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. 





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The Tentative Ontario Doctors' Deal-What it means to you

Whether you are an MD, a patient, or an Ontario resident, you should know what the tentative deal between the Ontario Medical Association and the Ministry of Health means to you. In essence, this deal will not provide greater access to care, nor will it meet the growing demand for care. With the proposed co-management arrangement, the Wynne Liberals will be dictating doctors’ services to an even greater extent, making it harder for many patients to get the care they need and harder for physicians to provide it.

It is clear something had to happen as Ontario MDs have been without a contract since 2014. Of the contract details, two proposed aspects are being heralded as breakthroughs: the 2.5% “increase” for doctors and the “co-management” of the system by physicians and Ministry of Health officials.

The sudden news of a 2.5% “increase” annually for four years arriving on the coat tails of the hard-nosed negotiations by the Ministry seems too good to be true. Understanding the details is critical to understanding what this contract really provides.

The 2.5% “increase” is for total services to be provided by physicians via the “Physician Services Budget” or PBS. Just as the name implies, this is a pool of money that government provides for physician services. It does not mean that your local physician will receive a 2.5% pay increase. This does not signal that s/he will now be paid more and able to provide more patient services or that patients will have improved access.

So, what does it mean then?

The 2.5% “increase” is simply an expansion of the funding pool to be spread across more people and more services as our population ages and expands over the duration of the four-year contract. However, this falls short of the demand for physician care. It is estimated that the need for physician services rises on average by 3.1% per year. That 2.5% “increase” per year is simply a continuation of the underfunding of the health care system by the Wynne Government.

Once again, hidden behind the headlines we see that political optics drive the self-serving Liberal agenda. This deal is not about access for patients or empowering front-line providers to meet the demand for care. If it was, it would have taken a very different form. Instead, the tentative agreement is all about self-preservation, by both the Ontario Medical Association and the Ontario Liberal government. It’s about how best to sell the public (and the physicians) on the merits of a possible contract that will continue to underfund health care.

The harsh reality across Ontario has many medical clinics struggling to stay viable and hospitals being forced to cut front line workers in order to meet their budget obligations required by law.  Meeting the growing need for patient care is being made harder and harder under the Ontario Liberal government. As costs of overhead continue to rise due to flawed provincial energy policies (and now we all must brace ourselves for the introduction of the provincial carbon tax), costs of operating medical facilities will grow—whether they are hospitals or community clinics. Under the Wynne Liberals, it is harder and harder to provide medical care to a larger and aging population.

It is an understatement to state the Ontario Liberals have been undisciplined in their management of tax-payer dollars. The waste, spending scandals, and mismanagement are well-reported over many years. Ontarians have a billion dollars a month siphoned off to pay interest on the Wynne Government’s debt instead of addressing patient need and funding for patient services. Now, under this tentative contract, physicians will be co-opted into “co-managing” the health care system hand in hand with this reckless government. Is this something to be celebrated as the headlines suggest? Where is the independent physician organization that can stand up to government’s self-serving political agenda?

Co-management of Ontario’s health system is a slight of hand given the government’s ability to pay for the services Ontarians require is diminished with every monthly billion dollar interest payment. As is the Liberal tradition of naming their legislation, the new deal is being sold to physicians and to patients as “The Best Deal Ever for Everyone.” But it isn’t—far from it.

Physicians, patients, and the public in general should understand that the tentative agreement as it currently exists will not provide more access to care or meet the growing demand for care. What it will create is further rationing of care required contractually to be done by physicians. And, unfortunately, Ontario’s physicians, through their provincial association and the new “co-management” arrangement, will be co-managing our health system’s retractions.  

Ontarians and the province’s medical community are to learn more about the details of this Ministry of Health-OMA agreement in the weeks ahead. One can only hope that there is a more serious review of both the inadequate funding and proposed "co-management” arrangement. Our doctors deserve better; Ontarians deserve better.


Reader Comments (449)

For the MDs, ignoring the money issue, the issue is do you really want to become the "rationers". You have assume the role of "medical assistance in dying (MAID)", and now want to relish wit the new role of "deniers of care".

One thought your role was, "best care available".
July 13, 2016 | Unregistered CommenterMovingforwardOntario
The more one dwells on this,the more depressing it becomes.If you present in an ED,is the doctor you see obliged to the government,to assure best care is rationed, and death offered?

One wants one's doctor to preserve the best reasonable life.Not to deny good care, because of the need to "comanage" cost.
July 13, 2016 | Unregistered CommenterMovingforwardOntario
Realist, your introduction was great....just about says it all.

As I recall you were writing a book on health care....you must be tearing pages out as the rapidly changing circumstances in our health care overtake us all.

Can't wait to see who is right where the vote is concerned ...mfo or Skyvington?
July 13, 2016 | Unregistered CommenterAndris
To All Ontario Doctors: July 13, 2016
We vote ‘NO’!
DoctorsOntario urges members to reject OMA-MOHLTC ‘secret’ deal

“We must always take sides. Neutrality helps the oppressor, never the victim.
Silence encourages the tormentor, never the tormented.”

—Elie Wiesel, Holocaust survivor and Nobel Peace Prize winner

Dear Colleagues,

We have now had time to sufficiently digest the new Physician Services Agreement, which was negotiated in secret by the Ontario Medical Association and the Ministry of Health and Long-Term Care during the past two weeks.

After careful consideration, and full acknowledgement of what a ‘NO’ vote would mean, the Board of DoctorsOntario has unanimously reached the conclusion that for the good of Ontario’s doctors and our patients, we recommend you vote ‘NO’.

While there are a number of reasons to reject this ‘sleazy’ deal that appears to have been negotiated on the back of a napkin, and that the OMA Board gave its approval of by signing the agreement on the hood of a car in a dark alley, we’ve narrowed it down to the following five reasons:

1. The new OMA President, Dr. Virginia Walley, promised the OMA wouldn’t resume negotiations without the government first agreeing to binding arbitration as a condition for heading back to the table. Dr. Walley broke this promise, not only to her members but also to OMA Council, who made it clear that without binding arbitration there would be no deal.

2. While the OMA and the government will spin this to the media that Ontario’s doctors are receiving a 10% pay raise over the next four years, the truth is, this new agreement actually makes permanent the 15% cuts to our fees the government unilaterally imposed on doctors during the past two-plus years we’ve been without a contract.

3. By agreeing to ‘co-manage’ the health-care system with the government, the OMA has now put every doctor in the province in the position of helping the government ration care, thereby forcing us to throw our patients ‘under the bus’ in order to help the government save money, just so they can win the next election.

4. Should the province find it’s spent too much money on physician services at the end of each fiscal year, this agreement will make Ontario’s doctors solely responsible for that over-run, which will likely result in clawbacks as high as 10% to 20%.

5. By signing this agreement, and urging Ontario’s doctors to support it, the OMA has placed its own interests (i.e. the $50-$60 million per year in mandatory dues it takes from your pockets via the Rand formula) above those of its members and our patients.

For these reasons and more, we urge you to reject this offer and vote ‘NO’. We also encourage you to make sure you let the OMA know how you feel by exercising your franchise and taking part in the upcoming referendum.

We need a huge voter turnout to be successful, and will likely require at least a 60% ‘NO’ vote in order to ensure the OMA doesn’t ignore the will of its members and accept the deal anyway. Remember, this is a ‘non-binding’ referendum. It’s only meant to ‘advise’ the OMA Board. They can choose to ignore the results.

Should we succeed in voting down this latest train wreck of an agreement, however, we will demand OMA President Walley and Minister of Health Hoskins do the right thing and resign. We will also petition the OMA stop forcing us to pay dues and hold a new referendum, asking Ontario’s doctors who they’d prefer to have as their representative.

In the meantime, we need your help to get our message out to as many of your colleagues as possible before voting starts on July 27, 2016.

It costs $250 to join DoctorsOntario. We think that's a small price to pay in order to have someone stand up on your behalf so our collective voices can be heard.

We can do this. But it's up to you to take that first step.

Please fax (416-412-7297 or 844-495-4349) or mail (900-45 Sheppard Avenue East, Toronto, Ontario, M2N 5W9) the attached membership form back to us as soon as possible. Or if you prefer, you can also join online by visiting our website (doctorsontario.ca).

Here's the link: http://www.doctorsontario.ca/docson/?page_id=72.

If you have any questions, please don't hesitate to contact Stephen Skyvington at (416) 859-2239 or at politrain@sympatico.ca.

DoctorsOntario. Together, we’re stronger.


Douglas Mark, MD, Interim President
and the Board of DoctorsOntario

P.S. Even if your 2016 membership renewal isn't due for another couple of months, NOW is when your support will do the most good. If you already plan to renew later this year, please consider visiting our website at www.doctorsontario.ca and renewing your membership now, so we can be active in the public forum during the next few months.
July 13, 2016 | Unregistered CommenterStephen Skyvington
Skyvington is always right.

Except when dealing with my wife.

Perhaps we should unleash my sweetie on the OMA and MOHLTC.

Or at the very least, Jack the Russell Terrorist.

Still meaner than a junk yard dog at age 13 and a half and dying of cancer!
July 13, 2016 | Unregistered CommenterStephen Skyvington

You are the best.

I bow down to you as a writer.

Can I help you get your analysis into a major newspaper?

Let me know if I can be of assistance.

This has to make it's way out of this chat room and into the bigger world at large.


July 13, 2016 | Unregistered CommenterStephen Skyvington
Thank you for your thoughtful analysis. Well laid out.
July 13, 2016 | Unregistered CommenterRegina du Toit
Well said. Thanks
July 13, 2016 | Unregistered CommenterRegina du Toit
"However, the TPSA, obtained by QP Briefing and other media outlets, also contains a memorandum of understanding that would strip the OMA’s Charter challenge regarding bargaining rights of much of its substance.
Concerned Ontario Doctors, an activist group of doctors that has organized protests against the underfunding of health care, opposes the agreement. It is circulating a legal analysis that’s highly critical of the agreement, and argues that, if the deal is ratified, it will result in the OMA losing its court challenge. That legal analysis, obtained by QP Briefing, shows the OMA and Ministry of Health’s “spin in the media,” said one of the group’s co-leaders, Dr. Kulvinder Gill."

Laxk of transparency breeds mistrust. Lack of trust leads to many co sequences.
July 13, 2016 | Unregistered CommenterRealist
If this agreement goes through, government will have achieved its goal of keeping MDs so internally focussed fighting amongst themselves that they will be blind to what is happening externally with serious effects to medical care and patients.
July 14, 2016 | Unregistered CommenterRealist
Suppose the tentative agreement is ratified. How do we manage our conflict as advocates for the patient? And given the financial incentive to balance the budget within the arrangement, are we now responsible for shortages?

From the CMPA Sept 2012

"There are very few areas of healthcare that are not
confronted with some form of fiscal restraint. As
demands for healthcare services continue to
outpace resources in some areas, physicians are
tasked with managinq their wait-time lists and, on
occasion, with prioritizing patient procedures.
These decisions carry medico-legal implications
and mitigating these risks will benefit physicians
and patients.

Physicians have a duty of care to patients. This
duty may extend to resource allocation, and
ensuring patient care is not compromised. ln an
environment of constrained resources, or when
faced with an unexpected shortage of medication
or supplies, physicians should engage with
hospital officials or health authorities to request
resources to meet patient needs."
July 14, 2016 | Unregistered Commentereklimek
By ratifying the proposed agreement, MDs acquire a new role. Rationers.
July 14, 2016 | Unregistered CommenterMovingforwardOntario
In case you missed it,...

"physicians should engage with hospital officials or health authorities to request resources to meet patient needs"


seek economies and efficiencies for $100 million or " create further rationing of care required contractually to be done by physicians"

I need a shower. I feel dirty just reading this.
July 14, 2016 | Unregistered Commentereklimek
No process defined for "co-management" by the OMA/MDs and MOH.

I suppose even if there was a defined process it wouldn't be followed anyway as evidenced by the "exploratory" talks between the OMA and the MOHLTC instead of real negotiations.

If the negotiation team wasn't used, why not?

If the "exploratory" talks took the place of the process defined for negotiations then WHY? Who gave the ok for this?

Who do OMA members hold responsible for this negotiations deke?
The money will win out. In the short term, this leaves more money in the pockets of the frontline physicians, as they absorb the pressures of more frontline rationing.
July 14, 2016 | Unregistered CommenterMovingforwardOntario
Don't see your logic mfO.
This deal would create even more uncertainty as swaths of services are made precarious.
How does an MD or groups of MDs plan investment in their offices or clinics without knowing what services will exist with funding?

How do patients access care they "need" when co-management is cutting funding to what they need?
Or will the flavour of the day be expected to meet some standardized concept of what a patient is and what their needs are.

The idea that this "deal" will bring stability is based in fanciful thinking.
Conflict of Interest is expanding faster and faster.
The deal serves government optics and the OMA Board fiduciary duty to OMA existence.

More and more rationing, even if you call it "co-management", does not put patients first.
July 14, 2016 | Unregistered CommenterRealist
Who defines patient need?
In a "Patients First" scenario, shouldn't the patient define need?
If not, how is it "Patients First"?

With the current deal, it will be MDs who are required to comanage-ration care to patients despite patient need.

Physicians will be incented by government to reduce medical services and deny care. It's bizarre.

Fascinating how ethics can be distorted and MDs can be manipulated by government.
July 14, 2016 | Unregistered CommenterMerrilee Fullerton

If the MDs want to maintain control, they will need to sign. This deal doesn't stabilize patient care, it futher destabilises it. It stablities MDs incomes from further unknown reductions. They will however be, further reductions.
July 14, 2016 | Unregistered CommenterMovingforwardOntario
Control of what? Rationing?
Yes. They will control the rationing.
July 14, 2016 | Unregistered CommenterMovingforwardOntario
This is sounding worse and worse for patients. MDs will be conflicted. Who to support/save? The patient or the government agenda?
July 14, 2016 | Unregistered CommenterMerrilee Fullerton
Any comments?
The system is not built for patients.
July 14, 2016 | Unregistered CommenterMovingforwardOntario
Dr. F I think you said it all in your recent post: this literally spits in the face of the government's "Patients First" agenda.

This is an excellent example of the old 'suck and blow' - you cannot do both at once.

Something is going to give.
July 14, 2016 | Unregistered CommenterExecutive Lead Blogger
Thanks ELB.

Central has to ration. Will the physicians buy in,and take the hit for the rationing (which central will blame on the physicians as co-managers).One can almost hear the spin - The physicians reviewed and firmly supported this needed transformation in the services.

This a central desired deal - fixes the budget,drives down MDs incomes, and puts the responsibility for rationing on the MDs. A win,win, win for central.

The vote will be yes.Otherwise, central will spin that the doctors turned down a n assured 2.5% increase in their revenues. The spin is alreday prepared.

The OMA walked into a trap,and it has been sprung.

The young are done. They don't get the change.
July 14, 2016 | Unregistered CommenterMovingforwardOntario
I warned the OMA several years ago. It fell on deaf ears.
Alignment is not Leadership.

We need friction to create the best solutions.

We need a resilient system not a brittle system made more fragile with more and more rationing.

mfO, I believe you are correct.The idealism of many MDs will eventually fade to realism but it will take more pain. No, they don't get it.
The danger of an 80% yes vote is that the ministry might interpret it as that their deal was too good....that there was more room to tighten even further.

Bad as this agreement is for MDs it is even worse for patients....unfortunately they are completely unaware of the significance of the deal.
July 14, 2016 | Unregistered CommenterAndris
Cuts to medical school...Here we go again.
from Nadia Alam @OMSAofficial Confirmed: 200 Med Student spots under threat w current PSA from OMA insider. This is why #IVoteNo
The deal is dead

Dear Medical Colleagues:
As a member of the Negotiations Advisory Committee who sat on the “negotiations second table”, I urge all members to vote NO in the upcoming referendum.
My position on this OMA advisory group gave me an inside perspective of process, transparency, and outcome that I feel duty bound to report to you, my colleagues.
Council gave clear direction to secure binding arbitration prior to a return to negotiations. This was not respected by the OMA leadership despite a clearly stated commitment to this principle.
The Negotiations Advisory Committee was not consulted in any meaningful way. The PSA was presented to us as a finished document only hours before it was presented to the Board. We as a group representing the interests of the profession had NO input into the document.
2. Transparency
Despite numerous direct requests as to the status of negotiations, I was told that there were no ongoing talks. My last query came after bumping into Dr. Bell, the Deputy Minister of Health at the OMA offices. Once again, I was assured that there were no ongoing talks. It was as if the American tanks were rolling by in the background as the Iraqi Minister of Information declared that there were no Americans in Baghdad.
Another point of transparency is the language of the document. Much of it is vague and refers to future committees with promises of consultation. Given my experience on the Negotiations Advisory Committee, I have no confidence about the degree of input any doctor will have outside of those in the backrooms of the OMA.
To that point are issues already discussed and now openly denied. I was on the calls when significant cuts to new physicians entering the Ontario workforce and to medical school spots were discussed as part of the PSA presentation, yet it appears nowhere in the document except in the most vague language. A precise number was discussed as alluded to by Dr. Nadia Alam. How can we be sure that other major system changes are not also hiding in what is more of a pamphlet than a contract? Six-page contracts are between, friends, family, and fools, not between governments and professional associations.
3. Outcome
Make no mistake that this is a hard cap. Based on growth estimates, THERE WILL BE CLAWBACKS.
This is not a 2.5% raise. The increase refers to an increase in total funds available to a fixed pool of money. This will be instantly consumed by new physicians and increased utilization by our aging and growing population.
This is a massive cut. There will be a minimum of $200,000,000 cut from the physician pool. This is a permanent cut that will disadvantage all groups. This is in addition to the permanent cut that all physicians have experienced since 2012. It is also uncertain where this money will come from. How will this be titrated to ensure that the cuts don’t become $300,000,000?
The PSA does not address many of the major issues, including relativity, that we expected a binding arbitration process to deal with in a fair and transparent manner. There are no specifics in the PSA that any doctor can reasonably hold either the OMA or government accountable to.
We have been disparaged by a government in its dying days. We have been witness to an unprecedented increase in demands for our services and unprecedented decay in our healthcare system. Wait lists grow. Patients go untreated. Clinics close.
The PSA breaches process, lacks transparency, and has negative outcomes for both physicians and our patient. For these reasons, I ask you all to vote NO!
David Jacobs, MD, FRCPC
July 14, 2016 | Unregistered CommenterNimble
I was just about to post that!
July 14, 2016 | Unregistered CommenterMerrilee Fullerton
Thanks Nimble!
July 15, 2016 | Unregistered CommenterMerrilee Fullerton
Own the rationing, own the hard cap. Take the money. Interesting how backroom deals still occur in the "era" of transparency. Now hearing, just another backroom deal.
July 15, 2016 | Unregistered CommenterMovingforwardOntario
Sadly there is a sense of betrayal from OMA's hierarchy.

A sense that the Negotiations Advisory Committee was betrayed....Council was betrayed...the membership was betrayed...

The Negotiations Advisory Committee should be elevated.
July 15, 2016 | Unregistered CommenterAndris
If true, that the OMA's negogiation advisory committee was bypassed, clearly the OMA has issues about supporting its members. This is getting worse day by day.
July 15, 2016 | Unregistered CommenterMovingforwardOntario
This is an insurance contract for the government. Government is guaranteed the budget is capped and physicians accept the personal indemnification for cost over runs. Even better the OMA will assist in cutting the cost of service delivery by "modernizing" the schedule of benefits. In exchange the doctors have no immunity for the consequences of active rationing and no ceiling for cost overruns.
July 15, 2016 | Unregistered Commentereklimek
This is a great deal for central. Fixed budget, cost overruns to be covered, and the doctors take the accountability for health care utilization. If they are not frustrated now, they will be leaving in droves over this deal.
July 15, 2016 | Unregistered CommenterMovingforwardOntario
I do not know every fact in this case. Let's be careful about personal accusations wrt lies etc.
Thanks to all posters.
July 15, 2016 | Unregistered CommenterMerrilee Fullerton
I have edited a post to a degree that I am more comfortable with.
Please understand that we must be very careful.
Thank you.
Realist, you are an excellent editor.....the bottom line, the guilty should stand aside and the innocent elevated.
July 15, 2016 | Unregistered CommenterAndris
Clearly, the OMA has some internal issues it needs to sort through, but concentrating on the proposal itself, why would the doctors sign a deal, restricting the available resources, making them responsible for overages, allowing pent up demand to drive accessibility, and them getting all the blame?
July 15, 2016 | Unregistered CommenterMovingforwardOntario
Thanks Andris.
"why would the doctors sign a deal, restricting the available resources, making them responsible for overages, allowing pent up demand to drive accessibility, and them getting all the blame? "-mfO

Because there are a variety of groups who will perceive something in it or them. They do not consider the bigger picture or the ethics involved or where it leads.

The young MDs will see an opportunity to get into the better paying FHOs and FHTs.
The naive ones can't see the repercussions to access or choose not to.
Some don't care and just want out in a few years--can't cope with further conflict.
Some have been indoctrinated into believing that the government will take care of them.

Many physician leaders have paid positions with government with significant income through this mechanism or are paid for their work on OMA committees. They will still get that funding. They see alignment as a continued pot of money.

Of course, some believe that alignment to the government agenda is noble and necessary and that anyone who disagrees should be labelled with some kind of negative term.

Others just don't want to be critical. They see conflict as negative. Reality is that conflict is absolutely necessary for the best solutions to be created.

The vote will be "Yes".

We did have a similar situation about 10 years ago with what was called the "Drug Bribe". Government was offering a significant sum if MDs could restrict drug use by a certain sum. Can't recall the exact number. This drew a "No" vote from the membership.

But 10 years later, I do not see the same willingness to be as principled. Too bad.

The Vote should be "No" if MDs truly understood what is happening.

The OMA Board has a fiduciary duty to the OMA itself. Priority is the continued existence of the OMA not the members.
That is a tough conflict for a representative body that is also supposed to be a negotiating body and leads to all kinds of issues. The OMA depends on government for its very existence. It will ALWAYS align with government because of the fiduciary duty.
and I should add, that the OMA has been strategic in its governance transformation and structural changes to create enough "Physician Leaders" in paid positions tht it can sway sufficient pockets for support of these kinds of deals.

Interesting isn't it.

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