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The Ontario government and the province's doctors have agreed to clamp down on physicians who bill the system more than $1-million a year, as part of a tentative deal announced this week.

These high billers could be reined in through "progressive discounts on fee-for-service billings above $1-million," according to the proposed four-year agreement between the Ontario Medical Association and the government, a copy of which was obtained by The Globe and Mail.

This is just one measure being considered by the government and the OMA, which represents the province's 33,000 doctors, as a way of keeping costs in line. The two parties will look at changing the fee structure and other payments, as well as keep track of "data such as expenditures, utilization, practice patterns and billing profiles."

The proposed physician services budget has been set at $11.5-billion with annual increases of 2.5 per cent over the four-year contract. That means it will grow to $12.78-billion by the end of the agreement on March 31, 2020.

A key feature of the deal is that the two sides will co-manage the budget; they are jointly responsible for holding expenditures to the budget each year. They have also agreed to modernize the Ontario Health Insurance Plan fees, resulting in $200-million in reductions.

After months of acrimony between the doctors and the province, the tentative deal was announced on Monday. It comes as the government is struggling to keep its spending in check. It is the most heavily indebted subsovereign jurisdiction in the world; its net debt will be $308-billion next year.

The proposed deal, which is within the government's fiscal plan, will now be presented to the province's doctors. If it is accepted, it will go to the OMA Council in early August for approval.

The doctors had been without a contract for two years; in January, 2015, after contract negotiations fell apart, the government unilaterally cut fees by 2.65 per cent.

Health Minister Eric Hoskins has been calling for a clampdown on the big-billing doctors. He revealed in April that more than 500 doctors billed more than $1-million in 2014-15, representing 2 per cent of the physicians in the province, but 10 per cent of the budget.

The proposed agreement addresses his concerns, and deals with the issue of relativity – lessening disparities among what physicians earn. Some of the new money in the proposed contract would probably go to lower-billing doctors, such as family physicians.

The deal also builds in incentives for doctors to keep to the budget. For example, the government has agreed to one-time payments to doctors of $50-million in 2016-17, $100-million in 2017-18, $120-million in 2018-19 and $100-million in 2019-20. The money gets paid out only if the doctors stick to the budgets.

If they are exceeded, the agreement states, "then the one-time payment for that fiscal year would be reduced by any excess above the planned PSB [physician services budget] for that fiscal year."

But, already, some doctors are speaking out against it.

"I don't know if it should be on the backs of physicians to deal with public demand for health-care services and that's what the government and, it appears, the OMA is accepting with this agreement, which is if you go over this budget, we will have to claw back this amount," said V.S. Kapoor, who works at the Markham Stouffville Hospital.

"Sometimes if we're practising good medicine, we don't need … [a certain] test. But I must be honest. Sometimes we are pressured so much by patients to get a particular test … that we don't have time to argue with our patient," he said. "If you think about it from a purely fiscal point of view, would I rather do that X-ray and move on to the next patient, or would I argue with him and try to control health-care spending?"

Dr. Kapoor said that modernizing the fee schedule sounds to him like "code for trying to take down some of the high billers."

On average, Ontario doctors' gross compensation is $368,000 annually.

Neil Rau, who represents the 140 infectious disease specialists at the OMA but was not speaking on behalf of the association, said he understands some doctors' frustrations with the proposed deal, but he will support it, as it is better than the previous situation when they were subjected to unilateral cuts.

"It is very difficult to find a deal that pleases such a heterogeneous group of people," he said about the OMA membership. "Here, you have many people doing very different types of work, working different types of hours … [with] different training and different skill sets, and yet we are lumped under a big group for negotiation purposes."

Dr. Rau, who said infectious disease specialists are the lowest billers, argued that there cannot be total equality in how doctors are remunerated. "If someone is playing Humpty Dumpty and fixing somebody after a car accident, I think that is worth more than somebody being seen for a well-baby visit," he said.