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Dr. Chris Cavacuiti takes a patient’s blood pressure at a Toronto methadone clinic. He says government cuts have forced him to close two of the clinics he operated and had to cut back on staff and hours.Chris Young/The Globe and Mail

The dispute between Ontario doctors and the province over billing rates is threatening access to methadone treatment, with two private Toronto clinics closing their doors and patients in some rural communities facing an uncertain future.

The threat to service follows a 1.3-per-cent rate reduction imposed by the province last month on all fee-for-service billings. The money-saving measures also included targeted reductions, among them a 50-per-cent cut to rates paid to doctors for urine tests that are done once a week or more frequently as part of methadone therapy used to treat heroin and other opioid addictions.

Now at least one Toronto doctor says the fee cut amounts to roughly 25 per cent of his total revenue and means his smaller clinics are losing money. First Nations leaders also are warning access in rural and Northern communities is in danger because private clinics – where most methadone treatment is given – are not as financially attractive. Others say this latest battle over money points to deeper problems with how methadone treatment is delivered in Ontario that go beyond the current billing battle.

Either way, it is those seeking treatment who will feel the fallout.

"These doctors are saying it's not economically viable for me to stick around," said Ontario Regional Chief Isadore Day, who also holds the national health-care portfolio with the Assembly of First Nations. Three clinics serving mostly First Nations clients on Manitoulin Island in northern Lake Huron have given notice of closing and efforts are being made to ensure treatment continues at least in the short term with the help of a visiting physician, he said. "If they close up shop, First Nations communities will be left in the lurch."

The situation, which has the potential to become a crisis if clinics close in rural areas, illustrates the fine line physicians must walk in their wage battle. Ontario doctors, who have been without a fee agreement since 2014, have launched a Charter challenge, frustrated with the imposition of two rounds of unilateral cuts this year. They have long warned that patient care could suffer, but now, some of the province's most vulnerable populations could be the first to feel those effects.

The president of the Ontario Medical Association, which represents doctors in provincial negotiations, said he is aware of many doctors who are cutting hours and staff or closing various types of clinics. "Ontario's doctors have continued to tell the government that by further cutting necessary funding for physicians services, it is threatening access to the quality patient-focused care Ontarians need and expect," OMA president Dr. Mike Toth said in a statement.

Critics question how one fee cut could be enough to tip the balance, but the doctor who has already closed clinics said the province left him with no choice.

"When you crunch all the numbers, there is just no way any more to keep smaller programs up and running," Chris Cavacuiti, who operates seven private clinics under the True North Medical Centre banner, said after shutting two sites last month in Toronto. Since the cuts in October, Dr. Cavacuiti said he has lost four of the 12 doctors who work in his clinics, laid off one staff member and cut hours. He says it is uncertain whether he can keep running his three clinics outside Toronto, including one in Windsor that just opened but was planned before the fee cuts.

"The challenge is, if you have a community that has 30 or 40 patients you can't make it viable for fee-for-service," he said.

But one doctor who is a long-time critic of the current treatment system disputes such claims, saying there is no reason patients prescribed methadone should be seen in separate clinics.

"I will tell you it is disgraceful," Philip Berger, medical director of the Inner City Health Program at Toronto's St. Michael's Hospital, said when asked about potential cuts to service.

Dr. Berger, who has provided methadone treatment within his family practice for 24 years, says some private clinics have become a "megaprofit industry" and questions the actions of any physician who would abandon patients without making arrangements for alternative care. He noted he and five of his colleagues in his practice prescribe methadone.

Dr. Berger said part of the issue is that the audits and extra scrutiny required of doctors providing methadone treatment has discouraged many from including it in their practice, making way for the proliferation of private clinics. More than 42,000 patients receive methadone treatment in Ontario.

Ontario's Minister of Health, Eric Hoskins, said he has met with Chief Day and others and is working to provide service for patients on Manitoulin Island, and to find alternative ways for delivering treatment, particularly to indigenous communities.

As for the economic argument, he said he "finds it challenging" that a reduction to the fee for a "urine dipstick test" that does not need to be administered by a doctor can make the difference in the viability of a clinic – describing many doctors operating methadone clinics as "very well compensated."

Last year, 1,032 doctors in Ontario billed the province for the urine screening test in question, according to the Ministry of Health. Of those, 222 derived 20 per cent or more of their gross payments from that test, and 170 of those doctors had billings greater than $900,000.

Dr. Cavacuiti said the gross billing numbers fail to account for the high costs of running a clinic that often can't get space with other medical services because of stigma.

"The government might want to spin this and say these doctors are earning a bundle of money," he said. "I would not close a clinic that was making money. I have closed two clinics and I have lost four doctors. I am not making those numbers up."