Quick(well, it was supposed to be quick) post for those in Ontario about the OMA's tentative agreement with the Ontario government on physician compensation. It came out of nowhere and is causing quite a bit of outrage from more than a few physicians, some directed at the government, some directed at the OMA itself.
The OMA will be holding a non-binding vote on the matter, which apparently I get to participate in, despite being a student. Based on the text of the agreement, my vote will be a definite "no" for two major reasons.
First, and you'll hear a lot about this from practicing physicians, is a lack of binding arbitration. Right now the government seems to be getting away with unilateral action. The OMA has sued to retain their right to binding arbitration, but lawsuits can be difficult to predict. Few labour laws apply to physicians and for a variety of reasons, we have no ability to undertake real labour actions. Some form of binding arbitration is about the only protection we can expect to protect our rights as workers.
Without that assurance, even if this deal proves to be acceptable in the short-term, it leaves open the door for significant long-term reductions in fees over time. Death by 1000 cuts, as it were. If that were to occur, the only recourse would be for physicians to leave the province or profession, neither of which is good for physicians, patients, or the government. I worry about physicians having too much clout over their own income and we certainly shouldn't be given free reign, but some defense against competing interests is necessary. Absent any others, binding arbitration is a deal-breaker.
Second, the Physician Services Budget (PSB) has to be eliminated. Despite all my protestations above, if I had to choose between adding binding arbitration and getting rid of the PSB, I'd choose removing the PSB. The idea behind the PSB is logical at first glance - physician billings make up nearly 10% of the provincial government and are growing at a rate faster than inflation or tax receipts. If they could be effectively capped, the government would save a significant amount of money and put itself in a much better financial situation moving forward.
The problem with the PSB is that while it provides a cap, it does not provide any mechanism for it to be achieved effectively. Expenses for physician billings go down if physicians bill for less procedures or get paid less for each billing. The PSB ostensibly gives physicians an incentive to collectively bill less, in order to avoid any clawbacks. Unfortunately, because the cap applies to physicians collectively, and each individual physician cannot change the actions of physicians as a whole, individual physicians retain the same incentives as before, namely to bill as much as possible. The PSB does nothing to reduce quantity of billing.
So, the PSB instead becomes about reducing cost per billing by using the clawback mechanism. An effort to reduce average cost per billing on its own isn't too objectionable, but the approach taken with clawbacks is where trouble occurs. The clawback hits all services equally, from services that are paid more than they should be, to ones that are undercompensated. Theoretically the new agreement includes a mechanism for the OMA to tailor any clawbacks to economic circumstances, but no details or assurances have been provided on that front. Additionally, because the clawback could be variable, it makes financial planning for physicians very difficult. It's like buying groceries, leaving the grocery store, then finding out that the price you were given in-store changed and you suddenly owe more for some or all of your items. Makes it hard to plan a food budget!
Lastly, the PSB and clawback punishes physicians for factors out of their control. The number of patients go up? Well, then physicians get paid less. Patients require more services, either because they're getting sicker or even getting the extra help they need (think mental health services especially here)? Physicians get paid less. If physicians need an income reduction because we get paid too much, or certain services are too richly compensated, I'm fine with that. It's when it happens indiscriminately and due to factors unrelated to physicians' performance or ability that I object.
Money is not a major factor for me in my career. I'm choosing a relatively low-earning career path and am quite happy with that. I wouldn't object to a reasonable reduction in my future income either, given national and international comparisons. However, the process matters and the impacts of those cuts on patients, and the financial well-being of the system, do matter.
If I do get a say on this, I will be voting "no".
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