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.

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
Former Alberta Health Minister Tyler “You wanna fight?” Shandro

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.

OMA CEO Kimberly Moran

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).

Screenshot

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 PeriodDr. AlpineDr. 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 23/24One 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 -DecemberOne time payment of $89,583One 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
Ontario Health Minister Sylvia Jones

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.

Bureaucratic Vertigo in Ontario’s Home Care System

Bureaucratic vertigo in Ontario’s home care system, exacerbated by ineffective reforms and rebranding, has led to chaos and service stagnation, necessitating genuine engagement with frontline providers for meaningful transformation.

Dr. Merritt Cade (not their real name) is a concerned and experienced Ontario physician familiar with the current crisis in home care. Dr. Cade is worried about potential blowback from this blog that will affect their patients and so this blog is posted under a pseudonym.

Vertigo is a sensation where one perceives movement that isn’t happening. In the realm of healthcare administration, a similar phenomenon occurs—bureaucratic vertigo—an organizational dizziness that mimics change but leaves structures and systems untouched. Nowhere is this more glaring than in Ontario’s home care sector, a pivotal yet neglected component of our healthcare system.

In 2023, amid promises of reform, the Ontario government introduced Bill 135, the “Convenient Care at Home Act,” envisioning a streamlined home care service managed by Ontario Health atHome (OHAH). OHAH itself was to now be brought under the umbrella of Ontario Health, the implementation arm of the Ministry of Health. Hopes were pinned on this transformation bringing ease and efficiency. However, the reality has been a déjà vu of previous cycles of centralization and decentralization of health care structures, with patients and families shouldering the consequences.

Nowhere is the bureaucratic vertigo more evident than in the successive re-branding of home care over the last 8 years from “Community Care Access Centres (CCAC)” to “Local Health Integration Networks (LHINs)” in 2017 to “Home and Community Care Support Services (HCCSS)” in 2021, to the latest iteration, “Ontario Health atHome (OHAH)” in 2024. Meanwhile, regardless of the name used, the services provided by the home care system remained untouched.

Ontario Health and OHAH’s first substantive move—renegotiating contracts for medical supplies—illustrates how bureaucratic vertigo can lead to harmful consequences. Instead of solving issues, the new contract process disconnected decision-makers from frontline realities. The result? A severe shortage of medical supplies, medication delays, and a burden placed on already overwhelmed caregivers and families. Despite clear warnings from supply companies, these decisions disregarded frontline input, leaving healthcare providers to navigate chaos without support.

OHAH’s own front-line staff, the beleaguered Care Coordinators, were also caught completely off guard as rules regarding medications and catalogues of supplies changed overnight. Care Coordinators are the quarterbacks of the home care system, matching services to patients’ needs. What OHAH and Ontario Health did was akin to completely changing the playbook on their quarterbacks and teams, with sadly predictable results.

Despite all this, however, home care holds immense potential to address systemic challenges, from reducing ER congestion and the alternate level of care logjam to facilitating dignified end-of-life care at home instead of in hospitals. What is required is not another bureaucratic shuffle, but genuine engagement with those who understand home care’s nuances best: frontline providers. It is they who hold the practical knowledge necessary for meaningful reform.

The path forward demands that decision-making authority be shared with these healthcare professionals. Their experiences can inform policies that work in reality, not just on paper. This means abandoning the “bureaucrat knows best” mentality and embracing trust and collaboration. It means abandoning committees struck merely to check a box that says that frontline professionals were consulted when, in fact, their concerns do not meaningfully contribute to decisions made.

Furthermore, the status quo must not define future transformations. Further substantial changes to home care delivery, this time relating to the supply of equipment such as hospital beds, wheelchairs, walkers and other essential aids, was planned for rollout in October but has been delayed until January. Without a change in approach, we should expect similar upheaval when this takes place. Past failures demonstrate that superficial organizational changes do not equate to operational improvements. Genuine progress relies on a foundational renewal of leadership and strategy, prioritizing empathy, accountability, and proactive stakeholder engagement.

If we are to lift Ontario’s home care from its current crisis, change must be substantive, rooted in the insights of those who deliver care day-in, day-out. We must move beyond the spectre of bureaucratic vertigo and commit to sensible, informed solutions that truly benefit patients and families across the province. By trusting, listening to and involving the frontline, we can stop the spin and start the real work of reform.

Bureaucratic Stupidity in Covid Vaccine Clinic Case Will Have Far Reaching Consequences

I’ve repeatedly been told that I am too unkind and too harsh to Ministry of Health (MOH) bureaucrats. A senior staff member at the OMA once suggested I was “out of line” to a very sharp (but necessary) scolding I gave an MOH bureaucrat at a bilateral meeting we had. About a month later, that same senior staff person, when on a voice conference call with the same bureaucrat, got up and wrote “This is a waste of time” on a chalkboard at OMA headquarters. But I digress.

Yet every time I try to pull back, these same bureaucrats go and do something that is so incomprehensibly stupid that I once again wonder about the talent level and frankly intelligence of the bureaucracy as a whole at the MOH.

On this occasion, I’m referring to the Ontario Health Insurance Plan’s (OHIP) relentless persecution of Dr. Elaine Ma. The whole mess has been extensively reported and you can read all the details in the links, but I will summarize key points below:

October 25, 2024

Dr. Ma’s clinic in Kingston suddenly cancelled its October 26 drive thru flu/covid vaccine clinic. Over 600 patients had registered with more pending. The reason is that OHIP had notified her that she would not be paid to vaccinate patients at the clinic. Why? Because she was going to have medical students (who would be supervised) vaccinate. According to a 2001 bulletin OHIP pulled out, students are not employees and so she can’t delegate to them. (OHIPs story keeps changing and you’ll see that further down the blog). It also emerged that OHIP was attempting to recoup funds paid to her for running similar vaccine clinics in 2021.

October 30, 2024

It was now reported that OHIP was demanding Dr. Ma repay $600,000 that she billed to run outdoor vaccination clinics. She ran a number of mass Covid vaccinations clinics that gave over 35,000 shots. These were set up by her in response to the provinces call to “get shots in peoples arms“at the height of the Covid pandemic. Dr. Ma was widely lauded for her efforts at the time – and won the Ontario College of Family Physicians award of Excellence. Her area became the most vaccinated area of the province, something that should be celebrated.

OHIP now claims that she didn’t follow the rules for billing. Their excuse this time? That clinic was outdoors and not in a doctor’s office. (I told you OHIPs story would keep changing). Yes, you did read that right. In the middle of a pandemic caused by an airborne virus, OHIP wanted the vaccination clinics to be held in crowded indoor spaces!

November 1, 2024

Dr. Ma had rapidly gained the public support of the local medical officer of health (there was likely background support previously). She also had the support (previously background now public) of her MPP, the OMA and many others. She did not get the public support of Dr. Jane Philpott. Dr. Philpott, in her role as Dean of Queens Medical school was full of praise for the clinics. I suspect Dr. Philpott has 550,000 reasons to stay quiet publicly now. Hopefully she can influence behind the scenes.

OHIP now stated that the concern was that Dr. Ma used some of the funds to pay the staff who worked there. You read that right. They were worried because a physician billed OHIP (gasp!) then took the funds to pay overhead (double gasp!!). The horror!

Hannah Jensen, the Minister of Health’s Communications Director initially simply parroted the line that OHIP bureaucrats fed her about being ineligible to bill because of using medical students and it being outdoors. But she was rapidly exposed as being completely out of her depth when the Kingstonist questioned her about dates, which doctor, which clinics, how she arrived at figures and so on.

Additionally, her tone took a seriously ugly and aggressive turn. There was an accusation that Dr. Ma “pocketed the funds” which essentially is an accusation of theft. (No law enforcement is involved….yet).

November 7, 2024

The story hit the national news and it was reported that not only was OHIP asking Dr. Ma to pay back $600,000, but they were demanding $35K in interest as well (!). Who knew OHIP bureaucrats moonlighted as loan sharks??

November 8, 2024

Dr. Hijazi, leader of the Ontario Union of Family Physicians was interviewed by the CBC . He obviously was supportive of Dr. Ma demanded that the Ministry apologize to her. The Ministry issued an utterly and completely delusional statement to CBC radio stating that claims Ontario can’t get family physicians are “fictitious”. (Listen to the last 30 seconds at the link). 2.5 million people can’t get a family doctor in this province because doctors don’t want to work comprehensive care is “fictitious”????

Nothing much to see here. Just a fictitious clinic in Kingston, where fictitious people without a family doctor lined up hoping to get a doctor because a fictitious family doctor announced a new practice..

What consequences are there to this?

To0 many to mention, and they are all awful. Perry Brodkin, OHIPs former lawyer was quoted extensively in the articles about process. He pointed out that before attempting to recoup these funds, the bureaucrats would have run it up the chain to the deputy minister if not the health minister. There is therefore no doubt that this egregious action is one of the bureaucracy as a whole as opposed to one rogue bureaucrat. This cements the feeling that many physicians increasingly have had that bureaucrats as a whole are malicious (especially after the nonsense they claimed during arbitration).

It also badly threatens medical teaching. If the appeal that Dr. Ma filed is unsuccessful, then it essentially means that physicians would not get paid for teaching medical students. Which would effectively end teaching in Ontario. How exactly do you plan to replace the current supply of physicians as they age out, if no one will teach new ones?

With the story hitting the national news on CBC, it also will significantly impair attempts to recruit physicians from out of province. We are already losing younger doctors to provinces like BC and Manitoba where they see a co-operative relationship between government and physicians. Why would any of them come to a Province where you are called a hero one day, and then publicly embarrassed, harassed and vilified over a clearly outdated memo that needed to put aside during a once in a lifetime pandemic?

What SHOULD happen next (but probably won’t)

Unfortunately, Brodkin also points out that at this point there is nothing that will influence the appeal board. The process could have been stopped earlier before the hearing, but Sylvia Jones and her staff chose not to. But, if Dr. Ma wins, the government should immediately announce they will not appeal the decision to the courts. Additionally, Hannah Jensen needs to publicly apologize for her…..out of line…..comment on “pocketing” funds. And Sylvia Jones should also offer up an apology to Dr. Ma for the failure of her bureaucrats to recognize that rigid adherence to minutiae in a time of crisis is completely unacceptable.

Finally, what badly needs to be done is that the entire Ministry of Health bureaucracy needs to be given a very large enema to clear out the…….

Sunday Snippets – November 17, 2024

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: New reports show that marijuana use is linked to thinning of brains in adolescents.

My thoughts: It’s not just adolescents. And it’s not just brains. I’ve seen a marked rise in people with significant mood issues ever since marijuana was legalized. There has also been a significant rise in people with stomach/bowel issues in my practice that all other tests turn up negative for. Patients with these issues are invariably marijuana users and the blunt reality is they won’t get better until they stop. I continue to be in favour of decriminalizing marijuana and other illicit street drugs if and only if we do it the way Portugal did it and not the haphazard way it is being done in Canada. But we really need to re-think the full on legalization of it.

Item: A survey in Medscape showed that there were two factors critical to reducing family medicine burnout. First would be to reduce the Electronic Health Record burden, particularly the number of times family physicians have to chart from home. Second would be to build stronger physician/nurse teams. Crucially, the teams need to be led by the family physician and NOT a bureaucrat or some other team member.

My thoughts: I hope this finally gets the Canadian Medical Association (which despite over $2 billion dollars in their bank account is amazingly growing increasingly irrelevant to front line physicians) to SHUT UP ABOUT SICK NOTES ALREADY. That’s not going to solve burnout (even though I like every other doctor hate doing them). To paraphrase a political slogan – “It’s the Electronic Health Record, stupid.” My second thought is that I remain extremely concerned that while I do feel Dr. Jane Philpott is well intentioned in her new role (to lead a primary care action team) – the bureaucrats at Ontario Health will sabotage her. They will see “teams help”, then create teams that have the assistant to the secretary to the aide to deputy minister’s attache for the Primary Care Secretariat’s deputy vice president run them. That will be a disaster. Teams need to be led by family physicians. Full stop.

Dr. Jane Philpott, head of the new “Primary Care Action Team” designed to give everyone access to primary care in 5 years.

Item(s): The family physician crisis in Ontario continues to worsen. Tillsonburg lost four family physicians. Wallaceburg is launching a large physician recruitment program to deal with their shortage. Brantford is taking a more hands on role to get more family physicians. Brockville is hiring a consulting firm that employs former health Minister George Smitherman to help tackle their shortage.

My thoughts: It’s sad that we are in a seeming “Hunger Games” of one community fighting another for the precious resource that is a family doctor. If only someone had warned people a crisis was coming. Oh, right.

Dr. Nadia Alam, who, like others, warned that the crisis in family medicine (and health in care in general) was coming ten years ago, and was ignored by governments.

Item: Premier Ford promises to correct the mistakes at Ontario Health at Home that led to a large amount of suffering for patients. He also stated that the people who “messed this up” will be “held accountable”.

My thoughts: I’ll believe it when I see it. When I wrote about mismanaged bureaucracy in health care (back in 2015!) I pointed out that no decision seems to get made by bureaucrats without continuously “circling back” to one committee or another. The reason I’ve discovered, is because this way, no individual gets blamed for (the very many) bad decisions made in health care. I’ve yet to see a health care bureaucrat fired – and I’ve met many who deserved to be. I really hope that the comments by Premier Ford signal a return to the old Doug Ford who promised to end the “gravy train” and famously said:


“What drives me crazy is when you have a supervisor in government, and they report into 12 other supervisors. That’s unacceptable.“

Doug Ford, Premier of Ontario for almost 7 years, and the gravy train in Ontario Heath continues unabated

Item: Male doctors are working less hours in a week than they used to. They are still working more than the average Canadian worker, but there has been an unmistakable decrease in how many hours they work

My thoughts: Finally! Proof that men are getting smarter! There’s more to life than work, and good for the younger docs – all of them – for seeking balance in their lives.

Item: A young Ontario mother died of cholangiocarcinoma (cancer of the gall bladder), after encountering multiple road blocks getting a new treatment (Pemigatnib) approved for her.

My thoughts: This story is absolutely infuriating and encapsulates what is wrong with our health care system. Look, there is no guarantee that she would have survived if she had gotten the treatment (it’s an awful cancer she had). BUT – look at all the regulatory agencies involved in getting the drug approved. Health Canada approved the drug in 2021. But the Canadian Agency for Drugs and Technology in Health said the evidence wasn’t clear. (So why then did Health Canada approve it?). Furthermore there are multiple provincial drug agencies involved, which means she could have gotten it had she been a resident of Quebec, but not Ontario (two tier medicine anyone?). It’s the bureaucracy and double speak from having too many agencies involved that angers me greatly. A wholesale streamlining of the process for medication approvals is desperately needed.

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

Sunday Snippets – November 10, 2024

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: An article in the College of Family Physicians of Canada Journal suggests that “recycling” physicians would help address family physician shortages. This includes “Physicians who have had successful careers in general surgery, emergency medicine, family medicine, hospitalist practices, and other specialties…”

My thoughts: Sigh. I get that the Journal is trying to be open to all views to stir discussion. I get that we are in a family practice crisis in all of Canada right now and looking at unique ways of helping. But seriously – you want to turn a retired general surgeon into a pseudo family doctor? Do you realize just how much you are denigrating family physicians by writing that a good chunk of their jobs can be replaced by people who haven’t done the residency? Some ideas belong in the trash heap and this one deserves to go there. Comprehensive care family physicians CANNOT BE REPLACED by anyone other than another properly trained comprehensive care family physician.

Item: It seems that Quebec is looking to find ways to force doctors to stay in the province and work in their public health system. They are even willing to as far as considering to use the Notwithstanding clause in the Constitution (which they would have to, as their initial position impinges on freedom of movement/assembly to make this happen).

My thoughts: It really does kill me to use Star Wars memes instead of Star Trek ones (really and truly). But once again, for this issue – I’m going to quote Star Wars character Princess Leia:

I honestly don’t know what to do with politicians anymore. There is ample, repeated, overwhelming evidence that whenever they pick fights with physicians, they inevitably lose and health care suffers. And yet they keep doing it.

Item: Dr. Corli Barnes (who I was honoured to have as a guest blogger) wrote in McLean’s Magazine (cover story no less!) about why she moved to Madoc, Ontario and the incentives they provided. I understand she took less than what is listed in the article’s headline, but there were incentives.

Dr. Corli Barnes

My thoughts: I’m happy for Dr. Barnes. I’m happy for the people in her community as well, as they are going to get healthcare from a dedicated family physician and their well being will improve as a result. But I really do wish that our system was no so fragmented and that all communities could offer a consistent level of support to their family physicians.

Item: Premier Doug Ford told patients with minor illnesses not to go to the ER. In response, Drs. Drummond and Venugopal had an op ed where they point out that the Premier is not qualified to determine what is an Emergency.

Dr. Allan Drumond
Dr. Raghu Venugopal

My thoughts: This will surprise some of you who know that I personally favour the Tommy Douglas model of health care, which supports user fees to dissuade misuse of the health care system. However, that is frankly up to the patients to decide for themselves. Drs. Drummond and Venugopal are correct in saying that politicians are not qualified to hand out medical advice, and should not be saying stuff like this.

Item: A study out of Michigan suggests that more virtual care will not lead to more unnecessary testing. A huge concern has been that if you cannot see a patient in person to assess this, a physician would be more likely to order a test “just to be sure”. This study suggests no.

My thoughts: I think the big flaw of this study is that it looked at patients who were in existing practices getting virtual care from their own physicians. There is a HUGE difference between getting care from your own physician virtually, or getting it virtually from someone you have never met before on some fancy looking app. The two are not the same and it would be very interesting to see how many unnecessary tests are done when there isn’t a pre-existing physician/patient relationship.

Item: Amina Zafar had an excellent piece in the CBC writing about how poorly managed your medical information is. She builds on the story of Greg Price, an unfortunate 31 year old who died of testicular cancer, when he probably shouldn’t have. She writes how this mismanagement of health care information is common in Canada.

My thoughts: Yes, yes, yes, a thousand times yes. As far as I’m concerned, the mismanagement of health IT should be the number one issue to be addressed in health care. It creates countless inefficiencies in our health care system. It creates all sorts of admin burden. It leads to much higher expenditures and duplicate testing. This needs to get fixed ASAP.

Item: The Ontario Medical Association (OMA) announced that nominations are open for their annual election periods. Up for grabs are four Board Director positions and many other District and Section positions.

My thoughts: Physicians in Ontario desperately need a strong OMA. The only way that can happen is if front line physicians stand up and take positions. I’ll be frank (and will offend a bunch of people) – but when I was on the Board there were too many Board Directors who clearly were in it for their own self interest and were not thinking of their colleagues. The same could be said for some other elected reps. We will get the OMA we deserve, but only if front line docs take a leading role.