justanoldcountrydoctor

Health Care in the Ontario Election: Lots of Sound Bites, No Strong Policy

Last week, I had the opportunity to talk to Greg Brady, on his 640 am radio show, Toronto Today. The episode is on Spotify and, if you are in need of a great cure for insomnia, you can catch me starting from about the 19:30 mark:

Six and half minutes is not enough time to discuss health care in Ontario. Neither is a 1,000 word blog, but that won’t stop me from trying to expand on some of my thoughts.

The first and most prevalent thought I have is disappointment in ALL of the political parties for how they have addressed health care so far. Everyone on the front lines of health care has known for a least a decade that we need bold transformative changes in how health care is run and delivered in Ontario. Probably all of Canada.

And yet, the four would be Premiers all fail to outline a plan for such transformation. Instead, they have all resorted to that age old political vote grabbing stunt of saying “Let’s just throw more money at the problem” without actually reminding you that the money is going to come from YOUR pockets and is going to be, frankly, poorly spent.

The Conservatives hired Dr. Jane Philpott to oversee a spend of $1.8 billion in a plan to connect everyone with a “primary care provider” in the next few years. As I’ve written before, that plan, through no fault of Dr. Philpott, who I have a great deal of respect for, is doomed to failure.

The Conservatives did not start the downfall of family practice in Ontario (that was the miserable Eric Hoskins/Bob Bell duo during the wretched Kathleen Wynne years). But they sure haven’t done enough to fix the mess they inherited. Economist Boris Kralj, PhD, recently showed in the Medical Post that Ontario lost 238 family physicians in 2022/23 – the biggest loss of any province.

The Liberals for their part want to spend 3.1 Billion dollars. At least they promise everyone a family doctor and not a “provider” (and yes, there IS a difference, a BIG one between the two). However, their plan amounts to spending $1.3 billion more than the Conservatives. Spending more without changing things seems naive at best.

The NDP promise to recruit 3,500 more doctors, promise family doctors for everyone, cut red tape, establish a “Northern Command Centre” for health care (that’s actually a good idea) – all for the low low price of only $4.1 Billion dollars, a billion more than the Liberals.

The Green Party promises are actually the most detailed I could see, including lots of goodies, like recruiting more doctors, building more nursing homes, increasing nursing student spots, hiring 6,800 personal support workers and more. There is only one thing missing from the proposal (at least on their website). How much this will all cost YOU, the taxpayer.

Ontario spends $81 billion in taxpayers dollars on health care. Rather than look to see if that money is being spent wisely, and looking to transform health care, all the political parties are simply giving us sound bites. They promise to spend $83-$85 billion on the same failing system, without looking at changing things. Because spending more inefficiently will surely fix things.

OK Smart Guy – What do YOU Think Should Be Done?

Glad you asked dear reader, glad you asked. At an absolute minimum I’m looking for a party that has the political courage and wisdom to do the following three things.

First, A complete hiring freeze on all bureaucrats in health care, including not replacing those who retire, or leave for other reasons.

Currently Ontario has 10 times as many health care bureaucrats per capita as Germany. That’s too many. This means that any meaningful suggestions for change have to go through so many bureaucrats that the whole system is plagued with paralysis by analysis. Time to trim the fat.

Second, ensuring one, and only one, patient app that every resident of Ontario has, which will have access to all their health care data, and allow them to share this with the health care specialist or facility of their choice

Ontario is a digital health nightmare. Your health information often times can’t be shared if you go from one hospital to another, or one doctor to another. There are multiple inefficiencies and unnecessary repeat tests because of this mess and it should never have been allowed to occur.

It would be too expensive and too time consuming to force every health care facility to use the same electronic medical records system. What can be done however, is to force all the systems to integrate with ONE patient app. This will ensure a common standard, and moreover will allow a hospital you happen to be in, to access your out patient information (with your permission) which just doesn’t happen now.

Third, ensuring strong family physician representation at the board level of the Ontario Health Teams.

There is a lot of talk about the benefits of team based care. As someone who views one of his proudest achievements to be the founding Chair of the Georgian Bay Family Health Team, I would agree with this. The current plan for Ontario Health Teams does have merit. BUT, in order for these teams to succeed, they need strong family physician leadership at the GOVERNANCE level. That’s right, you need to put doctors (and more than just a token one) on the Boards of these teams and ensure the teams are led by them – for best clinical outcomes. I don’t see that in the plans.

Final Thoughts

My usual followers will know that I generally vote on the conservative side of the political spectrum (de gustibus non est disputandum). However, I’ve been frankly disappointed that the current Conservative government has been anything but conservative. Sadly, the other parties are really not offering the kind of transformative solutions we need in health care either. I firmly believe that we should all vote in elections, and I certainly will, but for now, call me an undecided old country doctor.

Re-Post: Hoskins Won’t Survive The Mess He’s Made Of Ontario Health Care

NB. The following is a re-print of a blog I wrote for the Huffington Post, published originally on July 10, 2017. It’s being republished here mostly for my own record keeping.

Recently, one of my medical school classmates (now a cardiologist) was awarded the Society of Thoracic Surgeons top rating for patient care outcomes. A great honour for her, and well deserved. Unfortunately for the rest of us, she practices in South Dakota, one of the many physicians who left Ontario during the protracted battles with Ontario Governments in the 1990s.

Back then, as I mentioned in my first blog, many health ministers continued to insist that physicians in Ontario were the highest paid in all of North America. Yet we lost physicians in droves. The reality is that while physicians wanted to be paid a fair wage (who doesn’t?), what they really wanted was to have a say in how health care was delivered and be able to advocate for their patients.

So when the then Ontario government of Bob “Super Elite” Rae made unilateral decisions about health care, physicians left for jurisdictions where they were paid less (according to then Health Ministers Frances Lankin and Ruth Grier). But at least they had a say in how health care was delivered.

I mention this because it appears that current Ontario Health Minister “Unilateral Eric”Hoskins and his Deputy Health Minister Bob Bell have been unable to grasp this fundamental concept. Hoskins (and, to a lesser extent, Bell) have based their whole political strategy on portraying the dispute in the media as one of doctors wanting endless sums of money. If only the doctors would take less, the health-care system would improve. They appear unable to grasp the fact that doctors VALUE the ability to advocate for their patients and contribute to health care decision making.

From a purely political point of view, the strategy had some benefits for Hoskins and Bell. They were able to pass both the Patients First Act and the Protecting Patients Act. There was muted public response because they were able to portray physician opposition to these Acts as physicians protecting their incomes. The fact that the Patients First Act does nothing but increase bureaucracy and that the Protecting Patients Act actually violates Charter Rights of all health-care workers, and will likely be the focus of a Charter challenge, meant nothing to Hoskins and Bell. Good PR in the face of mounting, repeated, ongoing evidence of the collapsing health-care system was all they wanted.

Surely the Hoskins/Bell duo thought their troubles were behind them when the OMA ratified the BA framework. Not so.

It must therefore have come as a shock to Hoskins and Bell when, after giving Physicians Binding Arbitration (BA), physicians actually increased their attacks on the Liberal Government mismanagement of the health-care system. Now to be clear, giving BA is not the same as awarding a contract. The Ontario Medical Association still has to negotiate a contract for physicians.

But central to Hoskins and Bell’s way of thinking was that all physicians cared about is money. And the spectre of BA does force both parties to negotiate fairly.

Also in fairness, it’s pretty evident that Hoskins himself didn’t want to give physicians BA. Not only did he deride physicians for asking for it and fight it in cabinet, but when the Ontario government sent a press release indicating they want to return to negotiations with the OMA with the first order of business being to develop a BA framework, it came from the premier’s office, not Hoskins’ office.

Regardless, surely the Hoskins/Bell duo thought their troubles were behind them when the OMA ratified the BA framework. Not so.

Wait Time Series: Cataract surgery patients are finding themselves on longer #waitlists as funding fails to meet demand in Ontario. #ONpoli pic.twitter.com/Nh466RND1k

— Ont. Medical Assoc. (@OntariosDoctors) July 5, 2017

Since then, the OMA has become even more aggressive in its attacks on the Liberals. Have a look at their Twitter feed where they attack wait times for cataract surgery and joint replacement surgery.

Also, a grassroots group of doctors have now begun tweeting multiple barbs at the Liberals. Saying that doctors are required to put the pieces of health care together, they’ve used inventive and creative images to drive home the point that the Liberals don’t know what they are doing in health care.

Finally, OMA President Dr. Shawn Whatley openly wrote in his blog that physicians need to be champions, not doormats, and fight for health care for their patients. Surely poor Hoskins and Bell never expected this when they actually gave the OMA a path to a fair contract via BA. Goes to show you just how much they misjudged physicians’ desire to advocate for their patients and for a fair health-care system for all of us.

Hoskins and Bell are now, as the old joke goes, officially “post turtles.” This joke compares a (usually inept) politician to a turtle balancing on a fence post. You know he didn’t get there by himself, he doesn’t belong there, he doesn’t know what to do while he’s up there, and you just want to help the poor thing get off the post.

Ontario Premier Kathleen Wynne basically has little choice now. Hoskins and Bell are just too easy targets for the mess that they’ve made of health care and the way they’ve badly misread physicians passion for protecting their patients. The differences are irreconcilable.

Hoskins is the easier of the two to deal with. Wynne needs to shuffle her cabinet and move Hoskins on to minister of sanitation or something.

Bell, being an employee, has certain rights and can’t just be fired. However, the anonymous surveys done by Quantum Transformation Technologies indicating how unhappy his own bureaucrats are should be enough evidence for Wynne to order a formal administrative review of the senior management team at the ministry of health. Maybe they can be salvaged with administrative coaching.

But what’s clear is that as the health system fails, Wynne needs front line physicians to help put its pieces back together. Wynne needs to regain their trust. The way to do that is to bring tangible change to the leadership of the ministry of health.

Stories From a Failing Health Care System

By now we’ve all seen multiple new stories of the failing health system in Ontario. It would not be inaccurate to suggest that our health care is now in a permanent state of crisis. But most of these stories deal in numbers that seem almost abstract. For example 2.5 million without a family doctor. 30 weeks to see a specialist from the time of a referral from your family doctor. Hospitals at 134% capacity.

They all are awful stories -but what does this mean on a human level? Do these numbers actually tell of the suffering of patients on a human level? Today, let’s look at what some of my patients (all anonymized) are going through.

Patient A

Patient A had a persistent cough for a number of months despite my attempts to treat them with the usual therapies (puffers, prednisone, antibiotics and a Hail Mary pass of trying to see if acid suppressants would help). I recently attended a Continuing Medical Education seminar on Interstitial Lung Disease (ILD). ILD is a bit of miserable new condition that is very difficult to diagnose and even more difficult to treat.

I ordered a chest xray which was done on July 29 – and concern was raised that this might be the diagnosis. A high resolution CT scan (gold standard for diagnosing ILD) was ordered by myself to follow up on this – and this could not be done until Sep 10. This unfortunately confirmed ILD was the correct diagnosis.

One of the things that was evident from the conference I took is that time to see a specialist for ILD was paramount. There is no cure for this illness. But timely treatment can salvage lung tissue and improve quality of life. A referral was immediately made to a Respirologist.

Six days later, I got a note from the first Respirologist, who refused the consult. Basically he was too busy and asked me to find someone else. A second Respirologist was sent a referral on September 16. On October 25, I got a reply, also refusing the consult. A third referral was sent and the patient was finally seen on Jan 5. But for five months, their lung tissue continued to deteriorate and worsen.

Patient B

Patient B is 8 years old. Has had a number of viral illnesses, mostly upper respiratory in nature. But all of them have been associated with wheezing. She has responded nicely to puffers, and I wanted her to get assessed for asthma and get some asthma teaching for her parents – help them understand what things to avoid and so on.

I referred them to the excellent paediatrics group in Barrie (our local referral centre). Unfortunately, I got the following message from their staff (and I understand why, but it’s heartbreaking):

“Due to large influx of referrals Barrie Pediatrics is booking into late fall 2025 – early winter 2026.”

This is of course, not their fault. But for children with health issues, many of whom will deteriorate without specialist care, this is devastating.

Patient C

I saw them in my office on February 8, 2023 with what clearly seemed to be sciatica. Because there were no red flags – I tried anti-inflammatories and physiotherapy first. After a month or so this did not improve, so I ordered an MRI. This was not done until AUGUST of 2023 and it confirmed that may patient had a left L5/S1 disc herniation in his spine, which was causing his sciatica.

Now six months with no relief of pain with conservative measures, the standard would be to refer him to a neurosurgeon for assessment. Which was done. Unfortunately, we got no word back from the neurosurgeon. In fact in September and October of 2023 – the patient called my office to check to ensure that the referral had been sent.

By June of 2024 (!) he was in so much pain that I wound up referring him to a pain clinic for control of his back issue. In November of 2024 (!) he finally saw the surgeon who agreed with my diagnosis, and that my patient was a good candidate for surgery. But by now the MRI was felt to be too old – and – another one was ordered (still not done yet). And of course. my patient continues to be in chronic daily pain.

I could tell many more stories. I could probably write two dozen blogs just listing the difficulties I have had accessing psychiatric care for my patients. But by now I hope you get the point. Behind each number you may read about in the news (12 hour wait time in Emergency! 9 months to get diagnostic testing! 118% average overcapacity in hospitals!) – there are a large number of real human beings. People who are in constant pain and whose health is deteriorating faster and more than it should.

Hopefully you can spare a thought for the individual patients and what they are going through as our health system continues to collapse.

OMA Board Betrays Members By Latest Action and This Changes My Vote

OMA Elections period has opened. A chance for members to have a say in how the organization is run and what strategic direction it should take .

After my last couple of missives on OMA Elections, I was going to leave this alone and see what transpired. However, when I went to vote, I noticed a curious thing. None of the non-physician Board candidates were up for re-election. This sent up a red flag. There are three non-physician Board Directors – and every year, as members we have to vote for either one or two of them (the terms are staggered).

If one looks at the OMA website, this little nugget is hidden away in the depths of the Elections FAQ page, a page that I suspect extremely few members would access, much less be aware of:

“…In the case where the director holds a non-physician position and is interested in serving an additional term, the director would be presented to the membership as a re-appointed director…”

There are some conditions the sitting non-Physician Board Directors have to meet, but the blunt reality is that the OMA has taken away the right and ability of Members to vote for these 3 positions if those Directors want another term. This represents 27% of the Board (11 positions total) – which is frankly a large block of votes and can sway a close vote at the Board.

Worse is the vagueness of what is written for IF there was a vacancy. There are a number of requirements for running for the Board for these candidates – all of which are appropriate – however the very last sentence simply states:

“Shortlisted candidates will go through detailed vetting by Promeus Inc., including reference checks, police record checks and social media checks.”

Nowhere does it clearly state that in the event of a vacancy – there would be an election for the non-physician Board Directors. Perhaps this is still the case – however not mentioning it definitively in writing suggests the possibility that this may change.

I was on the OMA board when the governance changes took effect. I supported the overall thrust of them (still do). One of the issues when discussing non-Physician Board Directors was a concern expressed that the type of candidates that might help the OMA out would not want to run in an election. Apparently, these candidates would be “used” to being recruited and simply expected to be given a job.

I personally thought that was silly. If you’re a strong person, have a sense of self-worth, and are confident in yourself, you should be willing to run in an election. You might lose but that’s life (I’ve lost elections). But the personal integrity to run is essential. If the OMA is to represent members, then the members must have the right to vote for all Board Directors. Up until now, that’s what was happening.

Perhaps some non-Physician Directors are thinking “if I was on another board, they’d simply appoint me, and I wouldn’t have to take a chance on losing and ruining my precious resume.” But those are NOT Boards of representative organizations like the OMA

As far as I’m concerned, worrying about offending the egos of some candidates is not enough reason to take away the rights of members to choose ALL of their Board Directors. How much longer will it be before these 3 non-Physician Board candidates will simply be chosen by a process set up by the OMA without any input from the part of members? In case you think it unlikely, that is actually what was initially proposed by the governance consultants in 2019, until we shot it down.

Worse this change was made without an open discussion with the membership. The OMA should have presented arguments for this change to the members in an open, transparent manner. By hiding it in a FAQ without informing members is a betrayal of the principles of giving members power over the OMA. That was the main thrust of the governance changes in the first place.

What can members do? I mentioned in my previous blog that I personally won’t vote for incumbents. It seems that there’s only one incumbent up for re-election, current Board Chair Dr. Cathy Faulds. I have a lot of respect for Dr. Faulds (really). She’s accomplished much in her career (her resume is incredible) with work in health systems transformation/patient care advocacy and bilateral work with governments.

I was considering voting for her based on the fact that a good Board does need to hear all view points (even those that differ from mine) but I so fundamentally disagree with this move, and the current culture the Board has overseen that I personally can’t vote for her now. Whether other members see it that way is up to them.

A glance at the other candidates for Board show that there are 11 candidates who couldn’t be bothered to do a video statement to advertise themselves. Sorry – but as much as I disagree with the current elections process – if you are going to run for the top position at the OMA, and you can’t even find the time to put a video together to advertise yourself – well that is concerning.

My few loyal readers will know that I strongly supported Dr. Ramsey Hijazi last year – and continue to do so this year. He has consistently stood up for members – most recently by setting up a petition demanding that the government stop tormenting Dr. Elaine Ma for running a Covid Vaccination clinic. He’s also been strong in the press. He will get my first vote (which in the weird way the OMA weighs votes is the most important).

After that, there are a number of candidates that caught my eye – in alphabetical order – Dr. Khaled Azzam, Dr. Douglas Belton, Dr. Joy Hately, Dr. Pamela Liao, Dr. Afsheen Mazhar, Dr. Shawn Mondoux, Dr. Sameena Uddin, Dr. Darija Vusovejic. To be clear, members should review all the candidates themselves and vote, but I am going to vote for them after Dr. Hijazi.

As a family doctor, I also have a vote for my SGFP representative. Lots of great candidates running there. It will again, not surprise any of my followers that I will strongly endorse Dr. Nadia Alam for SGFP Vice-Chair. She’s an excellent leader and a dear friend. She took a well deserved break from medical politics for a bit. But it’s good to see her getting involved again and our profession will better for it. I leave the rest of the voting to your good judgement.

Dr. Nadia Alam, Candidate For SGFP Vice-Chair

Disclaimer: NONE of the candidates listed asked me to endorse them.

OMA Does a Disservice to Members with Veiled Threats to Board Candidates

OMA Elections will soon be upon us. This year the possibility of significant change to the organization exists as half of all physician Board Director positions are up for grabs. A review of the OMAs election page shows that there are 58 (!) candidates running for 4 Board positions.

My three loyal readers know that I have long felt that the first and foremost responsibility of the OMA is member advocacy. Many have heard me say time and time again that you cannot have a high functioning health care system without happy, healthy and engaged physicians. The OMA needs to consistently and effectively promote physicians.

Unfortunately the government of the day continues to disrespect physicians by forcing us into a never ending arbitration process. It also, despite the correct warnings of the OMA, continues to expand the scope of practice of non-physicians. I therefore wanted to see which of the Board candidates would be willing to take a more aggressive approach to this issue. So on a bunch of Social Media forums, I posted a request for all Board Candidates to sign a pledge if elected.

#medtwitter Are you a candidate for Board Director of @OntariosDoctors? There are 58 candidates for 4 positions. In order to help me choose my preferred type of candidate – there is a pledge I'm asking all candidates to sign. DM me for details. (spam DMs will be blocked)
— Dr. Sohail Gandhi, MD (@drmsgandhi) December 24, 2024

What exactly was this “pledge”? Was it a demand to remove the compulsory dues that all physicians have to pay to the OMA? Was it to split the OMA into two organizations- one for specialists and one for family doctors like they have in Quebec? A demand to fire certain staff?

Nope. It was a pledge to get data on how much allied health care providers (in this case NPs) cost the health care system when they try to do the work of family physicians. See below:

Now, did I think the culture of the OMA, that has been put in place by and is overseen by the current Board, would be happy with this? Of course not. Despite what my kids tell me, I’m not that out of touch. I expected some sort of push back suggesting this was (in their view) inappropriate.

But I confess I was taken aback by not only the factual errors in their response, but what quite frankly can only reasonably be perceived to be a veiled threat to myself and Board candidates. Here’s a copy of what I got:

The first factual error is to conflate the governance transformation (which I supported, and still do) with the elections process. The governance transformation was about reducing the size of the Board, and making it electable by and therefore responsible to the membership as a whole. This is opposed to the mishmash of ways people got on the Board before. It was also about sunsetting OMA Council (which had long served it’s purpose) and putting in a better, more co-operative General Assembly system, along with a Priorities and Leadership group to advance the needs of the members.

I did, and continue to support all of that (trust me, the old system was much worse). BUT – that is completely separate from the elections process itself. The intense over regulation of what candidates can and cannot say or how they can act during elections is NOT governance transformation, it’s micromanagement.

The second error is to suggest that it is because of my previous role at the OMA that I am “viewed as a leader”. Apart from the obvious fact that I have a bunch of detractors, the blunt reality is that there are a whole lot of ex-OMA Presidents out there who would not have influence because of the title itself. They have influence because of who they are/what they advocate for/actions they take outside of any past title.

The email to OMA Board Director candidates was almost as bad:

The underlying message is quite clear. Sure you can run for Board Director. BUT, if in OUR opinion, you “campaign”, or take a position WE don’t like, or speak out of turn – WE disqualify you. Intentionally or not, it creates the impression that the organization only wants a certain kind of Board Director. Not a strong independent type who can think on their own, and, dare I say it, take a bold stance that perhaps requires come chutzpah (like signing the pledge would!) But rather a benign, meek, Board Director – who will simply rubber stamp what’s been presented to them.

Unacceptably, in my view, is the more subtle threat of damaging our careers. The comment that this is”not in keeping with OMA’s code of conduct and civility”can really only be viewed as a veiled threat. Charging someone under a code of conduct violation has the potential to be extremely damaging. Many physicians, when they apply for new positions have to answer questions like “are they now under investigation” for such and such, even if there has not been a ruling yet. Being charged with this would force them to answer yes and potentially damage career options.

To be clear, I actually support the code of conduct and civility. I saw in the aftermath of the miserable 2017 tPSA debacle some incredibly unprofessional comments made towards the OMA staff (and others). I also am aware of many instances since where staff have been verbally abused by members and that is completely unacceptable. The staff are a very hard working bunch – who follow the direction and the culture the Board puts in place. It’s the Board that should be – respectfully – held into account.

But to tell a potential Board Director candidate (and me) that stating an opinion that might be viewed as controversial and advocating for that as part of an election process might see them charged?? Especially when there was absolutely no foul/derogatory/demeaning language used in the posts? Sorry but that simply comes across as attempting to censor a view point that you don’t happen to like. And that’s just wrong. Worse, it gives credence to the many critics of the policy who feared it would be used to suppress discussion.

Members deserve a strong, independent thinking and bold OMA Board. An elections process that goes to these extremes to prevent candidates from taking a stand on issues, advertising to members their skills (or lack thereof!) and their philosophy does not serve the membership at all. It will only disenfranchise them and lead to more voter apathy. About the only thing members can do at this point is NOT vote for any incumbents for Board Director and hope that will trigger some changes to this process.

As for me, I will try to get through the elections material – and pick candidates who I think will work to change the organization for the better. I will let you know my thoughts in a later blog.

OMA’s Recent Messages to Family Physicians are Disappointing and Misleading

Last week, Alberta, the province that once had a health Minister who went to a physicians house to berate him in person, created a new pay model for their family physicians. Even Alberta, the province whose premier told the health service to not talk about vaccines, realized the obvious. Family physicians need to be paid commensurate to the foundational work they do, and the role they play, in a high functioning health system.

Alberta Premier Danielle “Covid? What Covid?” Smith

I’ve taken a look at the new Alberta model. Some of the specifics are gated but the rough overall numbers are public. My back of napkin math suggests there is about a 24% increase in gross income for family physicians with a practice size of 1200. This includes payments for indirect work (checking labs, reviewing reports, supervising staff – all the admin work that Ontario refuses to recognize) and increased payments for more complex patients. I congratulate my colleagues in Alberta on this accomplishment. It WILL stabilize not only family medicine, but their whole health care system.

In response OMA CEO Kimberly Moran sent out an email on Friday Dec 20th. (A complete guess on my part is that she saw some of the responses to this deal on Social Media). I personally was offended (but not surprised) by the manipulation of figures and data in her email. While it’s true that every thing she wrote in the email was technically correct, the manner in which it was presented created an impression of successes that just aren’t there when it comes to advocating for family physicians.

I hate to talk numbers, this stuff gets confusing. But here’s a short set of data you need to know (numbers rounded for simplicity).

2022/23 is the BASE YEAR for all future increases negotiated/arbitrated going forward
The 2022/23 physicians budget was $16 billion
For 2023/24 (the last year of the previous agreement) the OMA negotiated a 2.8% ($448 million) increase
for 2024/25 the Arbitrator awarded us 9.95% compounded to the 2.8% from 2023/24 – which winds up being 13.03% more than the BASE YEAR ($2.08 Billion more than 2022/23)

So what’s the problem? Well for starters Ms. Moran states that the OMA “successfully” advocated for a 9.95% increase without mentioning that the OMA asked for 22.9%. Getting less than half of what you ask for is successful? But more importantly she went on to tell family physicians that they will receive a higher increase than the arbitration award of 9.95%. (11.75 – 13.54% depending on the practice model). But here’s the thing, the arbitration award was the increase for one year only (2024/25). The increase that family doctors are getting is an increase from the BASE YEAR (2022/23) – so it reflects your increase for two years not one like the arbitration award. The two year increase to the physicians budget is, as mentioned above 13.02%.

Now I completely respect the fact that the numbers that I’m quoting do not reflect the fact that the the award is meant to be split 70/30 between fee increases and targeted funds (but neither did Ms. Moran’s email!!). A very brief summary of how targeted funds are supposed to work:

70% of the $2.08 billion are supposed to go to fee increases ($1.456 billion)
the other 30% is supposed to be targeted ( $624 million)
of the $1.456 billion, 25% ($364 million) is supposed to go to across the board (ATB) increases for everybody. Crunching the numbers means everyone gets a 2.27% increase to their 2022/23 (BASE YEAR) income. The rest of the increase is based on relativity. Ophthalmologists for example get an additional 0.18% for relativity, and family doctors get between 9.48 – 11.27% additional for relativity. But again – that’s the increase for TWO YEARS, whereas the 9.95% was just for the one year.

This type of sophistry in messaging from the OMA regarding family medicine is sadly all too common. For example, the OMA has said that Ontario Family doctors have the highest capitation rates in Canada. Is that statement true? Of course it is. BUT – what’s also true is that no other province has deductions for outside use. Also, at a bare minimum family physicians in British Columbia, Saskatchewan, Alberta and Manitoba (with Manitoba being on top) pay family physicians more. Maybe Nova Scotia as well. Ignoring that while trumpeting higher overall capitation payments is unsettling.

While I sadly did expect such sleight of hand over numbers from OMA central, I must admit I was very disappointed in the SGFP email that came shortly thereafter. The SGFP has recently really gotten quite a bit stronger at advocating for family doctors and done some good work. But even they sadly fell into the trap when SGFP Chair Dave Barber told members in his letter:

“…Family doctors will receive increases greater than the 9.95% arbitration award announced earlier this year”.

David Barber – Chair of the Section of General and Family Practice

Again, technically a true statement, but very inappropriate. I don’t know what he was thinking signing off on that.

The really sad thing is that it didn’t have to be this way. The OMA (and SGFP) could have been completely forthright and honest and simply laid out the facts as I did above. This still shows family doctors getting a relativity bump more than a lot of other specialties. And they could have said that they want a good chunk of the targeted funds to go to Family Medicine but the government continues to fight them. Finally, they could have blamed the government for not recognizing the seriousness of the crisis. All of that still would have talked about the positive work being done, without creating the impression that they were trying to hoodwink the members. But alas……

What can we done? Well, I’ve said it many times before. Only the members can change the OMA if they want to. This year in particular, four physician members are up for election for Board Director – which represents half of all the physician positions. There are also multiple candidates running for SGFP executive positions. This really represents the best opportunity in a long time to continue to change the culture at the OMA so that we don’t get disingenuous messaging like this.

I’ll have my thoughts on the election in an upcoming blog.

Arbitration Part IV: What to Make of the New, Updated Payment Schedule

Disclaimer: The payment schedule below is based on my personal analysis of information from the OMA as of December 6, 2024. It would not surprise me if there were more changes. Do NOT use this as your sole source of planning. Contact info@oma.org with any questions.

On Nov. 1, 2024, OMA Board Chair Dr. Cathy Faulds announced an update on how the arbitration award for Year I of our PSA (Fiscal 2024/25) is going to be paid out. The plan was to have final numbers in a couple of weeks. Follow up information didn’t come until December 6 in an OMA news alert. Some things never change.

Wait old country doctor! Didn’t you already do a blog on the Arbitration Award?

Yes, parts two and three of my Arbitration analysis did say what was planned. But the blogs were filled with with statements like “allegedly” “supposedly” and chances of some of the changes happening were “slim to none”.

So we read all your previous work for nothing?

At the risk of sounding somewhat less than humble – most to the stuff I wrote about has come to pass – including splitting the increase with 75% of the amount going towards relativity, and 25% for across the board (ATB) raises.

Well what changed then?

There are a couple of delays (of course) to some of the retroactive payments. But the big change is changing the amount of your increase based on your specialty. I don’t know who came up with the idea of doing this, and suggested it to the OMA’s Negotiations Task Force, but whoever it was deserves the thanks of our profession.

This method is not perfect, because some billing codes are used by more than one speciality. For example, I’m a family physician, but I do joint injections. So do orthopaedic surgeons and rheumatologists. But the billing code (and thus payment) for doing a joint injection is the same. Applying an increase to that code will affect at least three specialties. Therefore, by given specialty specific increases instead, some of the lower relativity specialists will get more of an increase sooner.

The “permanent” changes to the fee codes will now not happen until April 2026 (!!). So expect your income to fluctuate some more then.

Don’t tell me you’re are going to toss large numbers and calculations at me!

I’m going to toss large numbers and calculations at you.

Here are numbers I needed to understand the contract. Numbers rounded for simplicity.

Fiscal Year 2022/23 is the base year for calculations. Physicians budget was $16 billion.
2.8% increase agreed to for 2023/2024 (from last PSA) = $448 million
9.95% awarded by arbitrator for 2024/2025 when compounded with 2023/2024 – total value =$2.085 billion
The plan was to spend 70% on fee increases, and 30% on “targeted” investments. For 2023/2024 this would be $314 million for fee increases, $134 million for targeted investments. For 2024/25 – $1.460 billion for increases, $625 million for targets.
Finally, as of now, it appears that we are going to stick to 25% of the total for fee increases (not the targeted money) will go to across the board (ATB) raises, and the rest based on relativity.

Wait a minute Old Country Doctor – didn’t everyone get the same percentage increase this year?

Yes. Under the terms of a previous agreement, if the OMA and government were not able to sort out how to divide the money for a fiscal year, ALL of it would be paid ATB on a temporary basis. Emphasis on temporary. So we all got a 2.8% increase for 2023/2024 (you should have gotten the retroactive pay in November). Additionally your monthly remittance should be 2.8% higher beginning on the MAY 2024 statement (The increase took effect April 1, but of course, that gets paid out on May 15).

For this fiscal year (2024/25) the OMA and government have conceded they won’t come up with a plan on how to divide the funds, and so everyone will get an ATB of 13%(1.028 x 1.0995). The way it’s paid out will be a mix of monthly increases and some retroactive pay.

However for fiscal 2025/2026, there will be specialty specific increases. Each physician will get another temporary increase in their billings, based on their specialty. The OMA and government will continue to ~~argue~~ negotiate. Probably need arbitration for this. The exact fee code changes are scheduled to be in place April 1, 2026 (!!)

You’re going to bring back Drs. Alpine and Valley to explain this aren’t you?

Of course dear reader. It helps to put a “face” to the numbers. However, on this occasion, let’s assume Dr. Alpine is an ophthalmologist (speciality chosen only because they appear to get the lowest increase) and Dr. Valley is a family doctor in a capitation model (for reasons that will become clear shortly).

I won’t restate the assumptions for my calculations (please refer to my previous blog on this issue). Assuming that Drs Alpine and Valley see the exact same number of patients every year – this is what their gross income will look like.

Time Period	Dr. Alpine	Dr. Valley
Monthly billings 22/23	$100,000	$30,000
Monthly billings 23/24 (increase not applied yet)	$100,000	$30,000
Monthly billings April 2024 till Dec 2024 (2.8% finally applied)	$102,800	$30,840
Nov 15, 2024 (retroactive pay added)	One time payment of $33,600 in retroactive pay for 23/24	One time payment of $10,080 in retroactive pay for 23/24
Jan 15, 2025 – 2.8% lowered to 2.55% as part of agreement to use funds to increase HOCC	$102,550	$30,765
Feb 15, 2025- April 15, 2025 – OHIP will finally given 1.0995 on top of the 1.0255 now	$112, 754	$33,826
May 15, 2025 retroactive pay for April -December	One time payment of $89,583	One time payment of $27,549
May 2025 – April 2026 monthly billings	$102,452	$33,525

WAIT A MINUTE! Capitated Family Doctors gross will go down as well??

Yes. As mentioned above, for 2023/24 and 2024/2025 the OMA and government could not agree how to divide up the now $2.085 billion, so it was given ATB on a temporary basis. This was meant to get some money into doctors hands sooner otherwise Allah/God/Yahweh only knows how long we would have to wait for the process to complete.

However, 30% of the $2.085 billion (or $626 million) was meant for “targeted funds”. The expectation is either through negotiation (very unlikely IMO) or through arbitration, a decision will be made on where to spend that $626 million for fiscal 2025/26.

Therefore, there is only $1.459 billion for general increases for 2025/26 (plus whatever increase the arbitrator gives us). Of that, 25% ($365 million) will go ATB. So everyone will get 2.03%. The remaining $1.094 billion is distributed via relativity.

With less money to distribute – well, there is less of an increase. Now of course the possibility exists that some of the targeted funds will be spent on captitated family medicine too, but who knows at this point? This is why virtually every specialty sees a decline in 2025 when you look at the OMA’s spreadsheet.

Keep in mind the fee increases for April 1, 2025 to March 31, 2028 have yet to be negotiated (more likely arbitrated) so there will be more money in the future – we hope.

I’m not a family doctor or an ophthalmologist- how do I find out my numbers?

I suggest you go to the table that the OMA has prepared for you. Use your base 2022/23 monthly income to figure out your projected numbers. If you have specific questions about your situation, I urge you to contact info@oma.org. The organization can’t really answer questions if they don’t know what they are. Also please register for the live Zoom Webinar on this process, and ask your questions there.

So this is the final word on this issue?

Nope. I suspect there will be more to come. And that it will be just as confusing.

You’re just a bundle of joy Old Country Doctor.

I aim to please dear reader. I aim to please.

Dr. Elaine Ma Case is Proof Ontario is Unfriendly to Physicians

Last week, the Ontario Health Sector Appeal and Review Board (HSARB) denied the appeal by Dr. Elaine Ma in her fight against the Ontario Health Insurance Plan (OHIP). At the risk of upsetting Dr. Ma and many (? all) of my colleagues, that decision actually was legally appropriate. HSARB can’t actually look at whether a case is reasonable or not, their job is to go by what’s written in bulletins/updates. The real affront to physicians is that it should never ever have gotten here in the first place.

The Background

For non-physicians reading this, here is a condensed summary of what happened. It’s 2020. The Covid pandemic is raging. Ontario Premier Doug Ford appoints General Rick Hillier to oversee the Covid Vaccination program. He’s tasked with, as Ford calls it, “the largest vaccine rollout in a generation, a massive logistical undertaking, the likes of which this province has never seen.” Hillier’s stated goal? To get shots in everyone’s arms by August 2021.

Dr. Elaine Ma from Kingston realizes the need to act quickly to help her community. She organizes outdoor mass vaccination clinics. Over 35,000 shots were given and Kingston became the most vaccinated area of the province. Dr. Ma was given an Award of Excellence by the Ontario College of Family Physicians for her efforts.

Picture of an outdoor vaccination clinic found elsewhere on the web

The Dispute with OHIP

So what happened? For the Covid vaccine clinics, there were two sets of billing codes assigned. The first was a standard hourly rate. This was meant for physicians who attend a vaccine clinic and perform immunizations there. There were numerous such clinics set up by hospitals/public health/pharmacies and so on. Those agencies paid for the setup costs of those clinics. The physician just showed up and vaccinated.

The second set of codes is used by physicians who give vaccinations in clinics they set up. These codes pay somewhat more, but they’re meant to compensate physicians for the fact that they have to cover all the overhead in those clinics.

Dr. Ma would have had to make sure that things like electricians were hired to ensure that there was power and Internet access outdoors. She may have needed to arrange for commercial grade outdoor tents. Propane heaters to heat the tents and the propane might have been needed. Some staff were paid (others volunteered). All of this organizational work, and figuring out payments, needed to be done in advance. She did it.

She therefore billed OHIP the second code. This is entirely reasonable given the circumstances and the work she did.

So what happened?

The sudden increase in billings did not go unnoticed by OHIP and was flagged. This is absolutely appropriate. As taxpayers, we need to be sure that there is a mechanism to catch outlying bills. The anomaly was sent for review by the various bureaucrats at OHIP. Also appropriate.

So what went wrong?

Basically everything after that. The OHIP bureaucrats reviewed the situation. As pointed out by Perry Brodkin (OHIPs former lawyer, who was quoted extensively in the Kingstonist) – the information was sent “up the hierarchy” and would have reached the deputy health minister and minister.

Former Deputy Minister of Health Dr. Catherine Zahn

The bureaucrats and health minister decided she didn’t qualify for the codes. The reasons given (see the Kingstonist articles for more details) change at a whim. First it was that the clinic was outdoors not inside (you mean at a time when we are all social distancing – we should have crammed unrelated people into a clinic to immunize them??). Then it was that medical students were used (despite the strong endorsement of using medical students by the then Dean of Queen’s University Medical School, Dr. Jane Philpott). Then it was that she paid people to work there.

Dr. Jane Philpott – former Dean of Queen’s University Medical School – and a strong supporter of the vaccination clinics set up by Dr. Ma

Then things got ugly

And finally, after repeated questioning by the Kingsonist, things got really ugly when Hannah Jensen, the communications director for the Minister of Health issues a statement alleging that Dr. Ma “pocketed” the funds. This basically amounted to an allegation of theft by Dr. Ma and was widely viewed as a disgusting, immoral and reprehensible comment in the medical community. Even the Kingstonist was alarmed by this and called the statement “rife with allegations.”

Hannah Jensen, Communications Director for Minister of Health Sylvia Jones (photo from LinkedIn Profile page)

Why this offends doctors so much.

Let’s be clear about this. There is zero tolerance in the broader medical community for misappropriation of funds/intentional fraudulent OHIP billing. Zilch. Nada. But there is a recognition that the imperfect OHIP billing schedule needs to be interpreted with reason, especially when times are unreasonable (and what could possibly be a more unreasonable time than a once in a lifetime pandemic?).

Dr. Ma did all the work to meet the billing criteria (even the OHIP bureaucrats were forced to admit that yes, over 35,000 shots were given and yes she had planned and organized the whole thing). The fact that she did it outside and had medical students help when some 20 year old pre pandemic memos said not to is an unwarranted use of a technicality.

For many physicians, this brings back memories of when another set of bureaucrats persecuted physicians. They even told one paediatric respirologist that in order to bill a code, he had to perform rectal and pelvic exams on children!

What does this mean for Ontario Health care?

First, as Dr. Ma herself pointed out, it is now illegal for physicians to bill any procedures that they delegated to medical students. This means that medical teaching will effectively grind to a halt. Why would any doctor teach a medical student to say, suture a wound, when that doctor would now be financially penalized?

Second, this story has made the national press. It has also been reported in Canadian Journals that cater to physicians and other health care workers. The message to them is clear. Do NOT think of relocating/starting up a practice in Ontario. You will be treated grossly unfairly by the bureaucrats and health minister and there will be no reasonable interpretation of the rules.

What can be done?

According to Brodkin, Health Minister Sylvia Jones and Premier Doug Ford can direct OHIP to disregard the HSARB ruling. They need to do so immediately. However, because politicians only think of re-election, and not what is right, Dr. Ramsey Hijazi, the founder of the Ontario Union of Family Physicians wants to up the pressure on them.

Dr. Ramsey Hijazi, founder of the Ontario Union of Family Physicians – pictured inset.

His group has set up a petition that clearly demands that justice be done in this case. It demands that the Minister and Premier disregard the HSARB ruling. We need to support our health care heroes not penalize them on technicalities in outdated bulletins.

I urge all of my followers to sign the petition. If this case is allowed to go on, trust me on this, there will be negative consequences for health care in Ontario, and we don’t need any more of those.

Click here to sign the petition.

Sunday Snippets: Dec 1, 2024 (ft. Bonnie Crombie, Vaccines, Microplastics and more)

Item: More and more family doctors are turning to AI scribes to reduce their workload. Many physicians in the article state time saving is the main driver for adopting these scribes.

My thoughts: I’m piloting an AI scribe right now with my Health Team. It can reduce the number of hours spent on paperwork. However, one does need to review the note dictated to ensure it’s accurate (a few examples of mistakes so far). The notes also tend to be wordier than my own notes. Finally, it’s really important to review the examination section of the notes – as the scribe has no way of knowing what a patient “looks like” and it’s up to you to ensure accuracy.

There are of course some privacy concerns. That’s why I like the fact that the scribe I’m using is not integrated into my Electronic record. That way the patients name/date of birth/health card/other identifying information does not get sent into the ether when the scribe generates a note.

My hope is the government settles on one scribe (after appropriate vetting) and pays for all physicians to use it. This will have significant positive benefits for health care.

Item: Ontario Liberal Party Leader Bonnie Crombie has launched her first campaign ad. She blames current Conservative Premier Doug Ford for the shortage of Family Physicians.

My thoughts: It’s a bit rich for the Liberals to blame the current government for the doctor shortage when most of the problems with family medicine began during their tenure. But, just as federal/national elections are won based on the cost of living/inflation (the big reason why Trump won), provincial elections in Canada are often lost based on how the current government is managing health care. And this truly is Doug Ford’s Achilles heel.

I know it seems like Ford’s handlers have him convinced that he can win a third term if only he calls an early election. But the blunt reality is that an early election call will be viewed as cynical even by people who will vote for him. Similarly the $200 Ontario “rebate” cheques are going to be viewed as a bribe.

Will Ford win a third term? I don’t know. But I doubt it will be as easy as he or his handlers think. He really needs to take some significant steps between now and the spring on health care. If only some would give him advice, and on more than one occasion.

Item: We’ve all heard about the rise in measles cases across the country and in the U.S. It seems that now Whooping Cough is also on the rise.

My thoughts: Jeez. Get vaccinated and get your kids vaccinated already people.

Item: On that note, it seems very few adults in the United States are getting updated Covid/Flu and RSV vaccines, even in high risk populations like nursing homes.

My thoughts: Life expectancy in the United States continues to fall. These two articles are not unrelated.

Item: Microplastics have now been found in the human brain.

My thoughts: Not nearly enough attention is being paid to this story. There are significant red flags for the harm that microplastics can do to human health including increasing the risk of dementia/heart disease/stroke and reducing fertility and sexual function. While it’s true that most of the studies raising alarm have been in labs or in animal models that don’t give a complete picture of the effect on humans, there are just too many concerns to ignore. We need an urgent review of microplastics (along with a review of all the processed garbage in the North American diet).

Item: A great article in the Annals of Family Medicine shows that when your doctor is away, there is LESS downstream use of ER and associated health care costs if you see a doctor in the same group practice than in a walk in clinic.

My thoughts: This is yet another reason why expansion of scope of allied health professionals is a bad idea. Rather than getting your care fragmented between health care workers who don’t have your full health history – the ideal is to support your family doctor to make sure whoever is covering can see that information, to give you better care. And on that note….

Item: Ontario is going to allow the further expansion of scope of nurse practitioners. PEI is going to allow physiotherapists to order X-rays.

My thoughts: Go read the article from Annals of Family Medicine above. This move (to expand scope) will eventually be shown to have been a big mistake.

Item: Excellent (and unusual for the Trillium – ungated) article on the aging population of family physicians in Ontario and what it could mean for the future.

My thoughts: None of this is surprising. Four of the five doctors in my clinic are late 50s or older. We are heading for a real problem if we don’t immediately support family medicine now.

Item: I somehow missed this but it seems that Australia just had its worst flu season on record.

My thoughts: I wrote this in 2017 warning that our health care system couldn’t handle a bad flu season. The situation is worse now. I don’t know what the flu season will be like, but if it’s a bad one we will see a proliferation of horror stories about health care. At the risk of sounding like a broken record – get your flu shot people. Keep yourself safe.

Yours truly getting his flu shot this year.

That’s it for this week. I’m away next week. Might have a blog later on a specific issue that is making Ontario an undesirable location to practice medicine. Back in two weeks with more snippets.

Sunday Snippets: Nov 24, 2025

Another in a weekly series of brief snippets of health care stories that bemused, intrigued and otherwise beguiled me over the past week along with my random thoughts on the matter.

Item: Dr. Sarah Giles writes in the CBC about how she was forced to cut her hours because of the burnout.

My thoughts: Kudos to Dr. Giles for talking so openly about this. Alarmingly few of my colleagues are willing to talk about burnout and how the system is affecting them. Instead they suffer in private, and that’s not healthy for them OR the patients they serve. It’s an important story that needs to be told over and over again.

Item: “Involuntary medical treatment” for people with addiction issues seems to be all the rage. A great article in the “Conversation” shows that this won’t solve anything, and in fact will make things worse.

My thoughts: I really can’t believe we are even discussing this. It has been well known for…..well forever, that people will not get better unless they want to seek help. We have to focus on making seeking help easier, not forcing them.

Item: The always excellent Dr. Katelyn Jetelina, who most of my colleagues know as a superb voice of reason and information during the height of the Covid pandemic, writes about her feelings now that RFK junior has been nominated to lead Health and Human Services in the United States.

My thoughts: My heart goes out to her and all the hard work staff who have tried keep us all safe during the pandemic. They deserve better.

Robert F. Kennedy Jr., a leading American Anti-Vax conspiracy theorist, now tapped to head Health and Human Services in the United States

Item: TV Ontario had a segment suggesting that foreign trained physicians could help tackle Ontario’s physician shortage.

My thoughts: I’ll shout it out again, we already have enough family doctors in Ontario who are already licensed to practice medicine in this province and are familiar with the Ontario Health Care system. The number is approximately 6,000 or so (see the graphs in the linked blog for details). Can we just not make it easier to practice family medicine instead??? If we can get even 1/3 of those doctors already in Ontario to start a practice, we would end this crisis.

Item: Great article on the physician gender wage gap in Health Debate. Clearly shows that the gap is real and needs to be corrected.

My thoughts: One of the best accomplishments of the OMA Board when I was on it was to publish the gender pay gap report. It was arguably too late, but I believe we were the first PTMA to discuss this and to use that as a basis for future negotiations work. While I’ve had some issues with how negotiations have been handled since, I am quite comfortable in saying that positions of the OMA in negotiations would take this into account and that there is likely to be funds demanded to narrow this gap. The blame for the fact that there has been no progress on this lies mostly at the feet of the Ministry of Health. We don’t have an agreement yet on how to divide the arbitration award – and that means the Ministry is not responding to OMA proposals that would close this gap. Shame on them.

Item(s): Alberta announced that it hiring a large number of nurse practitioners to become “primary care providers” to patients who don’t have a family doctor.

My thoughts: The National Health System (NHS) in Britain is under fire for the fact that it too tried to replace the work done by fully trained physicians, with staff who were likely well intentioned, but had less qualifications. It turns out there is significant risk to this, and likely a markedly increase cost in providing health care. The article “My wife died because the NHS used cheap labour” should be, in my opinion, required reading for any politician/health care bureaucrat who thinks they can provide better care by using less trained people.

That’s all for this week. Back next week (probably) with more.