#ONhealth – Page 2 – justanoldcountrydoctor

Will the OMA Learn Lessons from OHIP’s Latest Attack on Doctors?

Last Friday (May 2), in what was a classic Friday afternoon bureaucratic dump, the OHIP bureaucrats at the Ministry of Health announced that they wouldn’t be paying the full amount of back pay owed Ontario’s doctors, as per the arbitration award. This was a unilateral decision on their part. It was contrary to what was in a signed agreement, and the OMA Board was notified at the last minute. (OMA CEO Kim Moran’s email is attached to the bottom of this blog). The bureaucrats promptly ran away an hid for the weekend hoping this issue would go away (kind of like how Sam Bennett cowardly hid from the press after putting an elbow to Leafs goalie Anthony Stolarz head).

This is, in my opinion, the latest attack on physicians as a whole from Ministry of Health (MOH) bureaucrats, who clearly are more interested in trench warfare than working co-operatively with Ontario’s doctors to improve health care for the citizens of Ontario. Don’t believe me? Consider the following:

The bureaucrats had the option of realizing that provinces like Manitoba/BC/Saskatchewan and even Alberta(!) recognized the need to work with their doctors and come up with a funding formula for them. Instead they chose to drag Ontario’s physicians through a protracted (going on three years now) and highly antagonistic arbitration/negotiations process.

Not only that, in response to now multiple stories of people lining up to find a family doctor in the press, their response was that there was “no concern” about the shortage of comprehensive family care physicians. (Seriously, how out of touch must they be to think that that type of Orwellian double speak is going to work in Canada).

People lined up hoping to get a family doctor in Walkerton. Photo originally posted in the farmers forum.

Frankly, this inept, combative and dismissive treatment of physicians is just par for the course for this bunch of bureaucrats. It saddens me, but it doesn’t surprise me.

No blame for this decision should fall to the OMA. They did negotiate a signed agreement (as per Ms. Moran’s email) and they clearly were not notified about the unilateral change until far too late. So the unilateral action is not their fault.

But….

What the OMA can, and should be held accountable for is how they proceed from here.

I don’t want to seem overly difficult here. If I truly was an obstinate person, I’d try to get a job at the Ministry of Health – perhaps on their Negotiations Team. The reality is that I actually have a long history of working co-operatively with government to improve health care in my neck of the woods.

I’m serious. In 2001 I helped bring in the first stage of Primary Care Reform called the Family Health Group. In 2004 I was one of the lead physicians who brought in a capitation model of payment for family physicians (it was initially a Family Health Network and it eventually evolved into a Family Health Organization). From 2007 -2013 I was the founding Chair of the Georgian Bay Family Health Team and From 2013-2015 I was the Health Links lead physician in my area.

And in each of these roles I worked closely and co-operatively with government to try to improve the health care needs of the patients in my area.

But – in those days, the bureaucrats wanted to work with doctors. They wanted to co-operate to improve health care and they were genuinely concerned about the lack of family physicians providing comprehensive care. They didn’t want to play power games with physicians or harass them or do dumb things like the current crop just did.

It’s important for the OMA to (finally) realize that there really is no hope that they can work with the current lot. They’ve already dragged us through three miserable years of negotiation/arbitration and fought us (thankfully often times stupidly – as even the Arbitrator pointed out) – for the sake of…….. I don’t know why really. Maybe it’s a power play? Maybe there are just bullies?

Recognizing the obstinance of the MOH bureaucrats is why I was proud (and still am) to have my name on an Op-Ed in the Toronto Star last year advising Family Medicine Residents to NOT start a practice in Ontario at this time. But I have to tell you the blowback from the OMA was saddening to me. I will not mention names – but one senior exec told me that the OMA was working well with the Government. Worse, one senior physician leader texted me the following:

Text from a very senior physician leader at the OMA

Remember – at the time this text was sent to me – we had already been locking horns at the negotiations table for two years and the government had done absolutely nothing to solve the family medicine crisis. Perhaps the physician leader felt the relationship was “best ever” because at least they weren’t sabotaging doctors left right and centre like the abhorrent Eric Hoskins did.

Despite all of that, there was some movement forward with arbitration. While no where near what other provinces got, it at least recognized the need to fund health care better, and provided hope for funding for offices, clinics, and frankly other badly needed resources.

Now the MOH has decided unilaterally to not pay, or pay whenever they feel like it, so we are back to – do NOT start to work in Ontario.

At any rate – as mentioned, while the OMA cannot be judged on decisions by the Ministry, what the organization does next will be telling. Will they finally recognize that the current lot of bureaucrats simply cannot be dealt with by reason? Will they recognize that physicians are essentially being bullied by these ruffians and the best way to deal with a bully is to stand up to them? Will they take legal action (according to Ms. Moran’s email – there was a signed agreement which the MoH is now in violation of)?

I don’t know the answer to any of the above. But I can only hope that the current Board recognizes that there is no hope of working in good faith with this lot of bureaucrats and that strong, frankly militant actions, are needed to support the members.

Addendum: After I published my original blog, an anonymous colleague asked that I publish a link to a survey about this issue. I’ve therefore appended my blog and ask all Ontario physicians to click on the link below and honestly reply to the questions:

https://www.surveymonkey.com/r/W2ZPMCC

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.

Re-Post: Hoskins Won’t Survive The Mess He’s Made Of Ontario Health Care

NB. The following is a re-print of a blog I wrote for the Huffington Post, published originally on July 10, 2017. It’s being republished here mostly for my own record keeping.

Recently, one of my medical school classmates (now a cardiologist) was awarded the Society of Thoracic Surgeons top rating for patient care outcomes. A great honour for her, and well deserved. Unfortunately for the rest of us, she practices in South Dakota, one of the many physicians who left Ontario during the protracted battles with Ontario Governments in the 1990s.

Back then, as I mentioned in my first blog, many health ministers continued to insist that physicians in Ontario were the highest paid in all of North America. Yet we lost physicians in droves. The reality is that while physicians wanted to be paid a fair wage (who doesn’t?), what they really wanted was to have a say in how health care was delivered and be able to advocate for their patients.

So when the then Ontario government of Bob “Super Elite” Rae made unilateral decisions about health care, physicians left for jurisdictions where they were paid less (according to then Health Ministers Frances Lankin and Ruth Grier). But at least they had a say in how health care was delivered.

I mention this because it appears that current Ontario Health Minister “Unilateral Eric”Hoskins and his Deputy Health Minister Bob Bell have been unable to grasp this fundamental concept. Hoskins (and, to a lesser extent, Bell) have based their whole political strategy on portraying the dispute in the media as one of doctors wanting endless sums of money. If only the doctors would take less, the health-care system would improve. They appear unable to grasp the fact that doctors VALUE the ability to advocate for their patients and contribute to health care decision making.

From a purely political point of view, the strategy had some benefits for Hoskins and Bell. They were able to pass both the Patients First Act and the Protecting Patients Act. There was muted public response because they were able to portray physician opposition to these Acts as physicians protecting their incomes. The fact that the Patients First Act does nothing but increase bureaucracy and that the Protecting Patients Act actually violates Charter Rights of all health-care workers, and will likely be the focus of a Charter challenge, meant nothing to Hoskins and Bell. Good PR in the face of mounting, repeated, ongoing evidence of the collapsing health-care system was all they wanted.

Surely the Hoskins/Bell duo thought their troubles were behind them when the OMA ratified the BA framework. Not so.

It must therefore have come as a shock to Hoskins and Bell when, after giving Physicians Binding Arbitration (BA), physicians actually increased their attacks on the Liberal Government mismanagement of the health-care system. Now to be clear, giving BA is not the same as awarding a contract. The Ontario Medical Association still has to negotiate a contract for physicians.

But central to Hoskins and Bell’s way of thinking was that all physicians cared about is money. And the spectre of BA does force both parties to negotiate fairly.

Also in fairness, it’s pretty evident that Hoskins himself didn’t want to give physicians BA. Not only did he deride physicians for asking for it and fight it in cabinet, but when the Ontario government sent a press release indicating they want to return to negotiations with the OMA with the first order of business being to develop a BA framework, it came from the premier’s office, not Hoskins’ office.

Regardless, surely the Hoskins/Bell duo thought their troubles were behind them when the OMA ratified the BA framework. Not so.

Wait Time Series: Cataract surgery patients are finding themselves on longer #waitlists as funding fails to meet demand in Ontario. #ONpoli pic.twitter.com/Nh466RND1k

— Ont. Medical Assoc. (@OntariosDoctors) July 5, 2017

Since then, the OMA has become even more aggressive in its attacks on the Liberals. Have a look at their Twitter feed where they attack wait times for cataract surgery and joint replacement surgery.

Also, a grassroots group of doctors have now begun tweeting multiple barbs at the Liberals. Saying that doctors are required to put the pieces of health care together, they’ve used inventive and creative images to drive home the point that the Liberals don’t know what they are doing in health care.

Finally, OMA President Dr. Shawn Whatley openly wrote in his blog that physicians need to be champions, not doormats, and fight for health care for their patients. Surely poor Hoskins and Bell never expected this when they actually gave the OMA a path to a fair contract via BA. Goes to show you just how much they misjudged physicians’ desire to advocate for their patients and for a fair health-care system for all of us.

Hoskins and Bell are now, as the old joke goes, officially “post turtles.” This joke compares a (usually inept) politician to a turtle balancing on a fence post. You know he didn’t get there by himself, he doesn’t belong there, he doesn’t know what to do while he’s up there, and you just want to help the poor thing get off the post.

Ontario Premier Kathleen Wynne basically has little choice now. Hoskins and Bell are just too easy targets for the mess that they’ve made of health care and the way they’ve badly misread physicians passion for protecting their patients. The differences are irreconcilable.

Hoskins is the easier of the two to deal with. Wynne needs to shuffle her cabinet and move Hoskins on to minister of sanitation or something.

Bell, being an employee, has certain rights and can’t just be fired. However, the anonymous surveys done by Quantum Transformation Technologies indicating how unhappy his own bureaucrats are should be enough evidence for Wynne to order a formal administrative review of the senior management team at the ministry of health. Maybe they can be salvaged with administrative coaching.

But what’s clear is that as the health system fails, Wynne needs front line physicians to help put its pieces back together. Wynne needs to regain their trust. The way to do that is to bring tangible change to the leadership of the ministry of health.

OMA’s Recent Messages to Family Physicians are Disappointing and Misleading

Last week, Alberta, the province that once had a health Minister who went to a physicians house to berate him in person, created a new pay model for their family physicians. Even Alberta, the province whose premier told the health service to not talk about vaccines, realized the obvious. Family physicians need to be paid commensurate to the foundational work they do, and the role they play, in a high functioning health system.

Alberta Premier Danielle “Covid? What Covid?” Smith

I’ve taken a look at the new Alberta model. Some of the specifics are gated but the rough overall numbers are public. My back of napkin math suggests there is about a 24% increase in gross income for family physicians with a practice size of 1200. This includes payments for indirect work (checking labs, reviewing reports, supervising staff – all the admin work that Ontario refuses to recognize) and increased payments for more complex patients. I congratulate my colleagues in Alberta on this accomplishment. It WILL stabilize not only family medicine, but their whole health care system.

In response OMA CEO Kimberly Moran sent out an email on Friday Dec 20th. (A complete guess on my part is that she saw some of the responses to this deal on Social Media). I personally was offended (but not surprised) by the manipulation of figures and data in her email. While it’s true that every thing she wrote in the email was technically correct, the manner in which it was presented created an impression of successes that just aren’t there when it comes to advocating for family physicians.

I hate to talk numbers, this stuff gets confusing. But here’s a short set of data you need to know (numbers rounded for simplicity).

2022/23 is the BASE YEAR for all future increases negotiated/arbitrated going forward
The 2022/23 physicians budget was $16 billion
For 2023/24 (the last year of the previous agreement) the OMA negotiated a 2.8% ($448 million) increase
for 2024/25 the Arbitrator awarded us 9.95% compounded to the 2.8% from 2023/24 – which winds up being 13.03% more than the BASE YEAR ($2.08 Billion more than 2022/23)

So what’s the problem? Well for starters Ms. Moran states that the OMA “successfully” advocated for a 9.95% increase without mentioning that the OMA asked for 22.9%. Getting less than half of what you ask for is successful? But more importantly she went on to tell family physicians that they will receive a higher increase than the arbitration award of 9.95%. (11.75 – 13.54% depending on the practice model). But here’s the thing, the arbitration award was the increase for one year only (2024/25). The increase that family doctors are getting is an increase from the BASE YEAR (2022/23) – so it reflects your increase for two years not one like the arbitration award. The two year increase to the physicians budget is, as mentioned above 13.02%.

Now I completely respect the fact that the numbers that I’m quoting do not reflect the fact that the the award is meant to be split 70/30 between fee increases and targeted funds (but neither did Ms. Moran’s email!!). A very brief summary of how targeted funds are supposed to work:

70% of the $2.08 billion are supposed to go to fee increases ($1.456 billion)
the other 30% is supposed to be targeted ( $624 million)
of the $1.456 billion, 25% ($364 million) is supposed to go to across the board (ATB) increases for everybody. Crunching the numbers means everyone gets a 2.27% increase to their 2022/23 (BASE YEAR) income. The rest of the increase is based on relativity. Ophthalmologists for example get an additional 0.18% for relativity, and family doctors get between 9.48 – 11.27% additional for relativity. But again – that’s the increase for TWO YEARS, whereas the 9.95% was just for the one year.

This type of sophistry in messaging from the OMA regarding family medicine is sadly all too common. For example, the OMA has said that Ontario Family doctors have the highest capitation rates in Canada. Is that statement true? Of course it is. BUT – what’s also true is that no other province has deductions for outside use. Also, at a bare minimum family physicians in British Columbia, Saskatchewan, Alberta and Manitoba (with Manitoba being on top) pay family physicians more. Maybe Nova Scotia as well. Ignoring that while trumpeting higher overall capitation payments is unsettling.

While I sadly did expect such sleight of hand over numbers from OMA central, I must admit I was very disappointed in the SGFP email that came shortly thereafter. The SGFP has recently really gotten quite a bit stronger at advocating for family doctors and done some good work. But even they sadly fell into the trap when SGFP Chair Dave Barber told members in his letter:

“…Family doctors will receive increases greater than the 9.95% arbitration award announced earlier this year”.

David Barber – Chair of the Section of General and Family Practice

Again, technically a true statement, but very inappropriate. I don’t know what he was thinking signing off on that.

The really sad thing is that it didn’t have to be this way. The OMA (and SGFP) could have been completely forthright and honest and simply laid out the facts as I did above. This still shows family doctors getting a relativity bump more than a lot of other specialties. And they could have said that they want a good chunk of the targeted funds to go to Family Medicine but the government continues to fight them. Finally, they could have blamed the government for not recognizing the seriousness of the crisis. All of that still would have talked about the positive work being done, without creating the impression that they were trying to hoodwink the members. But alas……

What can we done? Well, I’ve said it many times before. Only the members can change the OMA if they want to. This year in particular, four physician members are up for election for Board Director – which represents half of all the physician positions. There are also multiple candidates running for SGFP executive positions. This really represents the best opportunity in a long time to continue to change the culture at the OMA so that we don’t get disingenuous messaging like this.

I’ll have my thoughts on the election in an upcoming blog.

Bureaucratic Vertigo in Ontario’s Home Care System

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

October 25, 2024

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

October 30, 2024

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

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

November 1, 2024

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

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

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

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

November 7, 2024

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

November 8, 2024

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

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

What consequences are there to this?

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

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

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

What SHOULD happen next (but probably won’t)

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

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

Sunday Snippets – November 10, 2024

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We Know How to Save Family Medicine. Why Aren’t We Doing It?

I’m honoured to have Dr. Mark Linder guest blogging for me today. I first met Dr. Linder during our time advocating against Dr. Eric Hoskins unilateral cuts to health care. He’s exceptionally well spoken and articulate . He’s a former ER doctor and now full time family physician and clinic owner. His other claim to fame is that got fired from the Kaplan MCAT teaching course after one session – which apparently was a first.

I just wrote this in a flurry this morning. I see stupider and stupider proposals from the government and from newspaper editorials. I see our new grads learn from their teachers that they need to stay away from this job. I then see the domino effect this has on recruitment, job satisfaction and reinforced by absurd government initiatives to save the system. I watch the OMA get pulled in every direction to try and please everyone. So apologies in advance -this is just my take really-and mostly to get it off my chest-not that it will lead anywhere. So thanks for reading.

The Family Health Organization (FHO) is what saves family medicine. It has done it before and it can do it again.

In 2006 something unprecedented happened. It hasn’t happened before or since. And perhaps we didn’t quite appreciate how unique it was. The provincial Liberal government, under Dalton McGuinty and Health Minister George Smitherman, introduced an upgraded payment model for Family Medicine. It built on the existing capitation based Family Health Network (FHN) model to enhance it.

What was so unique about this? It stands out as one of the only times a government has thought beyond their 4 year term to the ultimate health of their population as well as their economy down the road when they may no longer be in power. Sure, it was going to make them look good if everyone got a family doctor out of it-but it was a big expensive risk, a risk based on an assumption that family medicine was critical to the system, AND that practitioners need to be paid fairly for their work if they wish to retain these doctors in the future. A different time to be sure!

It worked. Look at the stats from 2008 to 2018. Look at how many Family Doctors gladly embraced the new system. Look how the number of orphaned patients dropped.

The system had flaws. I mean this was the second iteration of what was described as an experiment. The “outside use” enforcement rule made little sense in most cases. The calculation of capitation payments wasn’t always a fair representation of how much work it took to look after the patient in front of you. Certain “in the basket” fees were bizarre and should never have been part of the package. Doctors were actually more incentivized to send people to the ER over a walk in clinic!!! But all in all, it was a great innovation, a great idea, and saved family medicine. It also, no doubt saved the province millions in treatment dollars and ER visits as family doctors made themselves available to look after patients.

And then, In 2015 Kathleen Wynne and Eric Hoskins, the health minister at the time, effectively shut down enrollment in FHOs And that was the beginning of the end. I presume they just wanted to control the immediate budget – paying for family medicine up front meant huge savings down the road. But it resulted in a pretty big chunk of budget going out the door NOW. And the Wynne liberals didn’t have a health care crisis, didn’t heed the warnings that we as physicians laid out pretty starkly at the time, and decided, nah, we’ll just “pause” the experiment.

Which they did. And the fall out was obvious. As a clinic owner and a family doctor, I had a front row seat. The residents and new grads had all been trained in the new system, and now were unable to access it. If they wanted to work, they’d be taking a tremendous risk setting up a clinic in a Fee For Service environment using a Schedule of Benefits that had failed to keep up with inflation for 20 years. They were screwed. The aging Family Doctor population continued to retire at a predictable rate, and the aging population continued to get more desperate to find doctors with increasing difficulty.

By the time the FHO’s opened up again in 2021, it barely mattered–The reputation of family medicine among new grads had been thrashed for 6 years.
With the new rules, new grads would have to gather 6 like-minded individuals (instead of just 3 like in the old days), or find a bigger FHO that was already established and could fit them in. Not so easy. Opening up your own shop had become increasingly more expensive with post pandemic inflation, so the debt would be crippling just to get started if you wanted your own clinic. And these are graduates who already had a huge amount of debt coming out of school.

Couple this with the insane increase in administrative burden as we become more and more efficient at having hospitals and labs forward us copies of paperwork. In theory, amazing, in practice hugely burdensome, time consuming and unpaid. Arguably, if the FHO rates had increased at the level of inflation, there’d be no complaints about this additional work. But the FHO rates had more or less remained static relative to the cost of doing business. Still better than FFS, still paid a lot less than the actual market value of doing the job as proven by the lack of uptake that continues today.

The thing is: The FHO is still the answer. It absolutely needs some significant tweaks. The rates need to go up. The outside use concept needs to go. Minimum size and shared EMR requirement needs to be softened so that smaller groups can join together in nearby geographic areas. Some sort of separate funding will be essential to help clinic owners to keep up with inflation. But it still achieves by far the best mix of physician autonomy, clinic management, and long term government savings. And it’s evidence-based! We have a recent history we can look back on to demonstrate efficacy!

Other solutions, such as having lesser-trained individuals diagnosing and managing patients give the appearance of short term gains at a huge future cost as more referrals to specialists are made and more referrals to the ER are made. Another concept of having government run all clinics is clearly so expensive as to be dead at the gates-Doctors currently pay for rent, administration and their own retirements out of their incomes. It’s not great for us, but it’s a heck of a lot cheaper for the taxpayer to do it that way, and simply pay the doctors more.

I recognize that my FFS colleagues are not helped at all by an enhancement and advocacy for the FHO approach. And I’m sorry. I obviously think there’s a lot of work that could be done to improve FFS rules and individual payments. No doubt.

But we actually have the evidence that the FHO saved family medicine when it was introduced. It was stunningly effective, and if nursed back to health, will absolutely work again.

Sunday Snippets – Oct. 27, 2024

I was away last week but I’m back with another in a weekly series of brief snippets of health care stories that bemused, intrigued and otherwise beguiled me over the past week along with my random thoughts on the matter.

Item: There was significant growth in the number of physicians in Alberta in the third quarter.

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

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

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

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

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

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

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

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

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

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

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

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

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