Voices of compromise dampened just now
TORONTO—A lot of Ontario doctors are furious with the provincial government, and not all that happy with their own association either. Doctors have found themselves locked in an arm wrestling match over compensation that dates back to before a temporary 2012 pack that scaled back their pay in which they find themselves in a battle with at least one hand tied behind their backs.
Subsequent negotiations have included both a facilitator and a conciliator, but not binding arbitration which is near the top of the doctor’s wish list. Oddly not designated as “an essential service,” doctors are essentially forced to negotiate hemmed in by their Hippocratic Oath to “do no harm.” That oath precludes many courses of traditional job action, such as strikes or work to rule which technically lie within their negotiating toolbox.
Dr. Stephen Cooper, former chair of the Ontario Medical Association’s Section of Rural Medicine Northern, noted that frustration over the lack of progress and perceived government reneging on earlier commitments has resulted in a deeply imbedded distrust that will be very difficult to overcome. Dr. Cooper himself is a casualty of that deep-seated anger, having campaigned for his seat on the board on a platform of working with the government to find a solution to the impasses that remain between the parties. He lost to an opponent who advocated taking a stronger stance in dealing with the government. “The majority of doctors, not all, but a majority, now want to have stronger action.”
“I need emphasis that I in no way speak for the OMA,” cautioned Dr. Cooper. “Currently I am just a regular physician with more than average OMA experience.”
Back in 2012 the OMA came to a short term agreement with the province resulting in a .5 percent reduction in physician fees. As part of that agreement there was a recognition that some form of co-management of the process would be in the offing. In 2014, there was another agreement reached that stretched to the end of 2015. A facilitator and conciliation were involved in finding some common ground between the two parties. “The facilitator recommended three things,” recalled Dr. Cooper. The OMA was advised to accept the government’s proposal, but the government was cautioned not to go back on its word and that the two parties should “find a better way of negotiating.”
“Essentially there was no way to negotiate in good faith under the current process,” noted Dr. Cooper.
The path forward continued to be fraught with potholes, with the Ministry of Health backpedaling on the agreement and the two parties were unable to agree on a better way to negotiate. “Over the next year and a half there was increasing animosity,” said Dr. Cooper.
What followed were “fairly aggressive” campaigns by both combatants seeking to win the public’s hearts and minds over to their side of the line.
While doctors’ attentions were focussed on the repeatedly lobbed public opinion artillery, the OMA and MOH were quietly hunkered down in what could be characterized as “back door negotiations” to come up with a negotiated plan. Unfortunately, the lack of transperancy in the talks came back to haunt the process, as doctors were essentially caught off-guard when they were presented with what many of them took as an attempted fait accompli.
“The OMA should have been more open,” suggested Dr. Cooper. In the end, a lot of doctors “rejected it out of hand.”
The province’s fixation on a “fixed” budget, with a clearly defined bottom line has proven to be major stumbling block, particularly when overages are clawed back from doctors when the budget line is exceeded in any set period.
A patient seen in an emergency room by a doctor results in a $33 fee paid by the government, but if the government’s budget line is exceeded in that pay period, the physician can find that payment taken back.
In 2015, the province clawed back fees for certain specialties as well, putting forward the rationale that those specialists are overpaid as a fiat, rather than trying to work with the doctors on the issue.
While Dr. Cooper said that he can see both sides of the fixed budget issue, his was a perspective that didn’t play well in the field of animosity and acrimony that has been nurtured by what many physicians see as an ambivalent government stewardship of their section of the health care reform.
From the doctors’ perspective, the arbitrary nature of the province’s fixation on a budget bottom line that is set in stone does not take a wide range of variables that can cause higher health care costs in a relatively shorter term and places a disproportionate amount of the burden of meeting fixed health care costs on the backs of doctors.
Two proposed government bills are adding fuel to the fire.
Bill 87, the Protecting Patients Act, which seeks to have more government say in the regulation and discipline of physicians (a job now performed by the self regulated College of Physicians and Surgeons) is another sticking point. The semi-autonomous nature of the current regime fits more closely with many doctors’ self-image as essentially self-employed contractors.
Bill 41, the Patients First Act, is setting off alarm bells for doctors who say its shortcomings include that access to a doctor will be decided by government employees; confidential patient health records can be accessed by bureaucrats; funding will be taken away from hospitals and the frontline care provided by doctors and nurses to instead hire more government bureaucrats; provincial medical standards will be decided by bureaucrats and politicians instead of by medical experts; and the government will have control over all aspects of a patient’s healthcare, with more emphasis on saving money instead of saving lives.
So with the Hippocratic Oath tying their hands in the way of job action and a prevailing general public perception that doctors are already well compensated, what avenues are open to doctors to bring the government to heel, or at least even the negotiating playing field? Especially since doctor perceptions of government intransigence is putting the OMA under a lot of pressure to bring in some form of job action.
“I don’t know what that will look like,” admitted Dr. Cooper, but the current climate of a complete lack of trust in the government on the part of doctors would seem to make some action seem almost inevitable.
The concept of withdrawing or delaying elective or non-essential procedures has been bandied in some circles, recent court interpretations in other jurisdictions of what constitutes non-essential or elective procedures found such delays cause undue pain and suffering for patients further complicates the playing field for doctors.
While the tentative agreement did contain some elements that could form the basis of a rapprochement, that prevailing climate of distrust is likely to prove to be an insurmountable stumbling block in the short term at least.