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Ontario doctors can be at the table, or on the menu

By Santis Principal Patrick Nelson, as published in the Toronto Star

A past president of the Ontario Medical Association (OMA) used an expression regularly when talking to doctors about the need to partner with government to design a better health care system. “If you’re not at the table, you’re likely on the menu,” he used to say.

The expression couldn’t be more poignant, as members of the OMA vote this weekend on a controversial new contract with the Ontario Ministry of Health, after almost two years with no contract. Doctors have been on the government’s menu for those two years. They’ve faced unilateral cuts to fees, the introduction of new policies that aim to rein in their practice freedoms, and a big spotlight turned on those doctors billing more than a million dollars annually.

The reasons for the lengthy impasse are many, but at its core is a fundamental disagreement about how to bring certainty to the physician services budget. In its battle to contain the massive health care budget, government has been determined to flat-line the money they’re paying to doctors in the hopes of freeing up funds for other areas, like home care and mental health.

Flat-lining the physician services budget is no easy task. Most physicians still bill OHIP for each individual service they provide. A flat line on this budget means either putting a cap on the number of services being provided to patients or cutting back on individual service fees in order to absorb the costs that naturally come from population growth, growing health needs of an aging population and new doctors entering the system. The OMA has ardently opposed the notion that doctors should be held responsible for the costs of things that physicians can’t control.

At the outset of these negotiations, government took a hard line on the overall physician services budget, wanting the OMA to agree to a hard cap on the total cost once and for all. After the OMA refusal led to a lengthy non-binding mediation process, the government acted unilaterally by imposing cuts to fees and retroactively clawing back payments to make up funding shortfalls.

What followed was a public battle between doctors and the government. The OMA stepped up its public relations activities this spring, running TV and radio ads and working hard to engage the public in their campaign. Doctors were united behind the OMA in their anger at government.

After almost two years of fighting, what were the changes that led to the recent surprise deal?

Simply put, both sides gave a little to get a little. The government loosened its purse strings in return for certainty in its financial forecasts and the OMA’s help in “co-managing” the physician services budget. In return, the OMA gave in to a funding cap, but got more money for doctors and a commitment that unilateral cuts would end.

The lead-up to the vote this weekend has been the most divisive ratification process in decades. The “Yes” camp – led by the leadership of the OMA and based on the recommendation of the OMA’s Board of Directors – is hoping that doctors will recognize that the proposed contract, despite its imperfections, is better than the alternative: more cuts to fees and no seat at the table.

The “No” camp, led by the newly-formed Concerned Ontario Doctors, is hoping that they can convince doctors that the OMA erred in its consultation process and that rejecting the contract will force government to come up with a revised deal that would presumably inject even more money into physician services.

If doctors accept the advice of their elected leaders and support the contract, the OMA will have new life and a revitalized relationship with the government. Comforted by a newfound sense of financial stability, doctors can get back to doing what they do best: caring for patients.

For now, getting the contract ratified is the hardest part. But the real work will begin when the OMA and government start the difficult process of finding$200 million in permanent savings to fees. The two sides will find much greater success saving money when they roll up their sleeves and work cooperatively. Physicians on the front lines have direct insight into where efficiencies can be found.

What is less clear is what happens if doctors reject the deal. The OMA will have some soul-searching to do. Government will be reticent to resume negotiations to avoid spending money it doesn’t have. The easier path will be to return to the status quo and continue to make doctors pay for future cost overruns through fee cuts and retroactive claw-backs. This path will be even more enticing for government if doctors continue to fight amongst themselves and fail to present a united front.

The vote has the potential to continue to divide doctors and create tension within the profession. The public face the OMA presented this spring was a unified group that was frustrated with the government’s interference in their work. Now, the existence of two groups on different sides of the deal is forcing doctors to align themselves in a public and uncomfortable way. Regardless of the outcome on Sunday, the OMA will need to find a way to unite doctors over the coming months.

Not only is this fight – or an even longer one – a major distraction for government and for doctors, it has the potential to consume and distract two of the entities most responsible for creating that health care system that Ontarians rely on. Both groups need to be at the same table, or we’re all on the menu.