While Dalton McGuinty discusses health care with his fellow premiers in Victoria this week, back in Ontario, his government is bracing for labour talks that could have a huge impact on how medical services are delivered.
At the end of March, the Ontario Medical Association's current contract will expire. That gives the deficit-plagued government one of its best opportunities to rein in soaring health costs by targeting the roughly $10-billion it spends annually on doctors.
To bend the cost curve meaningfully, insiders say, a showy gesture of wage restraint won't be enough. Instead, it will require structural changes to the way doctors go about their jobs – ones that would directly affect how they interact with their patients.
Just how much of a fight Mr. McGuinty's Liberals will be up for remains to be seen. But based on conversations with government and health-sector sources, here are some of the key areas the government will be trying to target.
FEWER FEES, MORE SERVICE
The province will continue trying to get more family doctors away from fee-for-service. But that won't do much good if it doesn't get better value out of "family health teams," which a majority of doctors have already moved toward because the Liberals provided financial incentives to do so.
The idea of those units, in which doctors work alongside colleagues and other health professionals and receive annual payments for each patient, is to provide more comprehensive coverage – and in turn to save the government money by keeping more people out of hospital.
Liberals now concede that because they didn't do enough in previous negotiations to ensure doctors make themselves available to their patients, including through "after-hours" services, it hasn't worked as well as hoped. They'll now seek to rectify that, arguing that doctors in family health teams are being overpaid for what they currently deliver.
Doctors have traditionally had a great deal of discretion in administering care. That's led to a belief among people in and around government that prescriptions or referrals are sometimes offered more to keep patients happy than out of medical necessity – and that setting tighter guidelines for when to write them could save large sums of money.
Understandably, people who spent much of their lives studying medicine don't appreciate politicians or bureaucrats telling them how to do their jobs. So the Liberals will try to engage doctors themselves in writing new rules or guidelines.
Unlike some other potential reforms, this one could create a public backlash if it appears the government is skimping on common treatments.
EASIER, FASTER … CHEAPER?
Among the most common criticisms of current health expenditures is that the government still pays specialists very high fees for procedures that were once long and difficult and are now quicker and more routine. Cataract surgery is the most common example, but cardiology and radiology also come up.
The government might argue that if it pays less to those doctors, it could afford more services from others. But it's unlikely that the OMA, which faces strong pressures from within, will just throw some of its members under the bus. As a result, it may go along with reduced fees for certain procedures only if the doctors who perform them get additional compensation in some other form.
RECONNECTING WITH HOSPITALS
A familiar argument, to be repeated in economist Don Drummond's much-hyped report on public services, is that there's too big a gulf between primary care and hospitals.
A partial solution, to ensure information about patients is shared between the two sides, is electronic medical records. On that front, the government dropped the ball and is still playing catch-up. But it may nevertheless use the talks to try to get more buy-in from doctors.
But there's also concern that too many doctors have withdrawn from hospital duty, in some cases leaving emergency rooms and other facilities understaffed. That could prove a much more controversial topic if the government tries to force new requirements.
WHERE, IF AT ALL, THE DOCTOR WILL SEE YOU
Going to the doctor's office won't become a thing of the past. But there are a couple of ways the province might try to get Ontarians going there less often.
One would be encouraging more interaction with patients via telephone or e-mail, particularly for follow-up. The key here would be to get doctors who are still on fee-for-service to accept lower rates for that form of service.
As well, there's the commitment the Liberals made during the campaign to get doctors to make more house calls. While mostly a quality-of-life promise aimed at getting votes, there's arguably a savings component here as well if it helps to keep seniors living in their homes rather than needing long-term care.