:

    Thanks for this Richard. I have read the agreement, thought about it, and will vote yes. The alternate is not acceptable in my mind.

    Victor (formerly from Queen’s, now at St Mikes)

  7. Kevin Leung says:

    Hi there Dr. Reznick.

    I’m afraid that as a front-line community physician, I am afronted by the government’s response of having our profession bear all the burden of cost increases. Without addressing patient demand, how can we ever hope to solve a problem through supply economics alone.

    I believe your reported salary is $416593.30 as per your 2014 salary. Your salary in 2015 was listed as $419498.32.

    How did you manage to increase your income when the government mandated a 3.5% cut to us all and asked us all to decrease billings/utilization? The cuts were already in place for the 2015 calendar year! Do you get OHIP billings on top of that amount?

    Us front-line physicians are being cut back a minimum of 3.5% (not including delisted services, restrictions, etc.) off the top line; double that in real world terms as my income is off the bottom line after office overhead of 40% – and I run a lean operation. Family doctors and new grads have been hit particularly hard so far. There are multiple fees that they have slashed off us.

    I accept that the we as a society should be working towards common goals of utilization and making hard choices. I accept that might include a pay cut or tax raise (which I thought we were already paying with the “health surtax”).

    I accept that you are an accomplished physician, a great dean of a quality school.

    It feels like you are telling everyone else that they should be thankful to accept a pay cut.

    It feels like you are telling the rest of us how great the cabbage soup is while you’re feasting filet mignon.

    I’m not sure if you are walking in our shoes.

    I do not accept that our profession should shoulder this alone.

    I will be voting NO.

    PS – I apologize if this feels personal. It’s not. I’m sure you are a great clinician and a wonderful dean.

    It’s just that from my side of the tracks, the cabbage soup doesn’t look so great and I’m not sure that we are eating from the same table.

    • reznickr says:

      Dear Dr. Leung,

      Thanks for your comments. I do support the agreement because I believe it’s critical that we move on from a very difficult situation. I do believe, that in good faith, both the OMA and the government have worked hard to break an impasse, a process requiring compromise on both sides.

      Just to state the facts, my income is not OHIP derived.

      Richard

      • Kevin Leung says:

        Hi there Dr. Reznick,

        I thank you for the reply, making the post public and for your candor.

        I wanted to offer my apologies for listing your personal salary. You have every right for it to remain semi-confidential (it is a matter of public record but interested parties can google it out themselves). You have my permission (and hope) that you will redact out the figures. As I honestly stated, this is not personal. It’s just a high charged item – my livelihood and a sense of injustice.

        I believe in appropriate remuneration for skill and I understand completely that no one “falls” into the job for dean of medicine in Canada. I know that you have worked hard and must have exceptional skills for the job. I do not for one second question the validity of your income. You will have earned it.

        But those of us that are OHIP funded are hurting. One basic difference is that I do not believe that the MOH is negotiating in good faith. There is nothing in this agreement to preclude them from running a bait and switch and walking away from the table again once we have signed.

        Of course we will exceed the budgeted amount for physician services – which physician do you know of has voluntarily reduced their workload/income since 2015 so that their colleagues won’t get clawed back? So those one time payments are just illusions.

        If we want to stay within budget, why don’t we just put an income cap on everyone again? How else will we stay within the budget target?

        But the government has out-witted and out-maneuvered us on every turn. We will have to cap ourselves with this agreement at a later date – they can let us tie the noose for ourselves later; they only need to sell us the rope for now.

        • reznickr says:

          Dear Dr. Leung,

          No need to apologize. The open forum of @DeanOnCampus is meant to encourage open dialogue and the exchange of honest differences of opinion. Thanks for expressing your perspective.

          Richard

      • Andre says:

        Your income is not OHIP derived. That’s all we need to know. My proxy will be voting no.

  8. Queen's Med 2016 says:

    Hi Dr. Leung,

    Given your interest in publicly sharing hard numbers, would you mind posting your 2014 and 2015 filed taxable income as well to complete the picture? I’m having trouble appreciating the “cabbage soup” part of your analogy in my head, and I think it would be informative to the discussion and to the public at large to know exactly how much money you make that places you on the wrong “side of the tracks”.

    – Queen’s ’16, disillusioned by the OMA

    • reznickr says:

      Dear Carl,

      Thanks for your comment. Taking about incomes is a highly charged and energy draining conversation. That’s one of the reasons I believe it’s important we move on and sign the agreement and focus on what we do best, take great care of patients, train physicians for the future, and focus on innovation and discovery.

      Richard

  9. Henry Dinsdale says:

    Dear Richard,

    Responses to your blog brought to mind my experience as Head of the Department of Medicine in the early 1990s. At that time there was a “ceiling” system that bundled base university salary and each member’s clinical earnings. If the total of salary and clinical earnings was higher than the individual’s departmentally assigned ceiling the “surplus” went back to the department budget to support academic activities. If earnings totalled less than the ceiling, the department reserve could be used to bring the individual up to his or her ceiling.

    I met every year with each member of the department individually to advise them of their ceiling, a number that would vary according to the specialty as determined by a department committee. After a few sessions of interviews, I came to realize that broadly speaking each department member fell into one of three groups, namely (1) those that were comfortable with their assigned ceiling, even if they had a sizable surplus that would be turned back to the department. That group agreed with the principle of the system and were content with their “excess” being used for academic activities. They were the largest group, (2) those that were accepting of their ceiling “as long as it was a bit more than Dr. X”,(usually a divisional colleague) or (3) the smallest group, those that were never satisfied with their ceiling, no matter how high it was.

    Payment systems will vary and some will seem more democratic than others, but I suspect those general reaction patterns will persist.

    Henry Dinsdale

    • reznickr says:

      Henry,

      As always, you still provide great lessons for all of us. I suspect the breakdown of your three groups would be the same today as when you were department head…plus ca change, plus ca la meme chose.

      Richard

  10. Behzad Etemadi says:

    Dear Dean Reznick,

    I am a graduate of the internal medicine and cardiology training program at Queen’s University. I feel you need to check your facts and present a more balanced view regarding your position on income relativity. Speaking only for my own sub-specialty, cardiology trainees have an extra year of fellowship compared to all other internal medicine sub-specialists. Your blog stated they trained for the same length of time. This is simply wrong. Cardiologists in practice and in training have call that is generally more frequent and more severe than the majority of medical specialties. You did not consider the average workload of each subspecialty in training and in practice in your analysis of relativity.

    You are entitled to your opinion on tPSA and regarding the ‘carve-outs’. However, as a Dean of my alma mater, I kindly request you present accurate information on the programs you help supervise as well as a more complete and balanced analysis of income relativity.

    With Respect,
    Behzad Etemadi

    • reznickr says:

      Thanks for your views. I was using, by way of an example, what I believe to be true, that incomes by specialty have evolved from historic realities, and discrepancies between specialties cannot always be reconciled. For example, I’m not sure we can explain why neurosurgery is one of the lower compensated surgical specialties.

      Richard

  11. Joy Hataley says:

    I do appreciate Dean Reznick that you have chosen to address this very important and timely matter in your Blog thus allowing us a forum for discussion.
    I have enjoyed your Blog and the sense of community it establishes but have never felt compelled to weigh in. Today is different……

    I am also a community physician currently associated with the Departments of Family Medicine and Anesthesia. I have a small family practice in Kingston. I provide anesthesia at HDH, KGH and LACGH as well as working shifts in ER at LACGH. Until 3 years ago I also provided obstetrical care at KGH. All this to say I believe I have a balanced sense of the impact of past and current politics on the health care of a broad sector of the patient population.

    I will tell you up front that mine will be a decided and thoughtful vote “NO”.

    I understand your prediction of short-term stabilization of our relationship with the current governing body as well as some increased predictability in physician payment. However, I fear this agreement threatens to destabilize health care in our province in the long term to the point it may result in a complete loss of Tommy Douglas’s dream.

    This is due to a failure to address 3 major factors: the current practice of dilution of our core services, lack of accountability for all players in the health care system and the intentional misrepresentation of all physicians in the province to the public as a political strategy.

    First, I do not accept the Ministry’s position that we are running out of health care dollars. It certainly appears that they are quick to fund any novelty that arises. New programs including funding for pharmacy “Med Checks”, new funding for physiotherapy, NP lead clinics, proposal’s for global pharmacare, a myriad of pilot projects, and the big kicker, the addition of another administrative layer to regionalize our provincial healthcare (a strategy incidentally that was employed in Quebec, the prairies and BC with equivocal benefit for much effort and expense resulting in only remnants of the decentralization still existing).
    This dilution of the power of health care dollars is a direct threat to the quality of care we are able to provide as well as our ability to continue to fund universal health care. I propose the Ministry define a core set of essential services which it funds to the point of excellence and all other programming be designated user choice and user pay. In a time of fiscal restraint it is neither prudent nor responsible to attempt to fund all desired programming.

    Second, this agreement undeniably asks accountability of physicians, which I believe is our responsibility. However unless all players are accountable our system will never be maximally efficient and will remain stressed, continuing to threaten it’s existence.
    If financial accountability for physicians is achieved through our agreement with the Ministry, how do we realize Ministry and User accountability?

    Third, at some level, voting “YES” legitimizes the distortion of information pertaining to physician funding and work ethic that we have all been subjected to at the hands of the Ministry. In a world in which we strive for respectful workplaces, the Ministry has failed to show leadership as they continually spin the facts for political gain.

    I am sure you can imagine I have much more to say on each of these points. Should you wish to engage in further discussion, I would be pleased to make myself available.

    • reznickr says:

      Dear Joy,

      Thanks for your comment. I do appreciate your thoughtful position and acknowledge your perspective. As mentioned in the blog, the agreement is by no means perfect, but it is a negotiated settlement by our legitimate representatives (OMA), and I personally believe that the ultimate benefit outweighs the liabilities. Thanks again for your views. They are much respected and appreciated.

  12. Dear Richard

    Joining this discussion a bit late on the day we learn the result of voting, I want to thank you for addressing this issue and explaining why you and other medical Deans supported the proposed contract.

    I am distressed by some of the comments that you have received and by today’s results. Historical evidence bolsters your position and helps to clarify the challenges ahead.

    Many of our colleagues seem unaware of the huge rise in income that the Canadian medical profession (writ large) experienced as a whole following the advent of medicare in Canada. Just a generation ago, the average income of physicians soared relative to that of average citizens. This striking rise occurred during the two-and-a-half decade period that saw the implementation of medicare across the country – 1962-1987.

    I draw your attention to my article published in the Am.J. Public Health in 2011 on the history of MD income and the impact of single payer. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110239/

    The graph –Figure 1 in the article– explains my point vividly.

    Figure 1

    Obviously, some doctors now feel hard done by – and justifiably so. But others are earning much, much more than their predecessors, and these figures show that as a whole, physician income grew enormously proportional to the average Canadian since the mid-1960s. As you noted, the discrepancies within the profession are wide, partly from the failure to adjust fees for procedures that used to take a long time, and now take only minutes.

    So you are right. Doctors–who claim to be advocates, communicators and collaborators–need to distribute their total earnings more fairly among themselves. How much more does one specialist need to earn than her colleagues (or her patients) to be happy and satisfied with the privilege of being a physician?

    By the way, the CMAJ rejected that paper without peer review. It expressed uncomfortable truths based on taxable income. Yes, gross income data misrepresents what physicians actually earn, but precise and finely grained data will come only when physicians allow their incomes (from their tax returns) to appear in the Sunshine Lists, as happens for all others who are paid directly by the taxpayer, including our basic-science colleagues in this faculty.

    The medical portion of the health-care pie and the budget need to be managed by the government who is accountable to the elected legislature. But the profession has the huge privilege and opportunity of being able to manage itself. The complaint that cutbacks in MD remuneration will affect patient care seems spurious. The argument is not about patients, it is about the division of funding among ourselves. Those who criticize “the government” or its leaders forget that the government represents the citizens who are our patients.

    So we need to get busy to draw up a new proposal and start negotiating—advocating, communicating, and collaborating–with each other. We are lucky people to live and work in Canada.

    Jacalyn Duffin

    • reznickr says:

      Dear Jackie,

      Thanks for your comments, which as usual are well thought out and articulated. You make several excellent points and I agree with your analysis.

      All my best and thanks again.

      Richard

    • Carl says:

      I distinctly remember that graph from your first-year lecture on the history of the Canadian health care system. This post should be required reading for life-long learners at all levels. Thank you, Dr. Duffin.

  13. Taranpreet Kaur says:

    I have to comment here.

    I voted NO in the agreement because it gave the government, a corrupt entity none of us should trust, the permission to determine the value of our consultations on a whim.

    But what we have failed to do as a profession is advance a fair, justifiable alternative to the government’s unreasonable demands.

    Looking closely you’ll notice that the loudest voices in the NO camp arise from the radiologists and ophthalmologists, two specialty groups with disproportionately large billings. The Ontario Association of Radiologists has mired the voting process for the PSA in a deluge of legal challenges.

    Recall that years ago, when the MOH was considering slashing fees for radiology, ophthalmology and cardiology by 10%, their legal teams intervened and instead had the ‘pain’ distributed to all physicians equally at approximately 4%, if I remember correctly. All of us were harmed to maintain their wealth generation.

    An accurate income survey for Ontario physicians from the CMA I believe pegs radiologists at a median income of approximately 650000 dollars, with the outliers raking in as much as five million.

    Cries of high overhead cause little sympathy. An exorbitant overhead of 90% on 5 million still leaves one with 500000 dollars which is not a paltry profit.

    The OMA has not stood forward and admitted that the fee schedule for disproportionately large billers needs to be updated to reflect current medical and scientific breakthroughs in delivery, timing and throughput. A cataract that took six hours to remove in 1980 takes 15 minutes to remove today, yet the billing remains the same. This is unsustainable and unjustifiable. Yet for whatever reason, the OMA has not admitted this very obvious fact, and thus cannot be taken seriously when it offers other, less attractive alternatives that damage our practices, particularly for the already-stretched-thin family doctors.

    In conclusion, for the OMA and MOH to come to an agreement, the fee schedule for high billers must be updated to bring them down to a normal level. The difference could be redistributed to the fields that suffer the most in terms of inadequate billings (which generally reflects the match rates for these specialists: family doctors, pathologists and psychiatrists)

    • reznickr says:

      Thanks for your comment. I absolutely agree that the “relativity issue” is a fundmental issue which neeeds to be tackled.

      Thanks agin,

      Richard

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