Medicine – Page 5 – justanoldcountrydoctor

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.

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?

Dr. Soni Writes to her MP About the Recent Tax Law Changes

My thanks to guest blogger Dr. Deepa Soni, an Emergency Room Physician at Credit Valley Hospital. She has written a much more eloquent letter to her MP about the recent tax changes introduced by the federal government, and allowed me to reproduce here as an open letter.

The Honourable Anita Anand,

MP, Oakville,

301 Robinson Street

Oakville, ON

L6J 1G7

April 20, 2024

Dear Minister Anand,

I’m writing to you as a constituent of your riding in Oakville regarding your government’s capital gains taxation measures introduced in this week’s budget.

As an emergency physician for the last 25 years, I and thousands of my colleagues in Ontario, were saving in our medical corporation to be able to fund benefits that many Canadians have available through their jobs: maternity leave, disability, and medical/dental benefits. In addition, and most importantly, incorporation allows us to save for our retirement as we do not have pensions (again, a benefit many Canadians, including government employees and civil servants have as part of their employment). Incorporation was a negotiated benefit that was given by the provincial government in lieu of increasing our fees, with the understanding that the structure would allow us to mitigate some of these factors about our career.

Anita Anand, President of Treasury Board

When planning for retirement under one set of assumptions, and then finding out that the federal government has moved the goal posts to extract revenue for its budget shortfall, you can understand why so many physicians are bewildered and disappointed by the Liberal government. This would be the equivalent of someone changing the terms of your pension or taking large chunks of it away. For many doctors, this will have profound impacts on their ability to retire when they thought they would.

In addition, as a daughter of first-generation immigrant parents, both of whom were physicians, I am certain you had a front row seat watching your parents work hard to obtain their medical degree, residency, and then establishing a practice. This is not to say that other Canadians don’t work hard: the one thing that makes doctors unique is that our fees are set by provincial governments and our fees have not risen to keep up with inflation. Unlike other incorporated professionals such as accountants, dentists, and skilled trades, physicians cannot increase their fees to make up for rising costs. We are locked into the fee schedule determined by provincial governments (who are always employing cost containing measures to balance budgets). The federal government is turning a blind eye to this important point as it does not fall under federal jurisdiction. Nevertheless, the impact cannot be ignored.

As a corporate lawyer prior to being elected an MP, I’m sure you would not have wanted your hard work and education to be characterized with the words ‘tax cheat‘ if you had been using a legal way to save for retirement. This is the narrative being circulated in the media and it is deeply disappointing. It is noteworthy that MPs receive an annual pay raise (this year ranging $8000-11900), along with pension and benefits. This makes an MP salary one of the highest earners in Canada, with guaranteed income through retirement.

Yet, it is doctors who are singled out as being in the wealthiest 1% and rhetoric implying that we are not doing our part for less fortunate Canadians. We pay into personal taxes and contribute to the economy like everyone else. As small businesses, doctors support the economy through employing staff (nurses, allied health, receptionists etc.), paying rent, and financially supporting many Canadian companies providing support services to our practices (electronic medical records, medical office supplies etc.).

We are also entrusted with caring for the population of Canada in the most sacred way. This taxation measure comes at a time when the medical profession in Canada is suffering unprecedented levels of burnout. Millions of Canadians cannot access a family doctor because they have closed their practises and left (in large part, due to rising costs and fixed fee schedules). Why in an era when attracting medical graduates to do family medicine is a priority, would your government eliminate one of the few advantages that help new grads set up comprehensive practices so they can care for Canadians from cradle to grave? Does your government understand the downstream effect this capital gains taxation will have on patients for decades to come?

From watching media interviews recently, it appears that the federal government’s solution to this is “we will just allow in more foreign doctors“. This is deeply hurtful on many levels: it devalues currently practising physicians who have put in their life’s work to bring excellent care to this country’s patients. In addition, it takes many years for a doctor to acclimatize to the healthcare system in Canada. What happens to patients in the meantime? The solution is not to “throw the baby out with the bathwater”. The solution is to step back and really take in the impact of these actions and the message that has been conveyed to the physicians of this country. I hope your government will rethink this and choose to act fairly regarding incorporation for medical professionals.

Sincerely

Deepa Soni MD CCFP(EM)

Are You Accepting New Patients?

Dr. Madura Sundareswaran guest blogs for me today. She’s a community family physician who’s resume is too long to print here. She helped found the Peterborough Newcomer Health Clinic and is a recipient of the CPSO Board Award which recognizes outstanding Ontario Physicians. This article originally appeared on her LinkedIn page.

The day people stop asking this question is the day we have fixed the primary care crisis.

I’m a family physician doing community-based comprehensive family practice in Peterborough, Ontario. I currently work in three different primary care models in our community – fee-for-service, a team-based family health organization, and nurse-practitioner led clinics. All of my colleagues work very hard providing excellent care to their patients.

Despite this, the latest figures suggest that 32,000 people living in the Peterborough region do not have a family doctor.

What does that look like?

A woman in Peterborough notices a breast lump today and is very worried about it. She frantically searches google and reddit to learn that there are no walk-in clinics here. She calls a number late in the afternoon for a local clinic for unattached patients, but all the spots are full for the day. Her options are a virtual doctor who will never conduct a physical exam – but she thinks an exam is important – how will they ever know what this lump feels like virtually? She wants someone’s expertise, she wants reassurance. She decides to go to the emergency department for this problem…but leaves after waiting for 9 hours. She is guilt-ridden as she waits there – she is not as sick as the others in the waiting room. No physician or nurse practitioner will have enough of a relationship with this woman to know that she recently lost her best friend to breast cancer and the impact this has on her illness experience. She is freaking out about this lump…alone.

Or…

A 68 year old male has seen a few pharmacists and virtual family doctor for his hemorrhoids over the last year. He decides that he just has to live with hemorrhoids. A google search says his symptoms are classic for the problem; he’s reassured. As a doctor, I know that this gentleman needs a physical exam but this man cannot find someone to do it. After a few months he winds up in the emergency department with terrible pain – a physical exam very obviously demonstrates rectal cancer. It’s had a year to grow.

Or…

George is a 58 year old man who has never had a family doctor. He has been on Health Care Connect for four years but no one has ever called him to say they have found him a family doctor or nurse practitioner. He is in “perfect health” so he does not need a doctor. He has never had his blood pressure checked, never been counselled on smoking cessation, and has never had bloodwork done. What he doesn’t know is that his Hemoglobin A1c is 7.4 (he has Type II diabetes but too early for symptoms), he has hypertension (high blood pressure – which in its most common form has no symptoms or signs), and his cholesterol is really high. George will probably have a heart attack in the next 10 years. The potential consequences of a heart attack are death. This was entirely preventable.

What we know: attachment to a regular primary care provider (family physician or nurse practitioner) leads to more preventative care, better chronic disease management, and lower rates of hospital admission (ref)

We need a solution ASAP

I eagerly watched as Ontario announced $110 million that will “connect up to 328,000 people across Ontario to primary care teams.” For my community this also translated to a promise for a community health centre (CHC) to connect 11,375 people to primary care. This is much needed but not enough.

Ontario Health Minister Sylvia Jones announcing expansion of primary health care teams

In order to develop a community health centre – a building must be built or set up, policies will need to be implemented, and several primary care providers including physicians, nurse practitioners, social workers, pharmacists, dieticians, etc. will need to be hired. Even if this could be set up within 12 months, where does that leave the other 20,625 in the region without a family doctor? I’ll tell you – scrambling door to door and still knocking asking if anyone is accepting new patients.

But wait! There are other options. A single full-time family physician working in one of Peterborough’s existing family health organizations can roster approximately 1300 patients and join an existing team-based model. We currently have job openings in every one of our five existing multi-disciplinary teams for family physicians. A clinic could be up and running in a matter of weeks. There are family doctors in this community who are very eligible to take on this job – and would likely consider it if they were fairly and adequately compensated.

Learning from British Columbia

I am a firm believer in learning what works and never reinventing the wheel.

In 2023, British Columbia completely revamped its pay structure for family doctors. They paid their doctors better and restructured compensation models – and apparently within a year they got 700 more doing comprehensive, community-based family medicine.

Dr. Ramneek Dosanjh, Past President of Doctors of BC, who called the new funding formula for family physicians in BC a “seismic shift”

I am going to make a few assumptions but I want to illustrate and oversimplify something here.

In the new BC payment model, the pay per full time doctor increased by $135,000/year (assume per full time equivalent). It wasn’t just a pay raise – it involved a few critical changes regarding what doctors could bill for and some restructuring. But the end result was a pay raise.
This resulted in an increase of 700 family physicians (assume full time equivalent) practicing comprehensive family medicine over one year.
Let’s say 1 full time doctor rosters 1300 patients.
If Ontario could get 700 new full-time family doctors to provide comprehensive, community-based family medicine, 910,000 people could now have a family doctor.
The entire rollout for the BC program is budgeted at $708 million over three years but this would include complete restructuring from fee for service care. Ontario already invests over $1 billion annually in interdisciplinary primary care teams and we have a significant head start compared to BC a year ago.
In contrast, Ontario plans to spend an additional $110 million to connect up to 328,000 people across Ontario to primary care teams.

Providing family doctors with the financial support and resources to set up their own practices is the best bang-for-your-buck approach if the goal is patient attachment to a primary care provider.

We need an all hands on deck approach. Support community health centres, nurse practitioner led clinics, but please also support family physician’s practicing family medicine. That is the only way you will achieve attachment for all Ontarians.

Your most obvious solution is pay family physicians better today – so they will hold off retiring for a couple more years and may actually sign on to take a practice.

British Columbia just proved that fair and competitive compensation for family physicians may result in more of them doing it.

Why do I care?

I have been in family practice for five years. I have a roster of patients who have access to a whole range of team-based primary care services – a pharmacist, a social worker, a nurse practitioner, an RPN and multiple other service through our family health team. Every day I get asked if I can take on a friend or family member as they do not have or just lost their family doctor. This simple ask creates a great deal of stress and guilt for me. I know what happens when someone does not have a family doctor or nurse practitioner. They will be sicker, they may die sooner, they will be alone trying to “doctor” themselves.

The moral distress of being made to feel like I am determining people’s fate – giving some people a high standard of care while others are left to fend for themselves will be what ultimately leads to my exit from this profession in this province. Why do I get to give a small handful of people comprehensive team-based care, while the rest (often marginalized, more vulnerable patients) get nothing? It is not fair.

What next?

We are all eagerly awaiting the next negotiation between the Ontario Medical Association and the Ministry of Health.

If we do not see a pay raise for physicians, or worse, we pay them less – everyone in Ontario can accept the reality that they may have a lovely multidisciplinary medical home with a diverse range of primary care providers – but a family doctor probably will unlikely be part of it.

The next time a leader or politician is raving about their new model for care – or pitch a strategy that does not include a family doctor I urge every tax payer and journalist to ask them:

1. Do you have a publicly funded family doctor? (Do you truly understand what it means not to have one? Have you ever had to endure the struggle?)

2. If you are so confident in your plan, would you be willing to give up your family doctor to one of the 2.3 million people in Ontario without one?

3. Why is fair and competitive financial compensation of family physicians not part of your multi-pronged approach?

We are listening to politicians and leaders sell us on an idea of a fully-funded, glorious renovation. Meanwhile the house is on fire. Your family doctors are a dwindling number of people who cannot contain the flames. What are they worth?

Exploring Medical Tourism? Here’s What to Consider.

Full disclosure: I am a consultant for Medicte, a medical tourism firm that provides high quality, cost-effective medical treatments for ALL health conditions in Turkiye. Contact: info@medicte.ca for more information.

Recently, former Ontario Medical Association (OMA) President Dr. Shawn Whatley wrote an opinion piece in the National Post (later reproduced in the Medical Post) quite correctly rebuking Federal Health Minister Mark Holland for insulting people who consider leaving Canada for medically necessary health care. According to an Ipsos Reid poll, that’s 42 percent of all Canadians. As Dr. Whatley pointed out, this isn’t exactly a new phenomenon. In 2017, well before the Covid pandemic that people like to blame for just about everything, over 217,000 Canadians left the country for medical care. God only knows the 2023 number, but it will most certainly be higher.

Ironically enough, the day after Dr. Whatley’s piece was reproduced in the Medical Post, the Medical Post sent me their daily email which included a link to an article that showed Canadians are waiting even longer for surgical procedures than they were in 2019, and it’s not like the 2019 numbers were any good to begin with. It’s well known that increased wait times result in worsening morbidity and mortality (i.e. the longer you wait, the sicker you become). So it’s no wonder that Canadians are exploring ways to get treatments quickly, even if they have to pay out of pocket. Heck, I’m already on record as saying that I will go to Turkiye if Allah/God/Yahweh forbid I got a serious medical illness.

If you too are exploring medical tourism, here’s a list of things to consider.

How safe is the country I’m going to?

The sad reality is that the world has turned decidedly ugly these past few years. Picking a safe country can be hard. Stories like the one about Americans who went to Mexico for medical tourism and got shot by drug cartels get widely publicized. But there are many unsafe countries in the world. If I was looking at south of the United States, I’d probably limit my choices to Costa Rica and Cayman Islands. There are simply too many economic, political and frankly criminal elements in the rest of the countries south of the U.S.

Even in different continents you have to look at safety first. About 5 years ago a patient of mine of Ukrainian descent went back to Ukraine for a procedure. Obviously would not suggest that now with the war on. So look for somewhere stable.

What is the quality of the hospital I will get treatments at?

No hospital is perfect. But you should at least ensure that the hospital you are going to get care at is accredited by the Joint Commission International (JCI). They are the leading international organization that accredits hospitals and other health care organizations in 70 countries across the world. JCI Accreditation won’t guarantee a successful treatment, but it comes with the assurance that you will be getting appropriate health care.

After ensuring JCI accreditation at the facility you are looking at, then check for references. See if you can talk to people who got care there for their first hand experience.

Get a video consult first.

It’s the 21st century people. Video calls are a thing. If the health care organization you are looking doesn’t offer you the ability to have a video consultation with their doctors, before flying out to their country, well that’s a bad sign. During the consultation, ask lots of questions. Specifically ask about their complication rates and what is covered if you are unfortunate enough to get one. Get a “feel” for the doctor. It’s a big decision, be 100 per cent comfortable that the health care organization you are considering, will be able to take care of your needs.

What’s the Cost?

Obviously, at the end of the day, you are going to have to pay for your treatment. I would, of course, not suggest getting the cheapest possible treatment – because that institution has likely cut a lot of corners to get the price down. But at the same time, I weep for the lady from British Columbia, who, frustrated with the long wait times to see an oncologist, spent over $200,000 (US) on cancer care in the United States. She could have gotten the same treatments for around $70-80K in Turkiye. That’s obviously a lot of money, but still a significant savings.

This is actually why I would recommend you NOT go to the United States for medical tourism. Firstly, they have quite a bit of variability in terms of the care they provide. Some facilities are really good and others……well, some are really good. Secondly, the cost just isn’t worth it. A joint replacement that costs $50,000 US in the United States, could likely be had for $15-$20,000 US in another country.

If you are on a budget, or if you, like many others, are going to take out a loan or dip into your retirement savings to pay for these treatments, that difference is significant.

In Conclusion

While some provinces are making necessary investments in health care, the reality is that improvement in wait times are likely years away. The Canadian public is not stupid, they know this. Only 17% of Canadians feel the health system will improve in the near term.

In the interim, I fully expect the number of Canadian citizens who opt for medical tourism to increase. This can be a safe and effective option for Canadians willing to explore this route, but it is important to do your homework first.

Another Open Letter to the OMA Board: Re-visit the Negotiations Mandate

Dear OMA Board Member,

Just me again. The grumpy, aged quack with a history of being a bit of a thistle in your obliques. Well intentioned I assure you (although I’m told some may not see it that way).

Negotiations with the provincial government on a Physicians Services Agreement (PSA) continue and mediation began on February 20th. That’s all great and part of the process. However, things HAVE CHANGED a lot since the last time I wrote to you and urged you to set a strong mandate.

I am asking you to revisit the negotiations mandate at this time, in light of three new key pieces of information that are very relevant to Ontario doctors.

To recap – the negotiations mandate is the bare minimum ask that the Negotiations Task Force (NTF) can accept on behalf of the Board. If the government makes an offer that meets or exceeds that – well, then they accept it on behalf of the Board and the Board is compelled to endorse it. The mandate is, quite correctly, confidential (you can’t let the other side know your bare minimum ask any more than they would let you know their mandate). But it’s up to the Board to determine if the mandate is enough (not the NTF).

Now to be clear, I’m not saying you should revise it, just revisit it. Perhaps the mandate is already sufficiently strong. That would be great. But things are different now.

The first reason to revisit the mandate:

Other provinces have surpassed Ontario physicians in terms of income. BC and Saskatchewan have significant deals to stabilize the physician work force. Manitoba’s deal with physicians appears to be the best of the bunch. Manitoba has not only a well deserved increase for all physicians, but significant steps towards gender pay equity.

As an aside, while I applaud the fact that DoctorsManitoba made steps towards gender pay equity, I’m forced to wonder what happened to Ontario? When I was on the OMA Board we were proud of the fact that although it was too late, we were the first PTMA to report on the issues around gender pay equity. We proved that the pay gap was not because “women work less hard”. What happened ?

Also, to be clear I want to acknowledge that the negotiations counsel (Messrs Goldblatt and Barrett) are very well aware of any topic that could affect negotiations. I remember Darren Cargill, who at the time was on our NTF, told me “they read everything.”

Howard Goldblatt, Negotiations Counsel for OMA

Therefore, I know they read the Manitoba Schedule of Benefits which is available online and reported back to you. I’m sure you are fully aware of the retention bonuses in that deal. I’m sure you know about the significant changes that decrease the gender pay gap. I’m sure you know about the fact that Manitoba pays physicians for Admin time. And that their capitation model has no negation (although a lower base rate). And that they have an age premium. A pelvic exam premium (gender equity again). And that they allow extra payments for dealing with more than one problem at a visit. I have absolutely no doubt that our negotiations counsel has fully and thoroughly advised you of this, along with the benefits of the deals in BC and Saskatchewan.

The second reason to revisit the mandate:

The crisis in family medicine is spiralling out of control, faster than I thought possible. Not only is it badly affecting patient care, but the health, well being and morale of physicians is sinking like a stone. Last September, I never dreamed that I, along with Drs. Alam and Mathew, would write a letter to Family Practice residents telling them to stay away from comprehensive family medicine in Ontario. I never dreamed that there would be story after story after story of individual family physicians openly talking about how they were burning out. This situation has gone form bad to desperate frighteningly quickly.

The third reason to revisit the mandate:

Bill 124, the piece of legislation that limited increases to the public sector, was used to promote a low ball PSA to us the last time. You even, admittedly and embarrassingly, convinced a guy who should have known better. It’s ruled unconstitutional and the government will not appeal this. In fact they will repeal the Bill entirely. In light of that, many other public sector workers will be asking for catch up pay.

So it really is time for you to re-visit the negotiations mandate. Just double check to make sure it’s as strong as it should be given the above factors. Make sure it takes into account that the the BC deal has attracted over 700 physicians to comprehensive family practice. Make sure it recognizes that Manitoba will likely be showing a net growth in physicians shortly, and can reasonably attract physicians from out of their province. If you have to revise the mandate upwards after looking at it, then do so.

NB – IF the NTF were to push back if you do revise the mandate upwards, then make sure you hold your ground. Remember, YOU are the Board and YOU give direction to ALL committees and task forces, including the NTF. I’ll be careful how I say this so as not to divulge Board confidentiality, but the NTF in my day did have a proposal on one particular issue (not the whole PSA) that they told us to approve and our Board pushed back and said no. We had to listen to some (quite eloquent) speeches about how hard they worked and this undermined their work and so on and so forth – but after that they went back and kept negotiating as directed. Don’t do any less this time.

These negotiations are likely to make or break the profession for decades to come. They are that important. You owe it to your members to take another look at the mandate.

Yours truly,

An Old Country Doctor.

Open Letter to All Family Practice Residents

The following letter was jointly written by the three of us and published in the Toronto Star on February 20, 2024. It is being reproduced below so that we can share the letter on Facebook as we believe it will be of interest to physicians across Canada.

To All Family Medicine Residents,

We are writing to say congratulations! You are nearly at the end of a decade of hard work, perseverance and sacrifice; ready to start your career and “real life”. You have joined a beautiful and unique specialty. You will be the key to the healthcare system. You will find answers when patients arrive with ambiguous symptoms. Others will tag in and out of a patient’s health journey. You will stay and be an essential part of the beginning, middle and end of every patient’s story. You will save lives.

Your skill and knowledge are unparalleled, and there is no substitute for your expertise.

Which is why with heavy hearts, we, the undersigned, recommend that you do not start your own family medicine practice in Ontario. Not right now.

Family medicine is in crisis. Family doctors in Ontario are unable to provide the care they could and should. We face unprecedented levels of administrative burden, unsustainable business expenses, lack of healthcare resources, lack of social and cultural support for our patients and ourselves and finally, a lack of respect. This has led to widespread burnout and exhaustion.

In short, it is becoming frankly unsafe to run a family practice in Ontario, especially for those just starting.

We are family doctors with decades of experience. We are also physician leaders, past-presidents and board directors of the Ontario Medical Association (OMA), academic faculty, and health policy experts. We understand the situation well.

Do not sign that contract. Do not sign a lease, hire staff, buy equipment, contract with an EMR or any of the million things that must be done so that you can start a comprehensive care family practice.

Starting a practice at this time will require you to continue to sacrifice everything else in your life. If you have debt, you may not be able to pay it down, let alone start living the life you and many others have postponed for so long. You will struggle to spend time with your family, buy a home, care for vulnerable loved ones and more. You will continue to work at a non-stop pace, this time with no end in sight.

You will burn out and like many others, leave family medicine for good. This is why millions of Ontarians no longer have a family doctor.

The Ontario Ministry of Health can solve this crisis.

Governments in Manitoba, Saskatchewan and British Columbia have done so. This past year, they made family medicine a priority – and backed their words with targeted funding toward key programs to support both new and established doctors. It comes as no surprise that they have welcomed hundreds of new family doctors into their communities.

If they can do it, so can Ontario.

What can you do in the meantime? Work in hospitals, hospices, operating rooms and long-term care. Work in obstetrics, anesthesia, as a hospitalist, in emergency or palliative care, oncology, sports medicine etc. Be a locum. Bide your time.

You are skilled, smart, and adaptable. Your knowledge is extensive, demonstrating an unmatched depth and breadth of training. Use it.

When people leave comprehensive care family medicine, they almost never come back.

We don’t want that to happen to you. When the government of Ontario recognizes family doctors as the foundation of medical care, negotiates a fair contract and improves health policies to reflect patient needs in 2024… well, when that happens, we will write a different letter and welcome you to the world you were meant to be in.

We hope by then it is not too late.

Sincerely,

Dr. Nadia Alam, comprehensive care family physician and anesthetist, past-president of the OMA

Dr. Sohail Gandhi, comprehensive care family physician and hospitalist, past-president of the OMA

Dr. Silvy Mathew, comprehensive care family physician and long-term care, past-board director of the OMA

Dr. Soni Reflects on the Delays in Emergency Rooms

Dr. Deepa Soni, and Emergency Room physician for over twenty years, reflects on the case of a young woman with appendicitis, and the delays in getting her care.

NB: Recently, Julia Malott spoke out on X (formerly known as Twitter) about how terrified she was about Canada’s health care crisis. She wrote how her daughter had not eaten in 18 hours as she continued to wait for surgery for appendicitis. She expressed concern about the lack of the beds and wondered if her daughter would get surgery before the appendix ruptured.

My friend Dr. Soni, who has worked in an Emergency Department for over 20 years, had, as usual, a very thoughtful and well spoken X thread of her own. (Dr. Soni was NOT involved in the care of this young woman). I thank her for allowing me to reproduce her thoughts here.

The only way these stories (about long delays in Emergency rooms) will stop being the norm, is when patients start sharing their experience like this mother did. Only voters can make federal and provincial governments change because votes are the only currency that matter. Doctors and nurses have been raising alarm bells for years without success.

Canada has one of the lowest number of hospital beds of all the OECD countries, around 2.3/1000 people. In comparison countries like Japan, Korea and Germany are around 13/1000.

Graph showing how Canada fourth from the bottom (!) in hospital beds per capita.

Why does this matter? Having low hospital bed numbers means that words like “flu surge“, and “winter surge” — which have been used for decades to explain away long wait times and hallway medicine, are actually not “surges.” Rather, they are the expected backlog in a system that lacks adequate beds and resources.

The population of Canada is increasing and aging. We are about to enter a silver tsunami where a large cohort of our population will be over the age of 65 and many over the age of 85. This will place unprecedented pressures on our health care system.

What happens when the hospital bed capacity is outstripped by the numbers of patients needing care? It means that the elderly patient who needs admission to a hospital bed to recover from a heart attack has no bed to go to and spends days “admitted” in the emergency department. Bureaucrats call these “unconventional spaces.” What they really are, are stretchers.

Photo of admitted patients lying in stretchers in a hallway as no beds available (found on X)

When the vast majority of the emergency department beds are being used to take care of hospital patients, that means that patients that are waiting in the emergency department waiting room, will wait for hours for care, much like this story is describing.

Media needs to scratch beyond the surface and hold government to account. Real solutions are going to require thinking beyond the four-year election cycle. What will our system look like in 20 years? How do you plan for that?

It’s going to require recognizing the backbone of our healthcare system is primary care. Family doctors are overwhelmed by administrative burden, trying to run their offices and taking care of large practises in the community without adequate resources.

Build community infrastructure with resources like palliative care so that people can remain in their homes comfortably in their last days; and sufficient homecare services so that patients can receive antibiotics and other intravenous treatments at home to ease the pressure on hospitals. These services are vastly underfunded and do not have enough staff to properly provide care for everyone that needs it in the community.

It’s going to require building more nursing homes, retirement homes, seniors services and dementia care programs, as our elderly population will be the largest it’s ever been in this country.

Incentivize and properly pay hospital nurses so that we can recruit and retain them to be able to run departments and programs properly. Currently, agency nurses make at least two times as much as a hospital nurse, and this has created instability in the workforce. Governments need to show that they value nurses and the important work that they do.

Creative solutions like interprovincial licensing of doctors and nurses and a National Pharmacare program will help. While the idea of recruiting from other countries sounds like an easy quick fix, it will not solve anything if those newly obtained doctors and nurses find themselves overworked and burning out soon after arriving to Canada. The system problems are going to impact them just as they have impacted those who are already working in the system. This type of strain is what contributes to moral distress and burn out.

The backlog in the emergency department is a reflection of multiple failing areas that create an overall system that is strained beyond capacity. With each passing year, Canada’s healthcare system has become more and more stretched, trying to provide more care to more people, with fewer resources. Throwing Band-Aids at it is like trying to mop up the floor under an overflowing sink instead of trying to figure out how to turn off the tap.

Stories like this one are happening every day in Ontario and all of Canada. Most patients and families are too busy dealing with the acute health problem to take the time to write to their MP/MPP or to go to the media. But when people take the time to bring these stories to light, a critical tipping point will eventually occur where they can no longer be ignored by government. Because votes matter.

No one who went into healthcare wants to work in a system that makes patients feel like this story illuminated. But we need more voices bringing their stories out in the open. It will improve the system for the people working in it, and for the people receiving care within it. And that is better for everyone.