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André Picard

Patients the losers in doctor dispute Add to ...

On Oct. 1, Ontario doctors will see their fees cut by 1.3 per cent. This is on top of a 3.15-per-cent fee cut that was imposed in February.

The province has also imposed targeted fee cuts in a number of areas such as diagnostic imaging and diabetes management, and set a cap on total billings, creating the real possibility that, come year’s end, doctors will not be paid for work performed.

Not to mention that, when fees are capped, doctors have to absorb the cost of additional care required because of population growth and aging.

All of these clawbacks have been imposed unilaterally after the Ontario Medical Association declined an offer calling for a 2.65-per-cent cut. (The OMA’s offer of a two-year wage freeze was rejected; its previous contract also featured fee rollbacks.)

The Ontario government is resorting to these bully-boy tactics because it wants to cut spending. And it thinks it can get away with it because “fat cat” doctors don’t garner a lot of public sympathy.

Among physicians, frustrations are boiling over, particularly that their only recourse is venting on social media. Regardless of what doctors are paid, they deserve a fair shake in labour negotiations, and not to be treated in a heavy-handed and undemocratic manner.

In recent days, provincial Health Minister Eric Hoskins and Ontario Medical Association president Michael Toth have exchanged letters in The London Free Press, both cranking up the rhetoric.

The OMA argues the cuts are going to affect patient care, and paints doctors as selfless defenders of beleaguered patients. The minister counters that the cuts are not affecting care, and that scaremongering is unprofessional.

While this may be entertaining, it is no way to negotiate, or resolve the system’s woes.

Ontario currently spends $11.8-billion on physician payments, and wants to cut that by $580-million; it’s pretty safe to assume access to care will be affected eventually.

Rather than setting random targets for spending cuts, the real question that needs to be asked is: Are we getting value for money for the money spent on 33,600 family doctors, specialists and residents?

Nobody really knows. We don’t know if the services individual physicians provide are useful or cost-effective.

We don’t even really know how much they are paid: Unlike British Columbia, Ontario does not publish individual doctor billings, and no province calculates the real cost of expenses.

What we know is that physicians have, on average, gross billings of slightly more than $328,000 (a figure that varies widely based on specialty) but, like small businesses, have to pay their operating expenses (which also vary dramatically between specialties and cities) out of those fees.

Doctors do not have pensions or benefits and, with medical-school tuition fees hovering around $25,000 a year, tend to have enormous debts. And don’t forget that it can take up to 12 years of training to become a specialist.

While doctors earn a good income, there is little evidence they are overpaid.

But that doesn’t mean they are paid sensibly either. Fee-for-service payment, which is commonplace, encourages volume, not quality. The complexity of care means interdisciplinary teams are the best way to treat patients, but creating sensible teams is difficult when you negotiate contracts of different professions separately. But, most of all, we need to find a way of paying health professionals – beginning with doctors – in a manner that rewards results.

These fundamental reforms are going to take time and require long, complex negotiations. They aren’t going to happen in an atmosphere of distrust and punitive clawbacks.

The government needs to get back to the negotiating table and hash out a deal. Several other provinces – including Manitoba, Saskatchewan and Quebec – have done so recently, in a similarly challenging fiscal environment.

If negotiating doesn’t work, then the province needs to agree to binding arbitration, especially because doctors do not have the legal right to strike.

Playing hardball may serve the government’s interests in the short term but, in the long term, it just delays the inevitable.

As Warren Winkler, the former judge who prepared a conciliator’s report on the dispute, noted, without fundamental system change, the government will not be able to achieve savings, and physicians will not be able to provide adequate care.

That’s a lose-lose, with the ultimate loser being patients.

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Follow on Twitter: @picardonhealth

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