Earlier this month, Dalton McGuinty's Liberals steamrolled over the Ontario Medical Association, unilaterally imposing fee cuts on doctors when negotiations broke down.
Now, with still more changes to the fee schedule on the table, they appear to be moving more patiently. Having already demonstrated that she can use regulations to do pretty much anything she pleases, Health Minister Deb Matthews is nevertheless making a show of trying to get the OMA back to the table.
Chalk it up, at least in part, to the government having incentive to preserve some manageable relationship with doctors – and struggling with just how much it can publicly neuter the OMA before that becomes a whole lot more difficult.
"This is the battle," a senior provincial official said recently of the push to freeze the total amount paid to doctors in 2012-13, "and there's a longer-term war." The point was that long-term sustainability in health-care spending will require structural changes, from changing relationships with hospitals and other providers to stricter standards for prescriptions and referrals, for which buy-in from doctors will be needed.
The government is already most of the way toward the immediate savings that it needs on its doctors' bill to meet 2012-13 fiscal targets. Moving too aggressively toward the rest of the needed short-term savings – likely to include a partial clawback of income over a certain level – could ultimately prove counterproductive.
The obvious concern is that, past a certain point, the OMA may decide it has nothing to lose. Straining to keep its membership on board, it could become a lot more militant – conveying to the public a sense of chaos, and refusing to co-operate on much of anything going forward.
But arguably the bigger danger is simply losing the OMA as a vehicle with which to communicate with doctors. It's an organization that has struggled over the years to hold together a diverse and intermittently fractious membership. And if it's proven powerless to stop or even slow the government from doing whatever it sees fit, there's a chance the association will fall apart.
Already, there are some signs of fraying around the edges, with anesthetists issuing an apparent warning last week that they might stop facilitating cataract surgeries – suggesting that the OMA's aversion to such threats could start going unheeded.
To some extent, the Liberals seem to welcome the opportunity to divide and conquer. Already, they have tried to go around the OMA to communicate directly to family doctors that their quarrel is really just with high-paid specialists. And they may even feel that a few anesthetists (or ophthalmologists or even radiologists) scaling back service would just help win the public-relations battle against doctors in general.
But there's a difference between weakening the association, and breaking it. If the OMA were out of the picture, or irrelevant, the government would be stuck dealing with the 57 different groups of doctors currently under the OMA umbrella – many of which would have big chips on their shoulders.
That would hardly be a recipe for any sort of consensus on changes to the way doctors go about their work. And history suggests the government knows it.
In 2004, a deal negotiated between the government and the OMA was rejected by the association's membership. That temporarily left the OMA facing a crisis, until the government helped sweeten the pot by $120-million – a move that then-insiders say involved a conscious decision by the government to help the association's leadership save face.
Back then, the money flowed a lot more freely. Today, the deficit-plagued government has much less wiggle room if it's serious about flattening total increases to health-care spending at 2.1 per cent annually, and about sending a message to teachers and other members of the broader public sector whose contracts are coming up.
That leaves Ms. Matthews in an awkward position, trying to seem conciliatory without having any major concessions to give. But it appears they're putting in at least a token effort, or else the next steamrolling would've happened already.