Politics – Page 2 – justanoldcountrydoctor

ONE MORE PATIENT SEEN – ONE LESS PATIENT WAITING

Note: This blog was originally published on the OMA website. I’ve reproduced it here, for those who don’t normally go to the website.

I am proud to be the President of Ontario’s 31,500 practising physicians. I know that making sure every patient gets the care they need, when they need it is every physician’s top priority. We are on the frontlines of the health care system, caring for almost 340,000 patients every day.

Ontario is undergoing a much needed, and absolutely necessary health care transformation. Our population continues to grow and age and people’s health care needs are increasing in their complexity. All across the province, doctors are working hard to care for more patients and reduce wait times.

Under our health care system, doctors are independent contractors who own their own practices and operate as small businesses. Physician services depend entirely on patient need, and that varies from community to community, specialty to specialty, and physician to physician.

Doctors bill for patients they see, procedures they perform, and in some cases, the tests they interpret. It is important to note that the amount a doctor bills is neither their salary nor their take-home pay. Physicians must pay for the costs of operating their practices, from staff, to rent, to medical and office supplies. These expenses take up a significant proportion of billings, in some specialties up to 50%.

There are also many different models for practices. Some are small and have limited staff while some have a much larger team of several types of health professionals including: physician assistants, nurses, nurse practitioners, technicians and medical assistants. Expenses and volumes of patients seen would be very different depending on the operating model.

A physician’s annual gross billing amount reflects demand for treatment. The more patients need services, the more OHIP is billed for those services. This demand may be intensified in remote and rural locations where there are limited medical resources. In fact, many physicians in underserviced communities may work 7 days a week to provide the best care for their patients.

It is also important to note that Ontario continues to have a lower number of physicians than most other jurisdictions in the world. We currently have 2.6 physicians for every 1,000 patients, whereas Germany has about 4 physicians for every 1,000 patients. This means that our physicians have to see more patients (and thus bill more) to help keep the residents of Ontario healthy.

The OMA (and I) support greater transparency of physician billings. But this should include appropriate context for the public and be governed by an Act of Legislature as it is in other provinces. The real value in greater transparency is to show how much patient demand there is for services. Looking at a select 0.3% of physicians will not do this.

Ontario’s doctors are working with the government to fix our health care system, solve critical issues like hallway medicine and deliver the high-quality care our patients deserve. Part of this work is to recognize the value of services patients need and how those services are provided. We will continue to do this work with the government going forward.

Each and every billing submitted by a doctor means that one more patient has been treated and one less patient is waiting.

A Personal Journey Through Public and Private Health Care

Disclaimer: The following blog was written by Dr. Darren Cargill (pictured below). He asked that I put it up for him. Dr. Cargill is a palliative care physician from Windsor, Ontario. Opinions are his and his alone, and do not necessarily reflect my opinions, or those of the Ontario Medical Association.

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Recently, a series of articles in the Toronto Star claim that Ontario Premier Doug Ford is looking at “private” options to end hallway medicine. This was, of course, immediately denied by Health Minister Christine Elliot who stated her government’s ongoing support for public health care.

To support this narrative, the Ontario NDP brought forward a leaked piece of draft legislation called the “Health Systems Efficiency Act”. This draft suggests that all 14 Local Health Integration Networks (LHINs) and many other agencies (Health Quality Ontario, eHealth, etc.) are to be rolled into one big Agency. NDP Leader Andrea Horwath claims that this draft legislation is a signal that private health care is the real agenda for the Ford government. Interesting times for health care in Ontario.

In Andre Picard’s book “Matters of Life and Death,” he eloquently outlines the history of Medicare in Canada, warts and all. I think we can all agree with his comment “Canadians want care that is appropriate, timely, accessible, safe and affordable, from birth to death.”

So here is our story. In 2007, my wife was diagnosed with cancer. She received excellent care here in Windsor as well as at Western in London as part of her journey. I can honestly say, that she would not be here today if not for that excellent care. I am indebted to our system for saving her.

Getting cancer at 29 is frightening. When we wanted a second opinion to confirm the diagnosis and ensure that we were receiving the best possible care, we booked an appointment at Karmanos Cancer Centre in Detroit. A second opinion in Ontario would have taken months. We got our appointment within days across the border. They confirmed that Windsor was giving us fantastic care.

At one point during her treatment, she needed an MRI. The wait was many months in Ontario. At first, she was ok to wait but as the days passed, the wait took its toll. Eventually, we decided to go to Detroit and have the MRI done, with only a few days wait and near instantaneous access to the results.

When we needed help conceiving following chemotherapy, this too was not covered by our public system and we paid out of pocket for that. We required help from physicians in both Windsor and Detroit. Today we have a son. And he has a mother.

Neither system alone gave us what we needed. It was both.

We already have private health care in Canada. Doctors’ offices are privately run businesses that rely on single-payer public funding to operate. We also have private care when we pay out of pocket for drugs, physiotherapy, psychotherapy, fertility treatments, and dental care. Canadians already spend money out of pocket for health care so the fears around a “two-tiered” system are odd, to say the least. Two-tiered refers to the argument about equity, not public/private, in my humble opinion.

Many will claim I am a physician and had “the means” to avail myself of private care. But for the record, I was less than 2 years into my career and still had over two hundred thousand dollars in debt from tuition gathering interest every day. We had to ask family for loans to support us.

For me, the price was worth it. I would have preferred to have all of our care provided in Canada, but the public system simply could not give us everything we needed. I believe it was providence that we ended up in Windsor, a short drive away from a world class cancer centre and fertility experts in Detroit. Ontario gave us most of what we needed and prevented catastrophic financial consequences but privately delivered care in Detroit helped to fill in the gaps.

Why couldn’t I have those options in Canada?

To be clear, I am not suggesting we adopt a US style for-profit system and I am not suggesting we abandon our public system. What I am suggesting is that we have a mature conversation about our system, it’s limitations and whether there is a way to supplement or augment our “good not great” publicly funded, single payer system with private options that could enhance the care we deliver. Can we make our system better through private innovation and efficiencies while preserving all the best parts of public Medicare?

I am asking for a conversation.

As a palliative care physician, I won’t benefit from privatization. End of life care and symptom management for patients with life-limiting illness will remain publicly funded. But end of life care does give us a great example of what a good conversation could look like.

In 2015 the Supreme Court of Canada’s Carter decision came down and we were required, as a nation, to address the issue of Medical Assistance In Dying (MAID). Previously, MAID was taboo and “verboten.” We could not raise it with our patients or even discuss it. But a funny thing happened. Once this prohibition was raised, it got easier to discuss death and dying. Whether or not you support MAID or not, one thing is indisputable. The conversation has been elevated.

In his book, Picard states “we talk endlessly about sustainability of Medicare but have no idea what we want to sustain. Our Medicare model is a relic, frozen in time. Tommy Douglas’s role in shaping publicly funded health care is celebrated, mythologized even. But we conveniently ignore that Medicare was designed to meet the needs of 1950s Canada.”

All on the first page of his chapter on Medicare.I couldn’t agree more. And while we are at it, let’s stop tilting at wind mills.

I do not pretend to have all the answers. I just know we need a mature conversation about public AND private health care. Let’s not shut down the conversation out of fear-mongering and ignorance. To paraphrase former CPSO president David Rouselle: “let’s not repeat the same sterile conservations again.”

Specialists in Ontario are Being Played…

Looking through my in box, I see:

A report from an interventional radiologist, who performed a percutaneous vertebroplasty (injecting a bone in the spine with a form of cement) on a patient of mine with severe back pain. She now walks without a cane.
A report from an interventional cardiologist who performed a very difficult cardiac stenting procedure (insertion of tubes in the blood vessels to the heart) on a patient of mine with unstable heart pain – probably saving his life
A report from an ophthalmologist, who expertly fixed my patients cataracts. She can now see her grandchildren clearly for the first time in years.

I think of colleagues like these (and many others) when I read about how Dr. David Jacobs, a radiologist and former Ontario Medical Association (OMA) Board member, would like to start a separate organization to represent specialists. Dr. Jacobs is well known in the profession for his actions during what’s become known as the tPSA fiasco of 2016. The former leadership of the OMA negotiated a deal with the despicable Kathleen Wynne government, but there were many questions about the process. Dr. Jacobs exposed the situation in the press, and helped to stop a deal that would have effectively destroyed health care in Ontario. It’s well known that I worked with him to stop this bad deal. However, I think he’s on the wrong path this time.

I can appreciate how hard it must be for some specialists to feel good about the OMA right now. On October 21, OMA Council passed an advisory motion recommending that the top three specialties might get cut by up to 6 per cent more (1% per year until 2024) than they have been already. Most Ontario physicians unilaterally had their gross incomes cut by 7 percent by the desultory Kathleen Wynne. Some of the higher paid specialties were cut more due to what’s known as targeted cuts. If the OMA Board agrees to the Council motion, some specialists would be even more angry at the Association.

But the reality is that if Dr. Jacobs is successful in his endeavor, specialists will get eaten alive by government. Any government.

The best example of split associations is in Quebec. Specialists and Family Doctors each have their own associations. One can certainly see the appeal of going that route when you read stories about the big “raise” that specialists in Quebec got in 2015. The “raise” was so large that some doctors actually protested it as being too much (no really) and wanted to give some of it back.

But one has to look at the facts first. The deal was meant to compensate doctors for the fact that there was NO increase from 2007 to 2015 (fat lot of good having two associations did then). Now, before the bulk of the “raise” sets in, a new government is in place and plans on eradicating it. Who do you think can fight against governments more? Two small groups or one large one with more resources than either one?

Additionally, I’m not convinced that most specialists are aware of what the OMA is asking for in arbitration. The OMA is asking for a repeal of all the cuts (targeted and otherwise), and normative increases (raises). By contrast the small specialist group seems to only want the cuts repealed. They have not asked for raises. Why would specialists want to join a group that is asking for LESS at arbitration than the OMA is?

Here’s where this really hurts the specialists. If I was the government, I would look at the fact that I was in arbitration with the OMA. Faced with the possibility of physicians being paid more than I was willing to pay, I would try to divide the OMA. I would probably send some sort of official to talk to the disgruntled doctors to encourage them on. See if I could cause dissension in the OMA while I was fighting them in arbitration. If I was able to split the OMA, I would happily start to advertise the high gross billings (while ignoring their overheads) of this group of specialists and then use that to cut their billings even more in the future. It’s called playing the long game.

Some specialists are understandably upset right now. But under the current Arbitration process with the OMA, they still have the potential to recoup more of their lost income than this new group suggests. Council also approved exploring potential dispute resolution mechanisms for relativity in arbitration. If this can be organized in time, they would have a fair, impartial avenue to address their concerns. Specialists will not have access to Binding Arbitration if they form a small separate group. What are the chances that any government would freely offer a valuable bargaining tool like Arbitration to a newly minted organization?

Many doctors are frustrated with the pace of change at the OMA. As someone who’s been accused (not altogether incorrectly I might add) of being too impatient himself, I understand that. The OMA has made significant strides in the past year. More is planned. But to bail out in anger only hurts people in the long run.

I worry that joining this group out of frustration and anger is going to further harm the specialists that I rely on to treat my patients. They’ve taken a huge beating (as have all of us) the past few years. The beating has not only been financial, but psychological and emotional as the loathsome Wynne government heaped scorn on doctors at every opportunity.

But in their anger, they are allowing themselves to be played by the government, and I fear they will be much worse off in the long run as a result.

A Few Random Thoughts

Disclaimer: As always, just a reminder that while I am President-Elect of the OMA, the opinions in the blog are mine, and not necessarily representative of either the OMA as a whole. I just like to tell people what I’m thinking.

Changes at the Ministry of Health (MOH)

Interesting change at the MOH. Nancy Naylor, who was the second in command, has left the Ministry. She is going over to the Ministry of Education. I had the opportunity to work (briefly) with Ms. Naylor when I was on the executive of the Section of General and Family Practice. I found her to be a very knowledgeable person and easy to work with. I certainly wish her well.

However, as my loyal fans (both of them) know, I don’t particularly believe in co-incidences (Bob Bell suddenly “retired” when the Liberals lost? Yeah, right). At the MOH Ms. Naylor was the person the LHINs reported to. Leaving that role during a transitional period is very curious timing. Given that Premier Ford has instituted a hiring freeze on bureaucrats, that means that the LHINs don’t currently report to any one other than new Deputy Minister Helen Angus. Frankly, looking after the LHINs as well as doing everything else the Deputy is required to do is a lot to ask. Unless (and this is pure speculation on my part) this foreshadows the long hoped for elimination of the bureaucratic quagmire that are known as LHINs. Be interesting to see how this plays out over the next couple of months.

Changes at the Canadian Medical Association (CMA)

This week, the CMA is holding it’s annual general meeting. Dr. Gigi Osler takes over as President. I had the pleasure of meeting her (however briefly) at the OMA Annual General Meeting in April. Dr. Osler is a remarkable woman with more accomplishments in her pinky finger than I have in my whole body. That the CMA is going to be led by her this year is unquestionably a benefit for the organization (given all their troubles this past year) and for physicians across the country. Dr. Osler is an incredibly passionate advocate for physicians health and well being, and we are all lucky to have her speak out on such an important topic.

I do wonder how she is going to handle the internal politics of the CMA. Based on the interview given by outgoing President Dr. Laurent Marcoux, it really seems to me that the old guard at the CMA (which still populates much of the Board and management) really doesn’t understand just how much they’ve alienated their members. You would think the uproar created by their flawed “Vision 2020” mandate, not to mention the sale of MD Management, would have made them at least reflect on their path. Physicians need a national advocacy association that places their interests first. I hope the CMA recognizes that Dr. Osler’s popularity is because she speaks to that need, and that the old guard doesn’t try to silence her.

More Thoughts on the Strike in Thunder Bay

The strike at the Port Arthur Clinic was finally settled last week, after a bitter, acrimonious period that included a fence being put up, and criminal activity being committed by somebody.

I still worry about what this means long term for the Port Arthur Clinic. They are all human beings there, and I can’t imagine that it will be easy for them to get back to work. It certainly will take years for the trust to rebuild. I suspect, sadly, that we haven’t heard the last out of issues coming from this clinic. I hope that first and foremost, the patients get the care they deserve.

Ontario Medical Association (OMA) Becoming More Outspoken

It’s been a couple of turbulent years at the OMA. However, it’s nice to see that the leaders of Association speaking out more and more on physicians issues. It started last year when Dr. Shawn Whatley was President and he advocated strongly for physicians first. Through his many blogs (which are required reading for anyone interested in medical politics) and his multiple TV and radio appearances, he really got the ball rolling. His simple mantra that you can’t improve health care by disparaging physicians, while self evident, really struck a chord and needed to be said.

This year of course, we have the incredible Dr. Nadia Alam. Another ridiculously accomplished young physician, she has moved quickly on her belief that the OMA must defend physicians when they are attacked, and defend patients when their care is compromised. This was most recently seen in her quick reaction to the strike in Thunder Bay. Whether in the news, or her personal blogs, she has repeatedly been speaking out on issues where physicians voices are compromised.

While there is still much more to be done at the OMA, it’s refreshing to see that the organization is speaking out on areas like this. It means I have huge shoes to fill next year, but I can honestly say I’ve been inspired by the actions of the last two Presidents.

“Smokey” Thomas Fails His Members

Authour’s Note: Once again, I would like to state that while I am President-Elect of the Ontario Medical Association (OMA), I have not spoken with any of the Family Doctors in Owen Sound about this situation. I did email them to ask permission to write this. All of my thoughts are strictly based on reports in the media, and news releases (all of which are hyperlinked).

Last week I had suggested that Ontario Public Services Employees Union (OPSEU) President Warren “Smokey” Thomas should change his approach on how he dealt with physicians in union disputes. Sadly, Smokey has doubled down on his tactics. In doing so, not only has he utterly and completely failed his members, but he risks endangering health care in Owen Sound.

In Owen Sound (population ~ 21,000) there are 22 family doctors who have organized themselves into a Family Health Organization (FHO). The FHO is a fairly common payment model that consists essentially of a salary and performance bonuses. Like all other payment models the FHO models experienced years of deep cuts to their budgets during the desultory tenure of Premier Kathleen Wynne. Cuts to physician payments, mean cuts to patient services. Hence, the FHO focused on controlling expenses as best it could.

The staff at the FHO chose to unionize (which is their right) but unfortunately chose to do so under OPSEU, and became Local 276. OPSEU and Smokey have absolutely no experience in dealing with intimate small office settings, and the necessary collegiality that is essential to providing high quality front line care. As a Family Doctor, you MUST trust everyone from the receptionist, to the nurse and even the cleaning staff. While disagreements occur, and are often healthy, the trust cannot be compromised, or patient care will suffer.

Smokey and OPSEU’s lack of experience showed almost immediately. Their bargaining team agreed to a contract and recommended it for approval to the FHO staff in May. That’s right folks, OPSEU actually reached an agreement. But the agreement was rejected by the FHO staff, a clear repudiation of OSPEU’s leadership.

This appears to be when Smokey went off the rails. He (and OPSEU) could have taken a hard look at themselves and asked a simple question – “How could we be so out of touch with the members we represent, to have endorsed a deal they rejected off hand?”. But they didn’t. Instead, in what seems to be an effort to prove to their members that they really are relevant, they doubled down and started hurling insults and threats. Doctors were “punch drunk with greed” they screamed.

The FHO staff then went on strike, and the results appear to be disastrous for them. Firstly, OPSEU should have told them that doctors office are not factories that make sprockets and cogs. They provide essential medical services and they cannot be shut down. The physicians continued to work, with legally allowable replacement staff (albeit at reduced levels). All a picket line would do is harass patients, and that won’t win you public support.

Reports of harassment and even a serious medical event involving a replacement worker appeared, although it’s unverified. Again, instead of stopping to think “What exactly are we accomplishing here?” Smokey, doubled down, increased his insults to physicians, demanded that the Health Minister and Owen Sound Town Council get involved (he failed miserably). He also made a ludicrous allegation that physicians were “private and for profit”. Has Smokey not read the Canada Health Act? Physicians haven’t been private since 1984.

Apparently, ten of the 30 FHO staff got wise to what a lousy job Smokey and OPSEU were doing, and actually quit their jobs. Yet another opportunity for OPSEU to reflect on their own failures as a bargaining agent. But yet again, Smokey lashed out, this time by asking the College of Physicians and Surgeons of Ontario (CPSO) to get involved.

Let’s be clear, the letter written by OPSEU is a collection of hearsay without naming any one physician. As such, it cannot possibly be investigated by the CPSO. If they were to do so, it would diminish the already poor standing the CPSO has in the eye of most physicians, and would send a pall over the entire profession. They would almost certainly faced increased calls from physicians to lose self-regulation if there was anything other than a cursory “thank you, but this is outside of our purview” type response.

But the reality also is that a letter to regulatory body like this takes you beyond any hope of restoring trust in your team. It’s the one thing that has potential to destroy careers. It’s the one action that essentially screams “irreconcilable differences”. By going down this road, in what seems to be a desperate attempt to prove his worth, Smokey has caused a toxic meltdown to the point where there is no hope of a resolution.

The members of OPSEU Local 276 would do well at this point to really ask themselves if this is the kind of leadership they signed up for.

Can Helen Angus Save Ontario Health Care?

Health Care in Ontario has been in a state of crisis for many years now. I’ve practiced Family Medicine for 26 years, and I’ve never seenwait times so long, nor have I seen such a dismal moodamongst health care providers. Clearly, a major transformation of how health care is delivered needs to occur.

Ten days ago we saw a new government in Ontario. By glancing at twitter feeds and media reports, the biggest news in health care seemed to be about the appointment of new Health Minister Christine Elliott. Minister Elliott is an excellent person and will bring the kind of common sense to the Health Ministry that was completely absent during the Kathleen Wynne/Eric Hoskins years. BUT, the most important announcement last week (and one widely ignored by the media) was actually that of Helen Angus to role of Deputy Health Minister. She takes over for the widely dislikedBob Bell, who suddenly retired once the Liberals lost the election. Curious timing that retirement, considering the post is supposed to be apolitical.

You see, the Health Minister is the person who produces high-level strategic directions for health care service delivery. But it’s the Deputy Minister who actually carries out the grunt work and implements the processes to carry on these strategic directions. Having been part of many organizations, I’ve seen bureaucrats both greatly benefit – and greatly hinder – the implementation of these strategic directions. It will be up to Ms. Angus to do the heavy lifting, and transform the Health Care system.

Is she up to it? Her bio shows she has been heavily involved in health care for many years, including various roles at the Ontario Renal Network, Cancer Care Ontario, the Ministry of Health and others. She was actually the interim Deputy Minister of Health for five months, until the aforementioned Bob Bell was hired. Then she suddenly left the health care field altogether to help out the Ministry of Citizenship. (More curious timing there). So with that experience there is a sense that she will bring a steady hand to the position.

Based on her speech to the “Breakfast with the Chiefs” she also has the ability to “speak the language” of health care bureaucrats. Phrases like “shared accountability”, “transformation secretariat”, and “stream of work” fluidly roll off her tongue. Personally, I find these phrases vapid and incomprehensible (eHealth Ontario for example is not “still a journey” as she states, it’s a disaster). However, this kind of verbiage is needed to communicate with other health care leaders, so I’m glad that she is able use it.

What does she truly believe in as far as health care goes however? Assuming she wasn’t just towing a political line, it also appears from her speech that she recognizes the need to transform health care and break down the various silos in health care. Silos refer to the fact that we have a bunch of different organizations in health care, e.g. hospitals, home care, your doctor’s office, that operate independently, and often not in a co-ordinated manner.

When I was the Health Links lead physician for South Georgian Bay, I recall Deb Matthews referring to Ms. Angus as “the silo-buster”. Ms. Angus of course, never got to work on that because as mentioned, she suddenly left health care altogether when Bob Bell became the Deputy Health Minister. Bell, under the guidance of the pitiful Eric Hoskins and the forlorn Kathleen Wynne never got around to busting silos. Instead the three of them thought it would be better to get into a toxic, pernicious, and vexatious relationship with Ontario physicians. We all saw how that worked out.

Ms. Angus spoke of the need to make health care more patient centred, and improve access for patients. Part of that will require a significant streamline to Ontario’s bloated health care bureaucracy. Part of that will require she forces a dollop of common sense down her bureaucrats throats (why does it take two years to make a change when everybody agrees something is a good idea?).

The good news is that she appears to have some cover in that current Premier Doug Ford wants to run a fiscally responsible government and reduce bureaucracy (though by natural attrition as opposed to layoffs). More good news is that the Ontario Medical Association (with whom she must partner if any transformation is to occur), recently decided to temporarily suspend the arbitration process they are involved in, in order to hear the new governments position. As a gesture of good faith, they didn’t even ask for a concession for this move. If she can help to repair the noxious relationship created by the Liberals, and give doctors a meaningful say in how health care is delivered, she will be able to move more effectively in her goals.

It’s a big job ahead for her. For the sake of all Ontarians I wish her well. Our health care system is too important to be allowed to flounder any longer.

Good company in a journey makes the way seem shorter. — Izaak Walton