Looking for Solutions in Health Care for 2006 and Beyond

Our health care system needs to change to accommodate new demographics, new technologies and new pharmacologic advancement.

The roots of compassion and caring in health care should not change however, and it is with this in mind that the dialogue of change should be had surrounding health care.

How can we adapt to different needs that emerge as our population ages?

How can we  find sustainability in the midst of so many new advancements?

How can individuals become more empowered in serving their own health care needs?

What role does the individual have in enabling the  health care of others  beyond paying taxes?

Many questions like these need to be answered and if we are willing to look with open minds at the problems within our health care system, and beyond political posturing, then we can find new  solutions to take us further into this century. 






Incorporation Encouraged by Ontario Liberals, Now Targeted by Federal Liberals' Tax Grab

With the turmoil surrounding Federal Finance Minister Morneau's scheme of divisive tax reform that pits Canadian against Canadian and that unfairly attacks small businesses our economy depends on, business people of all walks - farmers, doctors, and corner store shop owners - are giving MPs an earful.

With hope not to attract attention, the Morneau tax plan was floated out in the middle of summer with only just over 70 days for feedback from the public. Yet, as people are returning from their summer holidays, what has been a summer of discontent is now turning into the fall of fury.

Many business owners and professionals are angry with the characterization of hard working people as tax cheats. They are angry with the Finance Minister’s and Prime Minister’s deceitful portrayal of dedicated business people as having taken advantage of "loopholes" to pad their pockets. The PM has repeated the claim many times that many business people only incorporate to avoid paying taxes.

This is insulting and it is even more agitating in the case of Ontario physicians, many of whom were encouraged to incorporate in 2004 by the McGuinty Liberal government, who counselled incorporation in lieu of fee increases.

Morneau's attempt to misconstrue his tax reforms as being “fair” is a distortion intended for political gain only. Many previous federal finance ministers of both Liberal and Conservative stripe refused to go down this path. They saw this type of tax reform as a non-starter for they understood the risks involved in starting a business and maintaining a business are substantial and business realities can change quickly. So, what was the impetus for Morneau to want to target small business owners, professionals, farm families, etc?

First, some background: The right to incorporate was granted to Ontario physicians by the provincial government in 2001 under then PC Health Minister Elizabeth Witmer. Then in 2004, the Ontario Liberals under Dalton McGuinty claimed power in Ontario. He brought in the Ontario Health Premium (after promising no new taxes). In subsequent years, under the watch of the province's then Health Minister George Smitherman, physicians were offered special tax breaks instead of higher fees. They were encouraged to incorporate and were offered the right to split income with family members.

As reported in the Globe and Mail,  George Smitherman acknowledged that "it was definitely communicated as part of a package of benefits" and "it definitely had some official stamp of approval on it". The McGuinty Liberal Government not only sold physicians on the tax advantages of incorporation, but also promoted the maternity leave benefits for women physicians and the attractiveness of using their corporations as an investment means for retirement plans.

And the untold political story is that incorporating was a real win for the provincial government. The promoted tax breaks that came with incorporation – in lieu of higher provincial fees -  had the double effect of unburdening the Ontario Liberals from raising fees to compensate physicians, thereby lessening the drain on provincial coffers. This transferred costs from provincial to the federal government.

The spike in incorporation after 2005 by Ontario physicians shows up dramatically in Figure 3, pg 735 in Policy Forum: Private Companies, Professionals, and Income Splitting-Recent Canadian Experience by Michael Wolfson and Scott Legree from 2015.

This is all to say that the Ontario Liberals are complicit in the draconian tax reforms of Federal Liberal Finance Minister Morneau. The Ontario Liberals encouraged incorporation and income splitting by family businesses, corner store and small business owners, and self-employed professionals like physicians, and now these same businesspeople are being targeted by the Federal government, portrayed as tax cheats and used as political pawns to divide Canadians. This is unethical. And Morneau baiting Canadians against Canadians, that is unconscionable.

I am pleased to see those physicians who recall the business decisions they were encouraged to make a dozen years ago, now standing up to the provocation of Federal Finance Minister Morneau.

I am also pleased that physicians and medical professionals in Ontario - along with the tens of thousands of businesspeople and their families who are directly impacted by the proposed tax changes - are reminding the public of the sleight of hand the Ontario Liberal Government has attempted to get away with.

My message to the PM and his Finance Minister – and to the Ontario Minister of Health who has failed to speak out on this matter of principle: Stop your political gamesmanship. Physicians, like all hardworking, taxpaying, small businesspeople in Ontario and across our country, deserve to be treated with respect.


Understand the Implications of the "Framework"

It is shocking to me that Ontario physicians would be encouraged by the OMA or any other group to be supporting a deal with so many MAJOR pitfalls for the profession and for Ontario patients as this one.

It is WORSE than the tPSA that was voted down not so long ago with such extraordinary upheaval.

Let me be more accurate, the pitfalls are not just potholes, they are huge sharp cliffs in this case. There is a trap being set for Ontario physicians and apparently not even our own leadership can see it. The Wynne government is using Ontario physicians as part of its campaign, offering them an election goodie right before the potential of a snap summer election which may come sooner than you think...The Wynne government, after cuts to care and causing so much upheaval, is trying to deliver Ontario MDs on a silver platter and the OMA is complicit.

I will post some of the information put out by Concerned Ontario Doctors and from DoctorsOntario after this plea to think critically about the serious and dangerous ramifications of this potential "framework" not only to physicians but to Ontario's patients.

There are really four areas of concern that jump out from this contract which are more than unsettling:

1. One of the Ontario Medical Association's own negotiators is linked through family to a very vocal activist group. This in itself should have been recognized as a potential conflict of interest. This is extremely relevant since this conflict of interest puts into question the motivation for at least several contentious aspects of this potential agreement.

2. Tying arbitration to economic conditions in Ontario is murky. Although the government will say that Ontario is doing better than most other provinces in Canada with its GDP growth, this is a relative comparison and in no way indicates an overall positive econonomic picture here.

Ontario has a huge debt burden that threatens credit ratings and as it sells off revenue generating entities like Hydro One, drives up energy costs, and makes it harder for businesses to thrive, the current government is creating greater challenges for the economy for years to come. In addition, an aging population will have an effect on productivity. This too will have an impact just as need for care begins to surge. Make no mistake, tying binding arbitration to the economy is a major flaw in this agreement.

3. "Perpetuity"--any contract that requires those involved to be bound in "perpetuity" should be looked at with a special lens. Physicians must be aware that binding arbitration that is flawed by being tied to the economy, which is a problem in itself, will now be linked to other requirements that will be in "perpetuity"....items that because of this deal cannot be renegotiated.This is a major downfall and should outweigh any positive in this agreement.

4. After four years without a contract and major cuts to patient services, and being treated disrespectfully, physicians must not accept the Wynne government's newest election ploy. The Wynne government is luring physicians and the OMA with promises of  binding arbitration but the binding arbitration described  is so badly flawed that it will result in serious ramifications for doctors and patients now and in the future.

It will result in an agreement silencing physicians without any recourse. Legal counsel has confirmed that No Strike and No Job Action becomes effective immediately upon ratification, not later. The Liberal government and the OMA negotiating team with Steven Barrett will have silenced physician voices forever thereafter.

Ontario physicians and the OMA are being duped.




Facing our Opioid Crisis and What Comes Next


May 25, 2017 - The latest news reports confirm our greatest fears: the opioid crisis has been escalating for years and the provincial government and health care officials are caught flatfooted dealing with this issue.

Fentanyl is Ottawa’s deadliest drug, a dangerous drug which is 30 – 50 times more powerful than heroin. It has been available on Ottawa streets for years and there is a growing bootleg market for the tablets. In 2015, 17 of 45 (38%) opioid-related drug overdoses had fentanyl in the victims’ bloodstream. The latest figures show there has been 319 emergency department visits to Ottawa hospitals in the first three months of 2017!

So, it is good news that Ottawa's fifteen hundred firefighters will begin carrying Naloxone kits by the end of June. They will carry the easily administered nasal spray version of the opioid antidote naloxone saving time to first response and possibly saving lives. But our leadership in this community – and at Queen’s Park and the Ministry of Health – cannot be complacent with this band aid approach.

Addressing opioid use and abuse will require new resolve as naloxone-resistant fentanyl compounds emerge and move across boarders often in tiny but deadly amounts. Here are some important things to consider.

New types of fentanyl compounds resistant to the antidote are being manufactured off shore. One such compound is Acrylfentanyl. It has surfaced in the U.S. and there are concerns that it may be making its way to Canada as experts in B.C. are warning. Acrylfentanyl requires more naloxone to reverse and it lingers longer in the body. This means that not only may multiple doses of naloxone be needed but that they may also be ineffective.

Naloxone kits are not the end solution. They are simply a tool to be used for now. Our health officials must ask themselves why Canadians are the second highest consumers of prescription opioids on a per capita basis in the world. Our government must to do a better job of anticipating “what next?”.


On physicians, prescriptions and our health care realities

It has been easy to blame Canada’s physicians for over-prescribing. Efforts to reduce and control opioid prescribing have been ongoing in Ontario for over twenty years. Despite this, according to a recent Health Quality Ontario report, 1 in 7 people filled a prescription for opioids in 2015/16 and more than 9 million opioid prescriptions were filled—the highest rate ever in Ontario. Why is this?

It is simplistic to blame physicians for over-treating pain although in some cases this may contribute. This is not to absolve physicians from responsible and safe prescribing of opioids but to suggest that there are many other factors involved in opioid use in Ontario.

Conditions in Ontario’s health care system are contributing to this increase through long wait times for care. Patients waiting for definitive treatment for months or years with painful conditions seek relief. Physicians can attempt to provide it through a variety of means starting with non-opioid interventions including physio, acupuncture, exercise therapy as well as psychological support to name just a few. However, severe pain for degenerative conditions requires more robust pain relief efforts. The risks of addiction and dependence must always be weighed with benefit in the judicious use of opioid prescribing.

Of note, the rate of opioid prescriptions filled is higher in rural parts of Ontario and there is a shift toward more potent opioids such as hydromorphone. Prescriptions for hydromorphone increased by 29 per cent in Ontario while codeine prescriptions dropped by 7 per cent.

Lack of timely access to care in rural areas can result in unintended negative consequences and solutions should address this aspect of our health care system.

The drop in prescriptions of codeine, a traditionally acceptable pain reliever, may be in part explained by increased awareness over the past several years that standard doses of codeine may be toxic for people with the CYP2D6 genotype. With more point of care testing it may be possible to more safely prescribe codeine when it is a better option based on a patient’s unique genetic profile.

Difficulties with timely access to care in Ontario also have an impact on prescribing patterns. The overcrowding in emergency rooms across Ontario can result in more opioid pills being prescribed per prescription to prevent patients from having to return to the ER for additional pain relief. Difficulties accessing primary care may result in patients seeking stronger pain relief and more of it “just in case” they need it. While it is easy to comment on these prescribing practices as having negative consequences, the reality is that the environment in which we live has an impact on behaviour.

Prescribing by dentists and dental surgeons should also be considered in efforts to address excessive opioid availability in our communities especially for our youth. Wisdom teeth extractions should not result in every young patient receiving 25 opioid pills when smaller quantities would be sufficient in many cases and when even a less potent medication may suffice.

Health officials must consider the human behaviour contributing to opioid prescribing patterns but also reflect on systemic and social factors that may be contributing to the high rates. Even if opioid prescribing patterns by physicians were ideal all the time, the reality is that illicit fentanyl has changed the landscape of opioid abuse across Canada. As non-prescription fentanyl and its analogues from thousands of illegal drug labs that operate without government oversight or regulation in foreign countries seep into Ontario, efforts to curb inappropriate opioid use must take a more comprehensive approach beyond physician prescribing patterns.


Seniors and prescription drugs

The aging of the population with associated rise in cancer cases and other diseases requiring palliation results in more need for severe pain control especially for pain related to tumour metastases. As more patients seek palliative care for comfort from diseases at the end of life, effective pain control is a necessity. It is not unusual to see cancer patients taking large doses of opioids since their tolerance to the drug increases over time and more of it is required to alleviate their suffering.

Robust palliative care includes use of potent opioid drugs but how “left-over” prescription opioid medications are handled will make a difference to the circulation of opioids in our communities. Ottawa Public Health’s “Secure Your Meds” campaign is an effort to encourage patients and their families to lock up medications and to return expired and unused drugs. It is reported that 13 per cent of Ottawa high school students used prescription drugs non-medically and two-thirds of students got them from a family member or from someone they lived with.


We must do better

There are no easy answers to this opioid crisis.  However, the government and public health officials need to redouble their efforts to address the issues surrounding the deadly trends of opioid abuse and drug overdoses. These trends cannot be tolerated. They are unacceptable. We must do better. There needs to be new urgency and a comprehensive approach to address this crisis.



Improving Hospital and Emergency Room Capacity

Of all the telltale signs of mismanagement in Ontario’s health sector by the Provincial Governments of Dalton McGuinty and Kathleen Wynne, perhaps the most glaring is the current, sorry state of Ontario’s hospital and emergency rooms. 

“Gridlock” and “Overcapacity” are terms being used on a regular basis to describe the ongoing overcrowding of hospitals and emergency departments in Ontario. Overcrowding no longer occurs just in a flu season. Hospitals in eastern Ontario are over 100% capacity for most of the year. This lack of capacity has resulted in compromised ability to provide access to care for our most vulnerable citizens at their time of need.

The root of the problem is at the top. Instead of improving access to hospital care to serve our growing population and aging seniors, the Ontario Liberal government chooses to push care to the community and mercilessly underfund those very community health services.

Budget restrictions of the last decade, along with the lack of accessible hospital beds and relative shortage of affordable long term care options, have combined to result in gridlocked hospitals and emergency departments. Today, patients are at risk and it is commonplace to have cancellations of needed elective procedures, longer waits for specialist care, and a myriad of strain and negative health effects on patients and their families.


Liberals’ Frozen Budgets Create Chaos

The last five years of austerity funding for Ontario hospitals have been particularly harsh. From 2012-2015, funding for hospital operational costs were frozen. In 2016, hospitals received a 1% increase. Hospital budgets have fallen in real dollars when inflation is considered despite a growing and aging population that requires more services not fewer. It is estimated that hospitals require a 2% increase just to meet inflation, another 2% increase to address aging and population growth, and roughly 1% increase to address higher demand. (I will not broach the subject of the rising hydro and energy costs hospitals must budget for over and above other rising costs.)

The recent Ontario budget included $518 million allocated for hospital operating costs (roughly a 3% increase while the Ontario Hospital Association was asking for more than 5%). The Liberals have called this announcement a “booster shot” but it fails to come anywhere close to addressing the effects of the lack of funding over the past decade. The “boost” would be more aptly referenced in terms of the Wynne Liberals’ re-election efforts.

To address hospital and emergency department overcrowding and their negative effects on patient care, the government must budget responsibly rather than using a stranglehold on patient services in attempts to make up for the billions of tax dollars it has misspent on the eHealth spending scandal, the ORNGE fiasco, a bulging health management bureaucracy, and the one billion dollars a month it is spending on debt servicing charges. This money could have gone a long way to solving the overcapacity problems in Ontario hospitals and emergency departments.


There is Lack of Hospital Beds

Evidence shows that minor medical issues do not contribute significantly to ER overcrowding—it is the lack of beds that causes delays in the emergency department. The lack of bed capacity both in the hospital and in the long-term care community limits the ability of the hospital to deal with admissions and important treatment of our most ill patients. If incoming patients who need admission cannot access a hospital bed, the wait times build in the emergency department delaying care and causing waits that can extend from many hours into days. On average, one patient “warehoused” in the ER denies access to approximately four patients per hour to the emergency department.

A surprising fact about how low the last decade of mismanagement has taken our health care system is that Ontario has among the fewest number of hospital beds of countries in the developed world with 2.3 beds per 1,000 people--- ranking close to the bottom behind Turkey.

As part of the 2017 budget, Ontario Liberals are proposing to spend an additional $9 Billion to support the construction of new hospital projects across the province. Older hospitals are being replaced but building new hospitals with fewer hospital beds is not a solution to improving access to care especially when care in the community continues to lag.

Ontario’s growing population and increasing numbers of seniors will need more hospital beds despite the push toward care in the community. The ER overcrowding issue is beyond the point of being managed by doing more with less. Governments must restore additional bed capacity.


Alternate Level of Care Patients with No Place to Go

Outside of the hospital, community supports and long term care options also have potential to improve capacity issues within hospitals and emergency departments.

Long term care access is critical to restoring acute care bed capacity within hospitals and to improving waits in emergency departments. Roughly 15% of all hospital beds are occupied by patients who would be better served in a setting outside of hospital.

To avoid hospital gridlock, patients who cannot return home because of cognitive or physical limitations, so-called “Alternate Level of Care” patients, must have timely and respectful transition to more appropriate care. Early in 2017 there were over 3,000 ALC patients waiting in acute care hospital beds. It is estimated that about a third of ALC patients are waiting for a long-term care home. Even for home care in Eastern Ontario alone, there are approximately 3,000 people on a waiting list.

Addressing the home care and long term care needs of seniors including ALC patients is critical to improving capacity of Ontario’s hospitals both rural and urban. For more thoughts on this, please read my previous health priorities article A Way Forward with Accessible Long term Care in Ontario.

Here is something more to think about when considering the need to fund community health services versus hospitals. Over these past years, investments in primary care transformation to community managed services have not resulted in reduced numbers of patients visiting the ER. Statistics show that visits to Ontario hospital emergency departments rose more than 5% between 2012 and 2016. Patient visits are up and the patients are sicker. So, I suggest what the Liberals have failed to properly address is that our aging population means not only more chronic disease but also more acute events such as falls and infection.


If Ontario’s health care system were a patient, it would be whisked immediately to the ER

After a decade of mismanagement under McGuinty and Wynne, the Liberal legacy is: cuts to nurses and front line care personnel, ERs empty because hospitals cannot afford to run them, elective surgeries cancelled because of lack of ER beds, sick and elderly having to endure warehousing on gurneys in hospital hallways. These commonplace signs in Ontario’s hospitals are unacceptable. Our provincial government and health minister must do better at managing the health sector - starting with Ontario’s hospitals and emergency rooms.






Resignation of the OMA Executive-What Now?

So, the Executive of the Ontario Medical Association has resigned...sort of. The Executive is resigning to sit on the Board of Directors and then will go through an electoral process. At least that is what we are told currently.

This follows after a 55% non-confidence vote in the OMA Executive at a special meeting of the OMA Council but at which other motions failed to win the required two thirds majority to pass. These other motions if they had been successful would have led to the resignations at the individual executive level.

In the face of the quasi-win by the groups challenging the OMA's representative performance, there had been murmurings of requiring the OMA to hold another General Meeting of Council to address the non-confidence vote which had initially been arrogantly passed off by the OMA as a demonstration of support. Another General Meeting of Council would have been disastrous for the OMA. It managed to avoid that through this resignation process.

However, the OMA should know that this result was not the end of this non-confidence wrangling. It is just the beginning.

The Ontario Liberal government should also understand that the advocacy efforts of front-line physicians are not going away. These physicians are not dissidents as they have been labelled by some reporters. They are simply aware that the Liberal government's cuts to front line health care and patient care in Ontario will cause more and more hardship for patients as time goes on. It's not the 1990s anymore.

Fact is that we are up against the demographic wall made even more challenging due to a sluggish economy affected by the shift in aging--a double whammy. Instead of cuts to care, government ought to be planning how to allow more care for more people. Cuts do the exact opposite of what is needed. Even if the deficit is eliminated for 2018, growing health care need will not be eliminated. The pent-up demand for care will be even greater after 2018 due to the current Liberal cuts.

Physicians are becoming more vocal. Despite government-created positions for paid "Physician Leaders" to push through the government's self-serving and short-sighted version of transformation, many physicians see the negative impact of government's efforts to balance its budget on the backs of patient services.

Physicians I know and have known care deeply about their patients. They see that health care access is becoming more and more difficult. They want to continue to provide much needed services but they may differ on how those services can best be provided. We should be able to differ on the "How" and value different perspectives and approaches and still be united in providing quality patient care.

We must ask the "What if" questions.

What if the government is not forthcoming with more and more funding for care to adequately serve citizens who are dependent on it?

What if government providing  more funding leads to higher debt and greater interest payments resulting ultimately in fewer services?

Billions of dollars going to interest payments every month are one reason why Canada has fewer physicians and hospital beds per population than most developed countries and which results in lack of timely care, delayed diagnoses, and patient hardship--even death.

A couple years ago a fellow physician told me not to worry--all that was needed was a Liberal federal government and the money would flow. They were surprised to discover that the Trudeau Liberals are no health care saviours.

So what now?

I have no doubt that some of the former OMA Executive members will be re-elected to a new Executive. That will change nothing. Some new MDs may find themselves elected and in a position to create change from within the OMA but it is external factors beyond the OMA that have brought us to this point of upheaval. It is only by addressing external  structural health care system issues BEYOND the OMA that substantive, sustainable change can occur.

I'm hoping that a new OMA Executive will understand that their most important role is not to align with the government transformation flavour of the day. Instead, it is to give critical input on how more care for more patients can be realistically achieved while supporting our human providers who deliver that very necessary care.

We need to be asking the hard questions.

As always, thank you for your continued insights and thoughtful comments.