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Ontario's doctors have now been without a contract for more than two years.

While both sides – the Ontario Medical Association and the Ontario Ministry of Health and Long-Term Care – say they are willing to get back to the bargaining table, there have been no formal talks for more than a year. That's because each side has at least one daunting precondition to resumption of contract negotiations.

The OMA wants the province to commit to binding arbitration: If it is impossible to reach a negotiated deal, they want an independent arbitrator to examine the offers on both sides and impose a settlement. The province, more than anything else, wants predictability: For budgeting purposes, it wants to know how much physician payments (which were $11.8-billion of the $50-billion provincial health budget last year) will be annually.

Both of these are perfectly reasonable positions – and fundamentally unpalatable to the other side. So the standoff continues.

Doctors are entitled to a negotiated contract settlement. But, like other workers who provide "essential services," they have a limited ability to pressure the government by withdrawing their services.

Whether doctors can strike – legally and ethically – is a point of much debate. The OMA has filed a lawsuit that argues that doctors cannot strike and that's why binding arbitration is a right. (A January 2015 Supreme Court ruling greatly bolsters this position because it says workers are entitled to "meaningful" collective bargaining, especially if their right to strike is limited.) Students of history will recall, however, that doctors have gone out on strike; in Ontario, most recently in 1986, with disastrous consequences, because the profession was deeply divided and the public outraged.

Doctors are not your typical government employees. While some are salaried (a small minority in Ontario), most see themselves as independent contractors selling their services to the province. However, unlike other contractors, their fees are negotiated centrally (by the OMA) and, under the fee-for-service system, they can bill the province in an open-ended manner.

This makes budgeting virtually impossible. Last year, for example, the envelope for physician funding was surpassed by $250-million.

So, with no contract, no cap on billings by individual doctors and a desire to have a hard budget number, Health Minister Eric Hoskins has done pretty well the only thing left for him to do – unilaterally roll back fees.

Specifically, fees were cut 3.15 per cent in February, 2015, and another 1.3 per cent in October, 2015. Bigger cuts were imposed on physicians who bill more than $1-million a year, and there were some targeted cuts in areas like diagnostic imaging, diabetes management and methadone treatment, which were flagged as areas where there was excessive billing.

Still, despite the cuts, the overall physician-services budget increased, by 1.25 per cent; the number of patients and number of doctors continues to grow.

Across-the-board cuts are ham-fisted, ineffective and unfair. That's because some doctors (like ophthalmologists) are grossly overpaid and some (like pediatricians and family docs) are underpaid.

The OMA refuses to address these inequities within the profession, due to its paralyzingly complex internal politics. So, when negotiations broke off, the OMA had an offer of a two-year freeze on the table, and the province a 2.65-per-cent roll back.

Dr. Hoskins gave a rare glimpse of his frustration recently when he said publicly: "Unpredictable and frankly out-of-control billing by some doctors is a problem that creates huge income for some doctors, but leaves less for family doctors."

The OMA, in addition to launching a lawsuit, has spent a lot of money on its milquetoasty "Put Patients First" ad campaign and let the offshoot group Concerned Ontario Doctors do a lot of the venting on behalf of disgruntled docs. Doctors declaring that the health system will collapse if they don't get a raise helps no one; labelling them as greedy and obstructionist is no better.

The health system has changed in recent years, and it needs to change a lot more to provide proper care to the aging population. Part of that reform needs to be a fundamental rethink of how we pay doctors. That has to be negotiated, not imposed.

But, to negotiate a new approach, you need two parties at the table, both with open minds and a willingness to do major surgery, not apply more Band-Aid solutions.