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The Appalling Treatment of Dr. Elaine Ma Is Hurting Health Care in Ontario

I’ve written about the horrific treatment that Dr. Elaine Ma has been subjected to by the bureaucrats at Ontario Health before. The situation is so ridiculous that it could be a story presented at the Theatre of the Absurd.

What happened?

Dr. Ma is a family physician from the Kingston area. During the Covid pandemic she realizes the need to immunize as many people as possible to protect the community. She organizes a number of outdoor mass vaccination clinics, which resulted in Kingston being one of the most heavily vaccinated areas of the province. For her efforts, she wins the very well deserved the praise of many, and an award from the Ontario College of Family Physicians.

There are two billing codes for providing Covid vaccinations. One for physicians who work in a vaccination clinic that someone else set up (e.g. public health). Another for those who set up the clinics themselves, and paid for staff/heating for outdoors/tents/internet etc. Since she paid for all of that, Dr. Ma bills the second code.

Fast forward a couple of years and the callous and unthinking bureaucrats at OHIP decide that she has billed the wrong code and demand she pay back $600,000. I won’t restate all the steps she went through to fight this. I will state that the reasons for them wanting the money paid back varied between the clinic being outdoors instead of indoors, medical students being involved and so on. But eventually the case winds up at Divisional Court.

On Dec 16, the court handed down a ruling supporting Dr. Ma. What I had failed to realize before is that the Ontario Health bureaucrats main argument appears to be that there were no extenuating circumstances during the time of the Vaccine Clinics that Dr. Ma set up. Yes, you read that correctly. The whole country was in the midst of a (hopefully) once in a lifetime pandemic. Canada was effectively shut down for business. People were not allowed to visit loved ones in hospital or nursing homes. Travel had ground to a halt. But, in the minds of the soulless and spiteful bureaucrats, none of this constituted “extenuating circumstances”.

Thankfully, Divisional Court Justices Matheson, Varpio and O’Brien were having none of this nonsense. They clearly stated the decision by bureaucrats that there were no extenuating circumstances was “unreasonable.” (I would have, and will, call that decision much worse things). The Justices pointed out the obvious. There was clearly a public health crisis at the time, and that many leaders, including politicians were calling on physicians to get the vaccinations done.

More importantly they stated something the OMA’s legal team really needs to take a deep dive into:

…”that the wording of section 17.5 does not limit relief to unpaid claims; it only requires the presence of extenuating circumstances. Since OHIP typically pays claims first and reviews them later, a restriction on unpaid claims would effectively nullify the provision. The court called this interpretation unreasonable.”

Currently OHIP pays physicians whenever they bill. Later, OHIP decides if it was reasonable or not, and if OHIP feels the situation is unreasonable, they demand the money back. The justices seem to be saying this process is not fair. Which has implications far beyond this one case. Obviously, this would not apply to clear cut cases of fraud. It is a much much needed kick to the slow, incompetent, and spiteful OHIP review process. I can’t possibly understand the potential future implications for this – but I suspect there will be many.

Finally, the justices let their displeasure be known by ordering OHIP to pay Dr. Ma $10,000 in court costs. This strongly suggests to me that they were peeved at the OHIP bureaucrats for taking it this far, and really didn’t think it should have gone there.

How is this hurting health care now?

Ontario is currently seeing an unprecedented surge in flu cases. Flu season has come early. The current variant appears to be extremely strong. It is circulating at “sky high” levels among young people. Three children (at least) have died. Hospitals have declared outbreaks and wards are closed. Visitation has stopped.

Sign on the door to the Medical Ward of my Hospital

You know what would really help? If only some people would come up with some innovative ways of getting their communities vaccinated against the flu. Yes this year’s flu shot is a bit of mismatch for the current strain, but it still provides some protection and keeps you from getting really ill.

Or how about an innovative idea for where to safely look after patients like was done during the Covid crisis. My friend Dr. Bryan Recoskie set up a unique 18 bed ward in our local Legion, to look after non-covid patients while the hospital wards were shut with covid positive patients.

And yet, I don’t see any of that happening right now. Don’t get me wrong, doctors continue to go to work. We continue to care for the sick and continue to comfort those in need. We continue to do our best in these trying circumstances.

But I can’t find any evidence (please correct me if I’m wrong) – of where people are doing unique out of the box things to try and mitigate the currently unfolding nightmare. Given the potential exists that IF you try something unique, you may wind up undergoing two years of pure hell by bitter, ruthless and depraved bureaucrats – can you blame people for not trying?

To quote a good friend of mine, “The damage has been done. Nobody is going to stick their necks out now.”

What should happen (but won’t):

First, under no circumstances should OHIP appeal the decision from Divisional Court. The mercilessly inhumane bureaucrats need back down. Second, Health Minister Sylvia Jones needs to do what she should have done a year ago – and direct the bureaucrats not to seek any recovery at all from Dr. Ma. It’s just the right and decent thing to do.

Finally, it would really help if Minister Jones issued a formal apology to Dr. Ma for how she has been treated by the bureaucrats. It’s not just the OHIP bureaucrats. Jones’ own communications director, Hannah Jensen claimed Dr. Ma had “pocketed the funds“, a statement that clearly suggested malfeasance.

Do that, and maybe, just maybe, physicians would once again feel comfortable coming up with out of the box solutions for crises that are occurring.

Maybe.

Patient Accountability ESSENTIAL for Health Care Systems

Canadians want a high functioning health care system. This requires (but is not limited to):

appropriate funding
a seamless electronic medical record
strong support for Family Doctors (the back bone of a high functioning health care system)
a “Goldilocks” level of oversight to ensure the needs of Canada’s diverse areas are met
and much more

But one essential feature that is not talked about nearly enough is patient accountability.

Doctors diagnose and treat patients. More of us (thankfully) are also discussing proactive measures to prevent people from getting sick (appropriate screening, lifestyle tips, advice on menopause/andropause etc).

BUT patients also bear a vital responsibility in their own health outcomes. When patients are accountable—meaning they are informed, engaged, proactive AND use the health system appropriately—health systems perform better. In contrast, passive, non-adherent patients who misuse health care will strain health systems.

What exactly is patient accountability? Partly it’s the degree to which individuals take responsibility for managing their health. This encompasses adherence to prescribed treatments, lifestyle choices, attending medical appointments, following preventive care recommendations and so on. Certainly patients who adhere to current guidelines for, say, diabetic care, will have fewer complications and wind up in hospital less and use health care resources less overall. This is why investing in proactive teaching for diabetics has been shown to not just improve health care outcomes, but also the cost to the health care system.

Patient accountability cannot exist without adequate health literacy. Patients must understand medical terminology, navigate health systems, and assess risks to make informed decisions. Without health literacy, patients cannot be expected to manage their care effectively. A diabetic patient who learns to read food labels, monitor blood sugar, and adjust insulin levels exemplifies accountability in practice. When one looks at just how disjointed our current health care system is, it is clear we have much work to do to improve health literacy amongst our patients – and that dollars spent to promote this, will be money well spent.

But patient accountability also refers to how patients use the health care system. Our health system is under pressure from growing demand, finite resources, and rising costs. Patient accountability plays a pivotal role in mitigating these challenges.

Non-adherence to treatment alone is estimated to cost billions annually in avoidable hospitalizations, emergency room visits, and disease complications. For example, failure to take antibiotics properly can lead to resistant infections requiring more intensive care. Likewise, patients who frequently miss appointments or use emergency departments for non-urgent needs place undue strain on systems designed for more acute care.

By contrast, when patients manage minor issues at home, access preventive care on schedule, and comply with physician recommendations, they reduce unnecessary utilization of high-cost services. This not only frees up resources for patients with more serious needs but also ensures that funding is directed toward value-based care rather than avoidable interventions.

During my time in practice, I have only seen one government paper that talked about patient accountability – the (in)famous Price-Baker report of 2015. Written by lead authours Dr David Price and Elizabeth Baker, and including luminaries like Dr. Danielle Martin on their expert committee, one of it’s ten principles stated:

“The system is built on joint accountability: Each primary care provider group is responsible for a given population and their primary health care needs. Both provider groups and citizens are expected to use the system responsibly.”

Since then of course I have yet to hear Drs. Price/Martin or any of the other authours talk publicly about patient accountability.

How does this work in other countries?

In Finland, patients are told they have the right to good care that respects their opinions and ensures that there is informed consent with treatment. This onus is on the doctors. BUT, Finland also puts accountability measures on the patients in the form of user fees. They are generally nominal, but they are there, and I would suggest, serve to make patients think about whether they are using the health system wisely.

In Norway a similar concept applies. Health care is heavily subsidized by public health insurance. However there are user fees up to a prescribed annual maximum (currently around $250 if I’ve done the currency conversion correctly). After that, all your health care needs are covered (nobody goes bankrupt if they get cancer).

Then we have the Netherlands. There you are required by law to purchase health insurance (there are many providers apparently). There are various packages from basic to more comprehensive and the costs vary. There is also, unsurprisingly, a deductible, known as Eigen Risico, which you have to pay, before your insurance kicks in. It’s mandatory.

I picked these three countries as examples because not only do have a reputation for providing excellent health care, but because they are often talked about in glowing terms by the two physicians who seem to be driving the change in Primary Care in Ontario, Dr. Jane Philpott (Chair of Ontario’s Primary Care Action Team) and Dr. Tara Kiran (principal investigator for the ourcare.ca project)

Dr. Philpott frequently mentions countries like Finland/Norway, not just in her book (Health for All) but in various interviews. Dr. Kiran has frequently mentioned the Netherlands. They have generally spoken in glowing terms about how well the health system works in those countries and how almost everyone has a family doctor there.

I’ve also never heard them talk about how those countries require patients to be accountable for how they use the health care system.

Currently, our health care system is poorly rated compared to its peers. Canadians want, and deserve a better system. But in order to get that, we need to recognize that preserving our health care system is a shared responsibility. Despite what the politicians say, you should NOT be able just to walk into a health care facility and automatically expect it to be perfect. Rather, we should all recognize that we taxpayers own the system. As owners, we have a responsibility to use it fairly, wisely and appropriately. And yes, that means putting in mechanisms like deductibles to ensure people think about how they use health care.

Or we can carry on with a health system in a perpetual state of crisis. The choice really is up to us.

Primary Care Reform Needs More Than a Phone Call

Dr. Madura Sundareswaran once again guest blogs for me. 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. I happen to think she is one of our brightest young leaders.

I was feeling incredibly optimistic after Friday’s SGFP report, which articulated the importance of family physicians in addressing the current primary care crisis. But that hope was abruptly crushed by a recent email I received from Ontario Health East. Ironically, it serves as a prime example of how health systems transformation continues to follow a top-down approach with little regard for the realities of primary care delivery.

In its latest communication to its members, Ontario Health East outlines a two-step strategy for clearing the Health Care Connect waitlist.

Let’s talk about the good first.

Given that the Health Care Connect waitlist has been largely stagnant, the proposal to verify and update the list is reasonable and welcomed.

In its latest proposal, Ontario Health East also commits to providing “interim services” for patients who are not immediately matched to a family physician or primary care team. This is great – and arguably where the new “Care Connector” portfolio should focus. Why? Because this is what many Ontarians need right now: assistance navigating our complex healthcare system without a family doctor.

Now, the not-so-good.

A large part of Ontario Health’s plan is to connect with every primary care clinic in the OHT to determine available capacity. If I am reading this correctly, they want to cold call every primary care clinic in the region and ask if they are accepting new patients. Are they aware that people have been trying to do this for years…?

To their credit, Ontario Health has expressed a commitment to support capacity-building. They’ve emphasized exploring “creative ways” to expand capacity at the individual clinician level — but this language effectively masks the absurdity of the underlying ask. The expectation appears to be that family physicians, already working at or beyond full capacity, can somehow stretch further, simply by reimagining how we work — all while receiving little to no additional resources.

To their credit, Ontario Health has expressed a commitment to support capacity-building. They’ve emphasized exploring “creative ways” to expand capacity at the individual clinician level — but this language effectively masks the absurdity of the underlying ask. It assumes that family physicians already working at full capacity, can somehow stretch further, by simply reimagining how they work — with little to no additional resources.

I’d like to apply the trending analogy of comparing our healthcare system to the public education system.

Imagine 30,000 children in your community suddenly need a place in schools – all at once. Instead of building new schools, adding classrooms, increasing the budget for school supplies, or hiring new teachers – the plan is to call each teacher and ask if they can “accept a few more students.” Not just one or two students– try about 100 each. Now teachers, please brainstorm how you can better meet this need (on your free time, of course).

Parents and teachers – would you allow this to happen?

The dilution of services is not the solution to this primary care crisis. This government’s current focus is entirely on numbers – with little regard for the quality of care being compromised in this process. What happens when each of us have 100 more patients with little to no additional support?

Less time for direct patient care as we dedicate more time to an overflowing inbox.
Longer wait times to see your family physician.
More strict enforcement of rules like “one problem per visit.”
Even fewer family doctors choosing to practice family medicine. More choosing to leave or retire early.

Some argue that teams will offset this burden. Full disclosure: I do think teams can help. But whose responsibility will it be to create medical directives, identify how the teams can best work, and continue to engage in quality improvement and assurance as this new process evolves? Family physicians. Back to the classroom analogy – it doesn’t matter how many other support staff you hire, a classroom of 130 students needs more than one teacher.

This proposal assumes we haven’t already asked—more accurately, begged—family physicians to take on more patients. We have, many times. And with limited success. And before I’m criticized for being negative or dismissing innovation, allow me to share my own experience.

In 2023 I founded the Peterborough Newcomer Health Clinic with the intention of supporting newcomers to Peterborough transition to the Canadian Healthcare system. In this process, I follow newcomers for 6-12 months after which I personally cold call family doctors and primary care nurse practitioners to see if any of them will accept my patients after I have done a great deal of work completing intake assessments and consolidating all previous health records. I have already brainstormed and implemented strategies to make the transition as easy as possible. Have I successfully attached my patients? Rarely. Many of these patients remain unattached.

This is just one story. Many in our community — advocacy groups, primary care providers, and local organizations — have made similar efforts with limited success. And let’s not overlook the fact that this proposed model of attachment completely ignores the issue of inequitable access for marginalized populations (another post for another time).

As I sit here on a Sunday, preparing to enter the week without sounding like a “grumpy physician,” here are my final thoughts.

In this race to reach 100% patient attachment to primary care; we must advocate to ensure that this is not done in a way that dilutes existing resources, compromises existing access to care and devalues family physicians who are currently working at full capacity. We need to protect our existing workforce and support sustainable growth. I encourage every user of our publicly funded healthcare system to advocate for this.
Family physicians – I urge you to continue to advocate for better remuneration and exercise caution when pressed to roster more. Please remember that our contracts exist with the Ministry of Health and Long Term Care. When new opportunities arise – exercise due diligence to ensure that what is being asked of you aligns with the policies of your own practice/organization and the CPSO.
Rushed, expensive, and poorly planned reforms that focus on quantity, not quality is not good for patient care. Failing to address the core issues with primary care – demonstrated by fewer and fewer family physicians choosing to practice comprehensive, community-based family medicine – is resulting in top-down, expensive, and band aid solutions to the primary care crisis. It edges on careless spending on taxpayer dollars. We should advocate for a system that prioritizes sustainable, safe and equitable care – not just a solution for tomorrow.

Disclaimer: The views expressed in this piece are my own and do not necessarily reflect those of any affiliated organizations or institutions.

Dear Sylvia Jones, Here’s How to Make Health Care More Convenient…

Congratulations on winning the last election and being re-appointed health minister. The health ministry is the toughest job in government. I sincerely mean now, what I wrote before, that all of us should hope you are successful. Ontario deserves the healthiest possible population.

Of course, that still won’t stop me from giving you advice (whether you want it or not)……

I’ve noticed that you place a really high value on making sure that health care is “convenient.” Your government even calls the overall program “A Plan for Connected and Convenient Care.” Your talking points in the press always mention “convenient.” Even the second major outline for health care uses that word.

I would suggest that rather a lot of your health care platform is based on making people happy by giving them what they want and making things easier for them. For example, your boss, premier Doug Ford, when talking about the expanded scope of practice that allowed pharmacists to prescribe treatments for minor ailments focused almost exclusively on the fact that it was one of the most popular things your government has ever done. The public was satisfied, so it must be a good thing.

Now I appreciate that you don’t have a health care background. If you did, you would know, that convenient health care, and patient satisfaction in health care, actually have a negative correlation with health care outcomes. Essentially, when patient satisfaction with the health care system goes up, the health care outcomes get worse. A study published in Medscape showed that focusing on patient satisfaction lead to 12% higher hospital readmission rates, 9% higher health care costs and 26% higher mortality rates.

Basically, focusing on convenience and satisfaction in health care costs more, makes people sicker and kills more people.

However, at this point, I doubt that I can get you to shift away from this philosophy. So I have an idea that will make health care much more convenient for people. Something that will reduce the amount of travelling back and forth that people do, and will allow them to quickly and easily get their health care needs taken care of in one spot.

It’s time for you to amend or revoke regulation 114/94 under the 1991 Medicine Act. This prohibits physicians from selling medications to patients. My sincere thanks to OHIPs former lawyer, Perry Brodkin, for pointing this out to me on X.

How will this be convenient? Well, right now, when a patient goes to see a physician for, let’s say high blood pressure, the patient will get assessed by their family doctor, and based on their medical history, an appropriate medication will be chosen for them. They will then drive to the pharmacy with that prescription. The pharmacy will take however long it takes for them to fill out their prescription, and after a period of waiting, the patient will get their needed medication.

By allowing physicians to have their own dispensary, a patient will now go to the physician’s office, and if a prescription medication is deemed necessary, they can just purchase it from the physicians office right then and there. It saves them an extra drive, and perhaps even parking lot fees depending on where they go. This will, of course, be extremely convenient for the patient.

What’s that you say? Isn’t this a conflict of interest? I mean, if a physician is now able to sell the drugs after making a diagnosis, wouldn’t it encourage physicians to prescribe more medications?

Um, can I ask why that didn’t seem to bother you when the pharmacists were allowed to expand the scope of their practices by you? Pharmacists now make an assessment for certain minor illnesses, get paid to do that by the government, determine what in their opinion the right treatment is, and then sell the patient the drugs at a profit. (This is what naturopaths and some chiropractors do as well, but that’s a whole other story.)

What’s that you say again? Pharmacists have to abide by a certain code of conduct from their college. They are bound by their code of ethics to act in the best interests of their patients. Um, ok. You do know that physicians also have a college that we answer to, right? You do also know that physicians also have a code of ethics? That we all took an oath to do no harm to our patients?

Might I ask exactly what the difference is between these two scenarios?

Of course, while most patients would be happy for this convenience, I imagine not everyone will be happy. I suspect (Shoppers Drug Mart bigshot) Galen Weston would be quite annoyed if you did this. But hey, look at the bright side, at least you won’t have to deal with some miserable crotchety old country doctor spouting off in the media wondering who exactly the health minister was in this province.

Galen Weston, of Shoppers Drug Mart and Loblaw fame.

Look, at the end of the day, for me, it’s health care outcomes that matter the most. I want patients to have the best possible results for themselves and health care as a whole in Ontario. But if you are going to insist on “convenience” then at least do it in a way that’s fair to all of the health care professions.

Change or amend the 1991 Medicine Act to make life a little easier for the patients.

Yours truly

An Old Country Doctor

P.S. While you’re at it, don’t forget to direct your OHIP Bureaucrats to not seek repayment from Dr. Elaine Ma. Don’t think doctors in Ontario have forgotten about this situation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Final Thoughts

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

Stories From a Failing Health Care System

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

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

Patient A

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

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

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

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

Patient B

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

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

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

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

Patient C

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

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

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

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

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

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

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

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

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

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

So we read all your previous work for nothing?

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

Well what changed then?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So this is the final word on this issue?

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

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

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

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

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

The Background

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

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

Picture of an outdoor vaccination clinic found elsewhere on the web

The Dispute with OHIP

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

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

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

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

So what happened?

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

So what went wrong?

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

Former Deputy Minister of Health Dr. Catherine Zahn

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

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

Then things got ugly

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

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

Why this offends doctors so much.

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

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

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

What does this mean for Ontario Health care?

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

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

What can be done?

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

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

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

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

Click here to sign the petition.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Yours truly getting his flu shot this year.

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

Sunday Snippets: Nov 24, 2025

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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