#medicine – Page 4 – justanoldcountrydoctor

Sunday Snippets – Oct. 27, 2024

I was away last week but I’m back with 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: There was significant growth in the number of physicians in Alberta in the third quarter.

My Thoughts: Alberta is kind of a funny province. There are some very strange goings on with their health care policy. But it can’t be denied that despite all of that, if you provide incentives to attract younger physicians it will help. Having said that, it can all be easily undone if they don’t get on with it and implement the compensation for family physicians they promised, and for some reason appears to be delayed.

Item: The province of Nova Scotia has launched a physicians retirement fund initiative, helping physicians to retire well.

My Thoughts: What’s that you say? You mean ensuring that physicians have peace of mind about their retirement might actually help recruit (gasp!) and even retain (double gasp!!) physicians? Who would have thunk it?? In all seriousness, given the way the Federal Liberal government of our effete Prime Minister really screwed physicians with the recent tax law changes – this is a necessary move and I hope will get copied by all provinces. It really will help improve morale and reduce some of the burnout.

Item: John Richards and Tingting Zhang, from the CD Howe Institute wrote an op-ed in the Financial Post encouraging more use of nurse practitioners since they can “do almost everything an MD can”.

My Thoughts: El Toro Poo Poo. (This is a PG rated blog so that’s all I could get away with). I work with Nurse Practitioners and I have seen them help patients and I firmly believe they have a role in health care. But that role is not to replace physicians. The studies that show they can “do almost everything” are done based on what scope of practice suggests they can do. The blunt reality is nurse practitioners drive up costs and worsen care if used in settings as these characters suggest. The studies that show that NPs are cheaper ONLY look at the actual income an NP gets and compare it to a physicians income, as opposed to looking at the work that is actually done/number of patients seen/and number of tests ordered. The FP article isn’t even fit to be used for toilet paper.

Item: The crisis in Home Care supplies, first reported by Avis Favaro on X (formerly Twitter) continues. Home care nurses are reporting heartbreaking stories of patients buying their own supplies on Amazon since home care couldn’t provide them. Dr. Drew Moore and Dr. Hal Berman should be lauded for going public with their concerns. (I’ve met both of them and they are both mensches).

My Thoughts: I’m old. I’ve seen a lot of government screw ups in my time, especially in health care. But I have yet to see bureaucrats who screw up be truly held accountable and fired. Ever. They just get shuffled off to some other department. It it too much to ask that if someone makes a mistake at their job (and this is a BIG one) they get held accountable?

Item: Quebec is attacking family doctors for some reason. First they suggested they would link people to non-family physicians for care and even remove patients who were “healthy” from their own family physicians. Then they presented erroneous data suggesting that family doctors basically don’t work hard enough.

My Thoughts: There are 9 other provinces and 3 territories that would love to have these doctors.

Item: Penn State Medical Residents unionized, went on strike and got significant benefits (despite being driven off the hospital grounds by hospital security!)

My thoughts: Unionization of physicians is going to happen eventually. Whether through the long gestating Charter Challenge (yes my Ontario peeps – it is still working its way through the courts) or some other mechanism. The younger physicians clearly seem to want this model of representation and at some point in the not too distance future, physicians will be unionized.

Item: The Ontario government announced plans to effectively bar foreign students from attending medical school in Ontario.

My thoughts: My thanks to Am640 News for interviewing me on the topic, and my thoughts on this can be heard below. (This short version – this is populist rhetoric that will do nothing to help with the health care crisis):

My Interview on AM640 About the Current Crisis in Home Care

Was pleased to be interviewed by Ben Mulroney today discussing the current crisis in Home Care in Ontario. Unfortunately, the Ontario Health bureaucrats have really mucked up the process of ordering supplies for vulnerable patients at home, leading to immense suffering for patients at home and their loved ones.

Click below to hear more:

https://podcasts.apple.com/au/podcast/shortage-of-medical-supplies-needs-an-urgent-fix/id1677003384?i=1000673744931

Arbitration Part III: When and How Much Will Docs Get Paid?

Disclaimer: The information is based on my personal analysis and should not be your sole source of information. The payment schedule below is based on what we were told was “PLANNED”. Being a firm believer in “Murphy’s Law“, I would suggest that changes to the below may come at any time. Contact info@oma.org with any questions.

After writing why the Arbitration Award will be bad for patients and doctors, it seems my three loyal readers were unhappy that I couldn’t say when docs would be paid. Being a demure, sensitive, and eager to please sort, I feel compelled to try my best to explain when money is coming.

Once again, my two examples are Drs. Alpine and Valley. Both had 13 years of post secondary education (4 years for a BSc, 4 years for medical school and 5 years for residency). Dr. Alpine does a lot of procedures and can see more patients than he could 20 years ago due to improved technology. Dr. Valley spends a lot of time with intensively sick patients, so she sees the same number of patients as 20 years ago.

What assumptions am I making for the Calculations?

Drs. Alpine and Valley will each provide same number of OHIP services yearly from 2023 – 2026. We have to assume that the entire 2.8 % increase from last year, and the 9.95% award this year will be given across the board (ATB) until April 1, 2025. (The OMA and MOH could reach an agreement on distributing the funds more fairly- but I highly doubt it). We’ll also assume that the schedule for payments the OMA provided at their webinar will be met – I remain very skeptical.

Let’s assume Dr. Alpine billed OHIP an average of $100,000 a month for fiscal 2022/23 and Dr. Valley billed OHIP $30,000 a month. This time period is the base rate for OMA calculations, and hence mine. (Physicians who read this blog can put their average 2022/23 monthly billings into the calculations below to find out their own numbers).

What happened for April 1, 2023 to March 31, 2024?

The OMA and MOH agreed to a 2.8% increase in fees that was to be divided into across the board (ATB) increases and relativity increases. Because the agreement came late, and the OHIP Computers couldn’t be updated (sigh), Drs. Alpine and Valley continued to bill OHIP at the same rate as 2022/23.

What happened on April 1, 2024?

The OHIP computers finally updated to reflect the previous year’s increase. Since the two sides didn’t agree on a relatively formula, the 2.8% was given ATB. Dr. Alpine’s gross income went to $102,800 a month. Dr. Valley’s went to $30,840. Both increases showed up on the May Remittance. Doubtful Dr. Valley even noticed her increase.

What will happen on the Nov. 2024 Remittance ?

Well, finally all the reviewing and rejecting and re-submitting of claims for the year April 1, 2023 to March 31, 2024 will have happened. The computers will then pay the retroactive 2.8% amount of this year to the doctors. Dr. Alpine will get an additional $33,600 (1.028 x $100,000 x 12) on his remittance for retroactive pay. Dr. Valley will get $10,080 (1.028 x $30,000 x 12).

Isn’t there a drop beginning in December 2024?

The increase drops to 2.55% and the funds saved are dedicated to enhancing the Hospital On Call Coverage program (HOCC). Dr. Alpine will now see $102,550 (1.0255 x $100,000 and Dr. Valley will start to get $30, 765 (1.0255 x $30,000).

What happens for the January – March 2025 Remittance Advice?

Allegedly, the OHIP computers will be able to apply the 9.95% increase for this year now (I’ll believe it when I see it). The word “prospective payment” was used in the webinar, but I don’t know what that means. This increase is compounded to the now 2.55% from the previous year. As a result, starting with the January remittance, Dr. Alpine will now get $112,753.73 ( 1.0255 x 1.0995 x $100,000) a month from OHIP. Dr. Valley will be at $33,826.12 a month.

What is supposed to happen on the March 2025 Remittance?

What’s that you say? Wasn’t the 9.95% increase supposed to start on April 1, 2024? So what happened to all that money? Well, according to the OMA you will get a lump sum payment for April to December in the March remittance. Dr. Alpine can expect to see a one time retroactive payment of $89,583. 57 ($112,753.73 that he should have gotten subtracting the $102,800 that he did get, multiplied by 9 months) and Dr. Valley will get $26,875.08. This is in addition to their usual remittance.

OK, What Happens After April 1, 2025?

Well at this point the new ‘permanent’ fees are supposed to kick in. Up until now, everyone has been given ATB increases. Whatever is negotiated or arbitrated, is supposed to start now. However, the base rate will be the 2022/23 rates. In a previous blog, I assumed that we would carry on the process of giving 1/4 of the increase as ATB and 3/4 via relativity. IF this is done (not sure if it will be) then every speciality will get 2.46% (0.7% for last year + 1.75% this year, compounded) plus X percent – with the X varying from speciality to specialty based on relativity.

Let’s assume Dr. Alpine’s speciality got an X=0% and that Dr. Valley’s got X = 17.54%. In that case Dr. Alpine will now get $102,460 a month:

$100,000 base rate from 2022/23 x (1.0246 ATB increase + 0 for relativity).

Dr. Valley on the other hand will get $36,000 a month:

$30,000 base rate from 2022/23 x (1.0246 ATB +.1754 for relativity).

I imagine Dr. Alpine will be annoyed.

What are the chances of the new fees being ready on April 1, 2025?

Slim to none. Militancy on the part of the MOH and incompetence on the part of bureaucrats in charge of OHIP are two constants as sure as death and taxes.

Um…well what happens to our monthly incomes after April 1, 2025?

I honestly can’t figure that part out (and not for lack of trying). The procedural agreement states:

“Any unexpended portion of the targeted price increases will continue to be paid to physicians as a separate payment on the monthly Remittance Advice until such time as each targeted increase is implemented or unless the parties agree otherwise.”

This is the part that I think most people have missed (including, frankly, the OMA Board that approved this agreement – and yes I know it was an attempt to get real money in the hands of physicians). It’s one thing to accept 2.8% ATB. But to accept 12.75% ATB (2.55% from last year compounded with 9.95% from this year) is a bit much. You really have to wonder if there wasn’t a fairer way to spend this money, especially with so many Dr. Valley’s struggling. Time will tell what happens here.

Geez old country doctor, all you’ve done is fuzzify the muddification!

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

SPECIAL MESSAGE FOR FAMILY PHYSICIANS ONLY

Those of you who have read my blogs know that I (and many others) are really really upset with College of Family Physicians of Canada for inviting Dr. David Price to be a keynote speaker at the Family Medicine Forum. I view it as a slap in the face to family physicians, given his role on the Ontario Government’s Negotiations Team.

The Ontario Union of Family Physicians would seem to agree with me. They are asking all family physicians to sign the petition below to have Dr. Price removed as a Keynote speaker. PLEASE click on this link to read and I encourage you to sign.

Arbitration Part II: Award Implementation Will Hurt Physicians/Patients

Disclaimer: The information below is based on what a non-lawyer (i.e. me) was able to sort out after reading the OMA and Ministry’s 2024-2028 Procedural Agreement, the OMA Legal Counsel’s summary of the award, and attending the OMA Zoom session on the award. This may not be accurate (and I will correct the blog if more relevant information becomes available). I encourage all OMA members to contact the OMA directly with specific questions (info@oma.org) and not rely on this blog as your sole source of information.

OMA Negotiations Counsel Howard Goldblatt

The Numbers

First, let’s again review the numbers (approximated for simplicity).

Physician Services Budget, fiscal year ending March 2024: $16 Billion +

Arbitration Award: 9.95% – approximately $1.6 billion

OMA/MOH agreement on split of funds: 70% ($1.12 Billion) to fee increases and 30 %( $480 million) to targeted programs.

Previous contract (no guarantee this will repeat): 25% of the fee increases ($280 million) would go to across the board (ATB) fee increases for entire profession. The remainder ($840 million) would be distributed on the basis of relativity (giving more of a raise to low earning specialties and less to higher earning specialties). IF this pattern repeats, this equals a 1.75% increase for everyone. Then each specialty would get assigned an additional percentage (let’s say X) based on relativity. Ergo everyone should get 1.75% + X, where X varies from zero (for high billers) to higher (for lower billers).

The Implementation

According to the OMA webinar, the OMA and Ministry have yet to agree how to distribute the award. Mediation starts early October and all of this might wind up in Arbitration in March of 2025. My sense from watching the webinar is they are not close on an agreement.

So what happens to the money for this year? We are all supposed to get a raise now right? Well, that’s when the procedural agreement takes effect. It states (sorry for the legalese):

The Year 1 price increase will be implemented as follows:
a. The entire price increase under the Year 1 2024-28 PSA will be implemented
prospectively as an across-the-board increase to the fee-for-service payments
identified in paragraph 1a above, with a target date of the RA in the month 90
days following the issuance of the arbitration decision, and will flow through to
non-fee-for-service payments as soon as practicable.
b. A lump sum payment equal to the entire increase awarded for Year 1 for the
earlier period from April 1, 2024 through to the implementation date under
paragraph 12(a), will be paid as soon as practicable following the arbitration
award with a target date of October 2024.
c. To the extent practicable, the permanent year 1 non-targeted price increases
will be implemented at the same time as the April 1, 2023, price increases
under Year 3 of the of the 2021-24 PSA i.e. April 1, 2025, and in any event no
later than October 1, 2025. These increases will be calculated on a base of
2023-2024 expenditures …… The distribution as between across the board increases and relativity increases will be determined in such manner as the parties agree or, failing agreement, as the board of arbitration awards….

OMA staff confirmed at the webinar that this is in fact what will happen. They even had a complex schedule of prospective payments/lump sum payments/retroactive payments and so on that left me, frankly in need of high doses of Zofran.

To try and simplify things, let’s look at how this will affect two doctors.

Meet Drs. Alpine and Valley

Dr. Alpine and Dr. Valley both completed four years of an undergraduate degree. They then completed four years of medical school, and each did a five year residency in the field of their choosing. Dr. Alpine was always someone who liked to “do stuff”. He wound up in a speciality that does a lot of procedures and as technology has improved, has been able to treat more patients in a day than his specialty could 20 years ago.

Dr. Valley, who is no less smart, really enjoys patient interaction. She chose a specialty that requires more intensive time with patients, and as such, is not able to see more people in a day than someone in her field could 20 years ago.

With our aging population and increasingly complex health care needs – both Dr. Alpine and Dr. Valley are swamped and have long waiting lists.

Dr. Alpine, was able to bill OHIP $1 million for fiscal year ending March 2024. This represents his gross income, and to be fair, his office has a lot of leased medical equipment, along with staff that he has to pay for out of that $1 million. Dr. Valley billed OHIP $350 thousand for fiscal year ending March 2024. She too has staff and other overhead expenses, but not as much equipment.

What happens to Dr. Alpine and Dr. Valley under the procedural agreement? While the schedule for payments for the award is a convoluted mess, the reality is that for the fiscal year ending March 2025 – Dr. Alpine will gross $1.1 million, and Dr. Valley will gross $385,000.

Now the OMA states that the goal is to have new permanent fees in place based on relativity and targeted funding for April 1, 2025. The ONLY way this could happen is if the government negotiations team completely capitulates its positions in the next couple of weeks. Seriously people, the schedule shows that if there is no agreement this thing goes to Arbitration in early March 2025. IF that happens, it’s part and parcel of Arbitration for the 2-4 years of the contract. So the Arbitrator probably won’t even make a ruling until September 2025. Then another six months to re program the ancient OHIP computers and while the fees may be retroactive to April 1, 2025, you likely won’t see the money until Spring 2026.

Let’s assume that the arbitrator follows the precedent set where 1/4 of the increase ( $280 million) should indeed be ATB, and then distributes the rest based on relativity. And let’s assume that Dr. Alpine’s speciality was assigned an X of 0% and Dr. Valley got an X of 18.25%. Therefore Dr. Alpine for the fiscal year ending March 2026 will gross $1.0175 million – a reduction of $82,500 dollars from the year before. While Dr. Valley will get bumped to $420,000.

No matter how often the OMA reminds people that the increase for the first year is one time only, and NOT a permanent increase, the reality is that many members will have budgeted around their increase, and Dr. Alpine will, be very miffed at a $82,500 reduction in income for doing the same work.

But it’s not all that great for Dr. Valley either. She will have missed one year of a substantial increase that should have gone to her earlier. Not only that, but her offices cost pressures and admin workload have been skyrocketing. She needs the stability a relativity based formula provides right now, not in March of 2026.

Because of the delay in stabilizing her practice, she actually chose to leave her practice and do a different kind of medicine. Her patients now have to go back on a waiting list, and who knows when they can find someone to take over their care.

I understand why this procedural agreement was put in place. It was to ensure that doctors got a much need cash injection sooner rather than later. But unfortunately there are unintended consequences of this and those are coming to fruition. Specialists like Dr. Valley who need the relativity increases right now will not be able to hold out and may leave their practices. Dr. Alpine will be understandably miffed at the yoyoing of his income.

And all of this uncertainty will do nothing to help the health care system.

The Arbitration Award: The Good, The Bad, The Ugly

On Sep 12, Ontario Medical Association (OMA) Board Chair Dr. Cathy Faulds announced that the Kaplan Board of Arbitration awarded Ontario’s doctors 9.95% for the first year of their Physicians Services Agreement (PSA). Sounds straightforward right? Nope – it’s actually ridiculously complicated.

I’ve looked at the award. I may have some of this wrong (copious documents found on the OMA website induced catatonia, hypersomnolence and cluster headaches). But this is my take.

A simplified (I have a small brain) set of numbers first:

Total award: 10%, approx value $1.6 billion dollars

Amount for general feel increases: 7% or $1.12 billion dollars

Amount for “targeted funding”: 3% or $480 million dollars.

In the past the OMA and Ministry agreed 1/4 of the raises would be across the board, the rest done with “relativity in mind”. IF we do that again then $280 million (1/4 of $1.12 billion) will be in across the board increases. Every specialty would get a 1.75% raise. The rest of the money ( $840 million) would be for raises based on relativity. So all specialties would get 1.75% + X as a raise. The “X” would vary. It would be more for low income specialties, and the X would be lower or even zero, for the high income specialties.

The Good.
There’s a raise. The MOH Team stated that Bill 124 should not impact the deal. The arbitrator disagreed and felt that we were unfairly treated because of Bill 124 stating:

“Bill 124 directly impacted the bargaining even though physician compensation was not subject to its terms.”

Hence, the MOH Team completely lost their argument that there should be no redress, and there was a 6.95% redress given.

There was a recognition that family practice is in crisis. In his ruling the Arbitrator said:

“We accept on the evidence that there is a physician shortage. Somewhere between 1.35 million and 2.3 million people in the province are not attached to a family doctor. These are real numbers. The Ministry’s own documents – which we ordered disclosed–demonstrate that there is a problem to address.”

The arbitrator had to order the Ministry to disclose this?? Jeez. Additionally, the Arbitrator noted:

“Clearly, more family doctors are needed as are more doctors practising comprehensive longitudinal medicine…..it is obvious that the citizenry is ageing – the Government acknowledges this brings with it increased complexity…”

Contrast this with the Ministry’s absolutely laughable position that there is “no concern” about a shortage of doctors. This is frankly a warning shot, and a welcome one, to the MOH’s negotiations team to not say such stupid things again, and to change their position in future rounds of negotiations.

Dr. David Price, member of the Ministry’s negotiations team

In another shot to the now obviously inept MOH Negotiations Team, the Arbitrator agreed that admin burden also needed to be addressed with, you know, money. He stated:

“We have reached the conclusion that targeted increases – not necessarily baked in – should be allocated to the reduction and redeployment of administrative work that can best be performed by others or through digital or other measures.”

Finally, It was quick. OMA Board Chair Cathy Faulds had told us not to expect an award until the end of September. Who knows why Kaplan put the award out so quickly.

The Bad.

This will not be enough. The OMA asked for a 22.9% increase. They got less than half of that. This is not really the big win the OMA is portraying it as.

A 10% increase in gross billings for family medicine will not be enough to stop the haemorrhaging of doctors from comprehensive family practice. The “X” for family medicine (see above) needs to be high, and much of the targeted funding needs to go to family medicine too.

And, while it’s true that the Arbitrator recognized there was a crisis in family medicine, the award given did not really do anything in and of itself to stabilize family medicine. It’s true that was not part of the scope of the arbitrator for this round (this round was for a fee increase). The fact that some practical guidance in how to resuscitate family medicine is missing is still bad for all Ontarians.

The Ugly

The implementation of this award is going to be a nightmare. As I write this, there is no indication that the MOH and OMA have agreed on how to divide up the $1.12 billion in general fee increases based on relativity. In fact, indications are that the MOH will continue to fight the methodology, meaning it could be a very long time before fee increases for specialties are set.

Worse, the OMA and MOH have not been able to agree on how to distribute the $480 million in targeted funds. Which means….more mediation and arbitration. I continue to concede that the OMA states arbitration and mediation will be done by mid- March 2025. I continue to not hold my breath.

Even uglier is that one solution being proposed would be to give “everyone” a 9.95% increase right now, until the relativity and targeted funding is sorted out. But that would mean that some of the higher paid specialties would see a 9.95% for a bit, only to have a relative cut once the final fees are sorted out (also to be arbitrated by March 3-7, 2025). No matter how you message this to warn people – this will cause problems when people see a decrease in income after a rise.

All of which means that the retroactive pay for this year may not come for over a year. If you are a physician who has some decisions to make (eg do you renew the lease on your office at the higher rates the landlord is demanding) – you are going to be awash in uncertainty.

The ugliest part of all of course, is that a bunch of lawyers are going to get really rich as their billable hours go through the roof during this process.

There is a better way.

The government’s main concern should be about expenditures. That decision has now been made for them. The PSB will go up by $1.6 billion. That money will have to be paid one way or another.

The government can now, especially after being told off by the Arbitrator back off from their polarizing and obstructionist path, accept the OMA proposals for implementing the award. They cover what the government states it wanted (pay lower paid specialist more of an increase than higher paid ones). They also covers issues around admin burden which the Arbitrator acknowledged exist, and the shortage of family physicians (which the arbitrator also acknowledged).

The total amount spent by the government is going to be $1.6 billion regardless. Getting rapid agreement on the distribution of those funds will decrease the uncertainty about how much goes where and will shorten the time it takes doctors to get paid, which will stabilize the health care system.

Then, for the love of Allah/God/Yahweh/Great Universal Consciousness – the government now needs to realize that you can’t fix health care without working co-operatively with your doctors. Go look at other provinces. Copy them and get a fair deal for years 2-4 of this agreement.

Or the government can continue to obstruct, obfuscate, delay and impede any real progress towards working together with more protracted, internecine mediation and arbitration. The ball is in their court.

What should doctors do?

The above represent my personal interpretations of the documents I read. I encourage all Ontario physicians to register for the OMA live session on Tuesday Sep 17 from 7:30 – 8:30 pm to hear more details about this agreement.

Reflections on Leaving Family Practice

My thanks to Dr. Ramsey Hijazi, founder of the OUFP, and one of the strongest advocates for improving family medicine that I know, for guest blogging for me today. Unfortunately, the government didn’t listen to Dr. Hijazi, and as a result he left family practice earlier this year. In this blog he reflects on how his life has changed since.

It was a busy Saturday morning at my daughter’s dance competition in April 2024. The family had all got up at 5am to get ready for the day. The morning was hectic getting the kids and dog dressed and fed, making sure we didn’t forget supplies for the day, packing snacks and then rushing across the city to Hull for the competition.

My wife helped bring my daughter and her sister backstage to get dressed and prepare for practice. I watched my 2 year old son run tirelessly down the hall of the venue screaming in pleasure. I watched with a sense of calm and patience that I hadn’t felt in a very long time. More than I can remember I felt….present. The previous day I had left my family practice to pursue a position as a hospitalist. In less than 24 hours (and to my own disbelief) I noticed a distinct difference in my frame of mind.

Leaving family practice was not an easy decision. It is a rewarding and challenging career where you can make a positive difference in the lives of your patients. You get to know your patients better than anyone else in the medical system as you care for them from birth to old age. Their journeys in the medical system can remain with you forever. I became a family doctor because I loved family medicine and I am grateful for having had the opportunity to practice and take care of my patients. It is also part of the reason I started the Ontario Union of Family Physicians in July 2023 to help advocate for changes to improve the working conditions of family doctors. I had hoped to continue this work.

However, over the last several years the landscape of family practice has deteriorated significantly. The administrative or paperwork burden in family medicine has ballooned to almost 20 hrs/week. It is a constant barrage of work that is being downloaded or dumped on to family doctors from specialists, insurance companies and pharmacies. There’s also the extraordinary duplication of lengthy and sometimes irrelevant hospital reports that come in daily for review.

In essence, you supervise every single step all of your patients take in the medical system whether you have seen them recently or not. You ensure that tests and follow ups are completed and that nothing falls through the cracks. If my patients did not have me overseeing their journey in the system, countless tests and follow ups would get missed and never take place.

Like it or not, family physicians have been unofficially assigned the responsibility to make sure things actually get done when no one else will. It is mentally exhausting. There were days I would come home from work feeling so overstimulated I could do nothing more than sit on the couch and keep silently to myself for the rest of the night (although young kids make that a difficult reality to realize).

In an age where patients can simply email their family doctor you are never unplugged from your job. Despite trying to convince myself that I wouldn’t think or worry about work on vacation, I couldn’t help but have intrusive thoughts that occupied my mind. I would drift away from the present moment I was trying to enjoy. Often I would use the first and last days of my vacation as a desperate attempt to try and be caught up.

On weekends when not much was happening, such as watching TV with the kids or supervising them in the backyard I also couldn’t help but have the same intrusive thoughts of thinking my time could be better spent trying to catch up on the paperwork that was piling in. I very much resented having these thoughts.

Now add this to the stress of running a family practice. Business expenses have steadily increased with a dramatic spike in the last 3-4 years without any real increase in OHIP revenue. Running a business can be a stressful, but worthwhile endeavour. Unfortunately, this couldn’t be further from the reality of running a family practice. Revenue from OHIP continues to pay less year over year relative to inflation and expenses.

The OMA has kept track of OHIP rates relative to inflation to show current rates are only 37% of what OHIP used to pay physicians to run their practice. For the newer family doctors entering practice the future stability of the profession is truly grim. They enter practice with huge loads of debt and an almost guarantee they will take home less and less money every year despite the workload contrarily increasing year over year. With no pension, benefits, paid sick time or vacation to top it off, the reality for recent grads is that without significant changes to help the profession, it is no longer a viable career option.

Many family doctors work side jobs to help financially subsidize their practice. Granted, the entire medical system is plagued with poor working conditions, underfunding and increasing burdens of work, however, the situation is particularly magnified in family medicine. But you don’t need to take my word for it, just look around to see what is going on in your community and in our province. Despite the OMA showing statistics that we have more doctors trained in family medicine per capita than ever before, we are in one of the worst shortages ever.

Family doctors simply don’t want to do family medicine any more.

Changing my career path to work in the hospital as a hospitalist was a big risk and required a leap of faith (I hadn’t worked in a hospital since I finished residency). But unfortunately, in family medicine I had become increasingly unhappy professionally and personally. As it turns out, becoming a hospitalist was the best decision I could have ever made. Working in hospital means I am responsible only for the patients on my ward and not 1500 patients in the medical system. I must round on and see each patient to review their medical problems, perform examinations and order any tests or investigations. I follow up with family when needed and appropriate for medical updates. At the end of the day unless I am on call, I walk through the door to go home and my work is done until I arrive again the next morning. There is no appointment schedule to rigidly follow and I can take as much or as little time that is needed for each patient. If something unexpected occurs, I can deal with it and get back to my work without the worry or stress of being behind schedule and having irritated patients. It is also challenging and extremely rewarding.

No longer do I have all the stresses of running a business or see up to 40% of my OHIP billings go towards business expenses. No longer do I need to reconcile rushing several patients in and out of the clinic for appointments to stay on schedule and maintain a reasonable availability while also trying to give the appropriate time to address their concerns. No longer do I leave work at the end of the day, eat dinner with the family and go back to the computer to tackle the never ending pile of paperwork. No longer do I need to worry and stress while on vacation about all the work that is piling up in my absence. No longer do I have the intrusive thoughts of working on paperwork while watching the kids ride their bikes or to watch my son run down that venue hall aimlessly in pleasure.

I am more present and at peace. I am a better person, husband and parent because of my decision to leave family practice and that is perhaps the saddest and scariest thing about this entire journey.

It’s (Well PAST) Time to Review the Canada Health Act

The Canada Health Act (CHA).

Written by former Federal Health Minister Monique Begin, and passed into law forty (!) years ago, it transformed health care in Canada, and in many ways transformed the country.

Former Federal Politician and Health Minister Monique Begin

Viewed as sacrosanct by many pundits, it has now reached a status amongst politicians where health care is widely viewed as the “third rail” of Canadian politics. To question the reverential status of the CHA is to invite political ruin, and to be forever labeled as un-Canadian. I guarantee that I will be accused of being a proponent of “two-tier American style health care” simply for suggesting that the CHA should be reviewed.

Yet review it we must, because the reality is that a LOT has changed in health care in the past forty years. The CHA was written before the explosion of medical knowledge we have experienced. To expect it to still be appropriate is naive at best, willfully neglectful at worst. My much smarter friend Dr. Mathew pointed out: The CHA was written when health care was “episodic”. You got sick, you went to the doctor. You usually had a small co-payment. You got treated for the illness you had.

But since the CHA, health care has been massively transformed to focus on prevention. Whether with the explosion of screening tests for cancer, a focus on control of chronic illnesses, or a recognition of the benefits of being able to afford prescription medication, health care is different than 1984. In a big way. This is why the government is again promising pharmacare.

While there will always be a paper, or plan or policy on how to improve health care, very few people have the courage to address the root cause that is stagnating and impeding change, namely the CHA.

For example, Dr. Tara Kiran (Fidani Chair of Improvement and Innovation in Family Medicine at the University of Toronto) had a four part series on health care in the Medical Post where she compared Canada to Denmark. She looked at how Denmark organized their family doctors, how they pay physicians, their EXCELLENT health IT system and so on. All of which is wonderful and really should be emulated here in Canada.

Similarly, former federal Health Minister Dr. Jane Philpott has been in the news a lot with her new book “Health Care for All” in which she talks about the “right” to have a family doctor. In an interview with the Medical Post she glowingly references Norway, and how they build in health care infrastructure, much like they build schools, when planning developments. A lot to like about Norway’s health care system.

But, did you know that Denmark has a parallel private health care system (despite their high taxes) that allows faster access to care along with access to more specialists and other services? Did you know that in Norway, you actually pay for you health care at the point of service until you reach your deductible (2,000 Krone, about $250 Canadian)?

You mean Drs. Kiran and Philpott never mentioned that these countries whose health care systems they have been talking up had defacto co-payments for medical treatments (gasp!) and parallel private health care (gasp!). Gee, I wonder why….

Here’s the thing. EVERY single country that has a better health care system than Canada’s has TWO main features:

A universal health care system that is funded by taxes
An element of private care, usually some combination of a deductible for taxpayer funded services, and, a private system.

To deny the above is simply to deny the facts. To cherry pick what other countries do and to think we can do it here in Canada without also recognizing that much of what they do would contravene the CHA is naive at best, and disingenuous at worst.

Canada had a health care system that was ranked very highly in the mid-1980s. Ontario used to boast of having the “best health care system in the world”. It’s undeniable that since the CHA, health care in Canada has deteriorated markedly when compared to the rest of the world. This is not a coincidence.

What can be done? I believe the CHA should be changed to allow the federal government to have strong controls to ensure a fair universal health AND pharmacare program that functions like a true insurance plan (yes that means deductibles). It should also empower the feds to enforce a Canada-wide health IT system that allows patients to access their own data.

Why deductibles? Why not have the taxpayers pay for everything? Because without them you take away the responsibility for using a service properly. People feel as if it’s something they deserve as opposed to something they have a joint responsibility to manage and care for. By making deductibles illegal, the CHA has created a society of entitlement, instead of one of empowerment.

If you think I’m un-Canadian for suggesting that there should be a deductible on taxpayer funded health insurance, then I would ask that you be fair about it and also call the guy who said this un-Canadian:

“I want to say that I think there is a value in having every family and every individual make some individual contribution. I think it has psychological value. I think it keeps the public aware of the cost and gives the people a sense of personal responsibility.……there is a psychological value in people paying something for their cards……… We should have the constant realization that if those services are abused and costs get out of hand, then of course the cost of the medical care is bound to go up.“

That fellow? Why none other than the “Greatest Canadian” himself, Tommy Douglas.

Health care in Canada is at crisis. Patients are suffering terribly. One third of physicians are thinking of leaving the profession in then next two years, just when Canadians need them most.

A crisis demands you look at all options. The first step is to revisit the CHA.

This Must Be the Health Care System Canadians Want

Patients lined up to register for a family physician in Kingston (image first published on CBC.ca)

For this blog, I will be telling some patient stories. They are not all my patients, but people in my area. The stories are real – the identities have been anonymized.

Last week, I received yet another rejection letter from a specialist, in this case a neurosurgeon. He declined to see my patient because his practice was “too busy to see the patient in a timely manner”. Which of course means more admin work for me as I try to find another neurosurgeon for my patient. I do a lot of procedures as a rural family physician, probably more than the average doctor – but neurosurgery is a bit beyond my skills.

All of which got me wondering (again) how our health care system, which in Ontario was once rated the best in the world (no really) came to fall so far that a certain grumpy curmudgeon has openly said if he gets sick, he would go to Turkiye. The only answer to my mind, would be that it’s because Canadians are okay with it.

LC, early 40s, seen in emergency for sudden abdominal pain. CT scan sadly shows advanced cancer. Specialist refuses to see her until she goes to a “screening clinic”. Three weeks to get to the screening clinic, that agrees it’s cancer. Refers to specialist who orders more tests. Treatment doesn’t begin until 12 weeks after the diagnosis.

Why do I say Canadians are ok with this? Because for all of the noise on social media, and for all of the news reports highlighting ER closures, delays, and lack of health care staff, I don’t really see people organizing to demand change.

Look, if ten years ago, someone had told me, hey, in 2023 in Ontario there would be over 800 times when an Emergency Department has a partial shutdown, 2.3 million people would no have a family doctor and wait times would be forcing people to consider leaving the country to get health care, well, my first thought would have been “I need to avoid Queen’s Park, there’s gonna be a protest there every day”.

KX, 85 years old, in good health, debilitated by arthritis pain in his hip. Can’t get a fluorscopic cortisone shot to his hip for 5 months, and a specialist who does this in office under ultrasound is over 100 miles away, and has not responded to a referral request yet. Has been limping and on addictive painkillers for 3 months with no appointment in sight.

I see people protesting and demanding change for any number of issues (and I stress many of these are important causes that I support). I have yet to see the kind of sustained pressure on government needed to force drastic change in Health Care.

I’m not the only one to suggest this. Dr. Stephen Major, now the President of the Newfoundland and Labrador Medical Association (NLMA) suggested that the public has become “complacent” about health care. He correctly points out that while fish harvesters protested and shut down Confederation Building in May, he has yet to see a protest about the fact Newfoundland has over 100,000 people without a family doctor.

ET, severe sciatic style back pain. First sees the family doctor who correctly diagnosed this clinically. MRI ordered – which took 5 months to get, confirms sciatica. Referral made to back surgeon. 6 months later – still no word from back surgeon. Currently 11 months of waiting in daily pain to be assessed by surgery – still no operative time booked.

Canadians have a well deserved reputation for being “nice.” The BBC implies we can teach the rest of the world to be nice. We are polite to each other, polite to tourists and we have a habit of saying “sorry” to just about everybody – regardless of whether it’s our fault or not.

Perhaps it’s this inherent niceness that keeps us from protesting daily at each and every one of our Provincial Parliament buildings. Perhaps it’s because of an attitude that “at least our health care is free” (even though it is definitely not – your taxes pay for it). I don’t know. But I do know that for those of us in health care it really seems like the general public is content about the state of the health care system.

DD, 4 years old. Significant behavioural issues compatible with Autism Spectrum Disorder. Referral to paediatric team for assessment. Message returned informing there is a two year wait to see the paediatrician.

But wait, aren’t doctors and nurses organizations advocating for better health care? Of course they are. But the blunt reality is that there are about 43,000 members of the Ontario Medical Association, and 190,000 or so nurses in Ontario. To truly enact change – millions of people need to demand it because millions of votes will matter to politicians.

I’m not seeing that happening.

BC, 40 years old. Complex psychiatric situation. Referred by family doctor to psychiatry. Two months later a message back that this is not suitable and should be referred to Ontario Structured Psychotherapy. Six months after that an intake assessment is finally done, and was told will be entered into the program, but wait time to start the program is twelve additional months.

Our health care system continues to collapse all around us. Governments across the country appear to be making mild to moderate changes to the health care system. But the kind of bold, truly transformative change to health care (like has been done in other countries) will require Canadians to stop being so complacent about health care and protest regularly, repeatedly and with perhaps a little less niceness.

Will they?

Dear Minister Jones – Fire Your Negotiations Team.

Dear Minister Jones,

Just me again, a certain crotchety and increasingly cantankerous geezer offering you advice in an open letter that you are not likely to take. But you would be better off if you did. More importantly, so would the people of Ontario.

First, I would once again suggest that you have done some good work in the health ministry. Moving surgical procedures to outpatient clinics, increasing the number of diagnostic testing facilities, starting a new medical school focused on training family doctors and more are all good moves. While the effects of some of those decisions will not be felt for many years – the reality is that somebody had to do this to help health care down the road and you’ve done that.

Unfortunately however, the past couple of weeks have been catastrophic for your Ministry’s relationship with Ontario’s doctors. It’s funny how one dumb decision or comment can completely wreck a relationship, but that’s exactly what happened when your Negotiations Team stated that there was “no concern” about a diminished supply of doctors. Therefore, they refused to negotiate money for retention of physicians or admin work, like other provinces have (cough BC, cough Manitoba, cough EVEN Alberta!)

In essence, your Negotiations Team has been a disaster, first by militantly dragging out negotiations into a very adversarial arbitration process (when all the other provinces above figured out a way to, you know, respectfully negotiate with doctors) – and then by making a statement about the supply of doctors that is so comically stupid and out of touch that Ontario has become a laughing stock.

Three members of the Ministry’s Negotiations Team pictured above.

This will not bode well for health care in this province.

Look, I know there may be a temptation to say “Ok this was a mistake” and to try and walk back the comments.. While it’s abundantly true that the people of Ontario are a good and kind people who will forgive politicians if they own up to their mistakes (cough greenbelt, cough enhanced police powers and closing playgrounds during covid) – one thing that politicians can’t survive, is being made a laughing stock. Except Donald Trump of course. I still haven’t figured that one out and I don’t think I ever will. (N.B. Donald Trump is not someone you should try to emulate).

Anyway, the reality is that at this point you really only have one path left to turn this thing around. You have to fire your negotiations team. All of them. I’m not just talking about the seven who were appointed to lead that team, I’m talking about the multiple bureaucrats who give them supporting data and have influenced their position.

The only rational explanation I can think of for those bureaucrats promoting a position of “no concern” about physician supply, and saying doctors are not working hard enough, is that they hate doctors. Many of them were likely hired at a time when it was fashionable to bash doctors for billing “too much”. (BTW how did that attitude work out for the people of Ontario?) They’ve clearly carried on with that belief in the arbitration proposals.

I get that in arbitration, there will be some posturing. If your Negotiations Team had said “we’ll pay you $50 a month as a retention bonus” or “admin work doesn’t involve seeing patients, so we’ll pay you $20 an hour” – I honestly would have shrugged my shoulders, recognized it was part of the arbitration “game” and said nothing.

But to say retention and recruitment of physicians is not a major concern, when people line up for hours on end just for the faint chance of getting a family doctor?? That thought process can only be due to a pathologic hatred of physicians, or a delusional mindset totally divorced from reality. Either is a cause for termination. Can the whole team now.

A long line forms outside CDK Family Medicine and Walk-In Clinic in Kingston, Ont.. It was the first day of ‘rostering’ at the clinic, where four doctors will take as many as 4,000 new patients. (Jamie Corbett) – from CBC News

But what of negotiations with the OMA you may ask?

Actually, that’s not hard either. Your ministry has an appointee to the Arbitration Board, just like the OMA does. I believe your appointee is one Kevin Smith. The job of the appointee is to tell you and your team what the lead arbitrator, William Kaplan is thinking and how he is leaning. How they do that is beyond me. When I met Kaplan it was like talking to a Vulcan. There was absolutely no emotion or hint of what he was thinking – but apparently Kevin Smith is better than I am at figuring this out.

One of the above is William Kaplan, Arbitrator, and even after meeting him I’m not sure which is which.

What your appointee will tell you, and what the OMA appointee to the Board will tell the OMA is – Kaplan is wondering “this” or thinking “that” or leaning towards “X percent”. Find out what that X per cent is, offer it to the Doctors for the first year of the new Physicians Services Agreement (PSA). That solves things for one year, which gives you time to pick a brand new negotiations team for year 2-4 for the PSA.

Note to my three loyal readers, yes, this arbitration is ONLY for the percentage increase of the first year of the four year agreement. Worse, while the OMA and Ministry have generally agreed to a 70/30 split of whatever the amount is with 70% allotted to raises, and 30% to be given to targeted programs, they haven’t been able to agree on how the 30% is to be targeted. This means…..more arbitration for that piece. Then, it begins again next year for years 2-4 of the PSA. In essence, we appear to be locked in a perpetual, never ending antagonistic arbitration process (which is still better than unilateral government actions but really frustrating nonetheless).

As I told Premier Ford recently- if health care doesn’t get fixed – I don’t care what the polls say now, or how many by-elections you seem to have won, this is going to be a real problem in 2026. With health care in the crisis it is in now, you need all hands working together and co-operatively. Locking Ontario’s doctors into two more years of extremely adversarial arbitration shows that we are not co-operating and not working together. This is why graduates are leaving the province. And we can’t afford that.

It’s time for you to do the right thing for Ontario, and cut bait with your current negotiations team.

Yours sincerely,

An Old Country Doctor.

Perspectives on Ontario Health Care by a Recent Graduate

NB: My thanks to Dr. Tristan Brownrigg for guest blogging for me today. By his own admission, he never planned to be political, or seek out the limelight. But the situation in Ontario is such that he felt his perspective should be heard. I have a great deal of respect for people like Dr. Brownrigg, who are willing to step out of their comfort zone when necessary, and I commend him for doing so.

Dr. Tristan Brownrigg: I am a family physician, outdoorsman, and rural generalist currently working a mix of clinic, ER and inpatient care in the East Kootenays of British Columbia. I graduated from the University of Toronto Medical School, and did my Residency at Queen’s University (Kawartha site).

I completed family medicine residency in Ontario in 2022 and worked there for 6 months. Prior to this I completed medical school in Ontario, completed my undergraduate in Ontario, and had called Ontario home. Over the years I had watched my goal of working as a comprehensive rural family physician slowly become unsustainable amidst a collapsing system, decades of funding stagnation and poor planning, with a patchwork of good people on the ground trying to do their best in a system that doesn’t seem to value their input. Day after day the insidious march of the family medicine crisis grew closer to the forefront of peoples’ lives and garnered wider media attention, while the government either denied its existence or made no substantive changes that would realistically address it. This has not been the time for band-aids, let alone denial.

Last year I moved to rural British Columbia to try something different for a year, cautiously optimistic about the significant changes to family practice on the back of the LFP model implementation in early 2023. The Longitudinal Family Physician (LFP) model significantly changed how family physicians billed and were compensated in BC, including the ability to bill for the many hours family physicians typically spend on previously unpaid administrative tasks.

My experience has been night and day. For the first time in my medical career I have felt hopeful about the future of family medicine and find my day to day life to be sustainable. These changes have been received positively amongst all other family physicians I have discussed it with. It is not perfect and there are still kinks to be ironed out, but I at least believe my provincial medical association and government are trying to improve things for family physicians. I am not left questioning if government actions are purely incompetent or malicious with the intent to drive privatization.

I had retained my Ontario medical license until now, awaiting the May 2024 renewal deadline unsure if I would return home after a year of trying on a different life out west. Reading the recent government positions and negotiation briefs has been the final nail in the coffin for me. The disdain the Ontario government shows towards the hardworking family physicians who hold up the medical system is nothing short of repugnant. After more than a decade of training and education here, I will now be relinquishing my license to practice medicine in Ontario and stay in British Columbia.

The minister of health thinks recruitment and retention is “not a major concern.” That’s the problem; it should be. If I am not a prime example of this, I don’t know what is.

I wish all of my colleagues still in Ontario who do not have the luxury to vote with their feet the best of luck. If not this government, then I hope the next one learns to value your work and dedication.