New OMA notice - cuts to fees

[mavrik13]

Maybe I'm just a naive first year student, but the top two reasons I plan on choosing my specialty are: lifestyle (I want a family, and have time to spend with them), interest (I want to love what I do). If I'm not satisfied in those two areas, I don't care whether I drive a 10 year old Civic to work versus a BMW/Audi.

 

The bottom line is that, as medical students, we pretty much have carte blanche to decide what specialty we want. I would argue that while not everyone has the manual dexterity to do optho (and that's about the only example I can come up with), you can teach any other specialty to pretty much any medical student.

 

I'm not saying everyone should be paid the same, I'm saying everyone's pay should be relative to the amount they work (e.g. hours), +/- 25% at most. I'm willing to bet the people billing at over $1 million didn't work four times as many hours as a GP billing $250k, and I think that is a remuneration system failure.

 

I don't think anyone is really "inferior" to anyone else, except that it doesn't make that much sense that someone who spends an extra 5 years+ in school doesn't get compensated for the extra schooling/training/specialization.

 

I think they should be - as I said, no more than 25%. Are you telling me that rads, cardio, and optho deserve to make 3 times what the average GP does because they went to school 3 (probably 4 with a 1yr fellowshop, MAX 5) years longer? You're talking like making an extra ~75k isn't enough (throughout a 30 year career, this more than makes up for the difference in length of training).

 

Note I also mentioned after overhead costs (this is impossible to standardize, but this is theoretical).

 

Yea... I am not going through 10+ years of neurosurgery residency/PhD/fellowship working 90+ hours per week dealing with the sickest patients out there to make close to average GP salary. But life is not very fair anyway, so I won't complain too much. Just a little.

 

I'm saying that the pay per hour should be similar. If you work a 90 hour week, you should get paid twice as much as you would if you worked a 45 hour GP (or even neurosurgery) week. Sounds fair to me.

[medigeek]

 

I'm saying that the pay per hour should be similar. If you work a 90 hour week, you should get paid twice as much as you would if you worked a 45 hour GP (or even neurosurgery) week. Sounds fair to me.

Yes.... because going into the brain with sharps is as demanding as sitting on a chair reviewing lab work results and telling a patient to get some rest.

 

[Robin Hood]

Yes.... because going into the brain with sharps is as demanding as sitting on a chair reviewing lab work results and telling a patient to get some rest.

 

 

FM is not about sitting on the chair and telling the patient to get some rest, saying this is like insulting them. But I agree on the demanding part, surely, what a FP does is way less demanding than what a surgeon does.

[medigeek]

FM is not about sitting on the chair and telling the patient to get some rest, saying this is like insulting them. But I agree on the demanding part, surely, what a FP does is way less demanding than what a surgeon does.

 

I know that. I was just making a relative comparison (and this is coming from someone who would certainly become a family physician no doubt).

 

Family doctors have it great, I don't know why all these comparisons are being made. It's possible to work a regular schedule and make >400k/year while your specialist buddy works 20 more hours than you doing a more demanding job and they make 150k more for example.

[lostintime]

While everyone's work is certainly very important, handling critically ill and crashing patients or in an OR environment is a lot different than in a clinic setting with stable patients.

[lostintime]

Maybe I'm just a naive first year student, but the top two reasons I plan on choosing my specialty are: lifestyle (I want a family, and have time to spend with them), interest (I want to love what I do). If I'm not satisfied in those two areas, I don't care whether I drive a 10 year old Civic to work versus a BMW/Audi.

 

The bottom line is that, as medical students, we pretty much have carte blanche to decide what specialty we want. I would argue that while not everyone has the manual dexterity to do optho (and that's about the only example I can come up with), you can teach any other specialty to pretty much any medical student.

 

I'm not saying everyone should be paid the same, I'm saying everyone's pay should be relative to the amount they work (e.g. hours), +/- 25% at most. I'm willing to bet the people billing at over $1 million didn't work four times as many hours as a GP billing $250k, and I think that is a remuneration system failure.

 

 

 

I think they should be - as I said, no more than 25%. Are you telling me that rads, cardio, and optho deserve to make 3 times what the average GP does because they went to school 3 (probably 4 with a 1yr fellowshop, MAX 5) years longer? You're talking like making an extra ~75k isn't enough (throughout a 30 year career, this more than makes up for the difference in length of training).

 

Note I also mentioned after overhead costs (this is impossible to standardize, but this is theoretical).

 

 

 

I'm saying that the pay per hour should be similar. If you work a 90 hour week, you should get paid twice as much as you would if you worked a 45 hour GP (or even neurosurgery) week. Sounds fair to me.

 

I'm curious as to how people came up with the 25% pay increase for specialists vs. GP's. Why not 30% Why not 20%? Very interesting. Are we doing this per-year extra training and opportunity-to-earn-physician-salary loss? Nothing is really that objective with these things.

 

And the residency for most specialties (with a few exceptions) are lot more demanding than family med residencies for the first two years. Not because people are superior or whatever, but just because they are simply more rigorous in call, time commitments, and expectations/culture. That's one of the pros of family med amongst other things - more time flexibility.

[NLengr]

While everyone's work is certainly very important, handling critically ill and crashing patients or in an OR environment is a lot different than in a clinic setting with stable patients.

 

Extremely different.

[rmorelan]

I think they should be - as I said, no more than 25%. Are you telling me that rads, cardio, and optho deserve to make 3 times what the average GP does because they went to school 3 (probably 4 with a 1yr fellowshop, MAX 5) years longer? You're talking like making an extra ~75k isn't enough (throughout a 30 year career, this more than makes up for the difference in length of training).

 

You have a point! I will say that of course during those 4 years a FM will on average make say about one million (which they potentially can invest). So there is a big "head start" as it were. Also some of those fields you mention work a lot more than a FM would, have much higher insurance costs, and there is often equal or more overhead costs. I don't think you can just talk the training time into consideration I guess is what I am saying - you also have to factor in the work schedule etc after training

[mavrik13]

I'm curious as to how people came up with the 25% pay increase for specialists vs. GP's. Why not 30% Why not 20%? Very interesting. Are we doing this per-year extra training and opportunity-to-earn-physician-salary loss? Nothing is really that objective with these things.

 

And the residency for most specialties (with a few exceptions) are lot more demanding than family med residencies for the first two years. Not because people are superior or whatever, but just because they are simply more rigorous in call, time commitments, and expectations/culture. That's one of the pros of family med amongst other things - more time flexibility.

 

I pulled a number out of the air that seemed fair to me. Clearly others disagree. I would argue 25% is sufficient - if a surgeon works 25% longer hours than a GP, and gets paid 25% more for what they do because it's more 'demanding', they would be getting paid $390,000 instead of $250,000 for a GP. I see this being a totally fair (if logistically impractical) system which would remove the gross outliers in fee for service billings.

 

The bottom line is that I think the current FFS system is broken and grossly unfair with regards to making billing codes equivalent between specialties. I can't find FFS coding in Ontario online, but I can google MSI physician billings and the first hit is Nova Scotia's FFS billing book - it makes for an interesting read for how much specialties get paid for certain procedures.

[Lactic Folly]

A lot of the contentiousness simply has to do with the fact that reimbursement is going down. If we were attempting to address differences in income by increasing payments to undercompensated fields, there wouldn't be so much discussion.

[Med0123]

The bottom line is that I think the current FFS system is broken and grossly unfair with regards to making billing codes equivalent between specialties. I can't find FFS coding in Ontario online, but I can google MSI physician billings and the first hit is Nova Scotia's FFS billing book - it makes for an interesting read for how much specialties get paid for certain procedures.

 

in Quebec (document in french only): http://www.ramq.gouv.qc.ca/SiteCollectionDocuments/professionnels/manuels/150-facturation-specialistes/000_complet_acte_spec.pdf

 

a cataract: 365$ (page T-4 or page 692)

...

[rmorelan]

A lot of the contentiousness simply has to do with the fact that reimbursement is going down. If we were attempting to address differences in income by increasing payments to undercompensated fields, there wouldn't be so much discussion.

 

well true The medical profession has a history of running into this debates ever time something like this happens. Trouble is of course this is likely just the beginning.

[futureGP]

I pulled a number out of the air that seemed fair to me. Clearly others disagree. I would argue 25% is sufficient - if a surgeon works 25% longer hours than a GP, and gets paid 25% more for what they do because it's more 'demanding', they would be getting paid $390,000 instead of $250,000 for a GP. I see this being a totally fair (if logistically impractical) system which would remove the gross outliers in fee for service billings.

 

The bottom line is that I think the current FFS system is broken and grossly unfair with regards to making billing codes equivalent between specialties. I can't find FFS coding in Ontario online, but I can google MSI physician billings and the first hit is Nova Scotia's FFS billing book - it makes for an interesting read for how much specialties get paid for certain procedures.

 

http://www.health.gov.on.ca/english/providers/program/ohip/sob/physserv/physserv_mn.html

[trojjanhorse]

Compensation is never going to be fair in a system where a human determines how much doctors get paid (i.e. the system we have in place today). This whole discussion about which specialties should take a paycut is pointless for this reason. Only the free market can determine what is "fair" compensation.

 

They are going to remove few of the billing numbers... so if a patient comes in for Epileptic consultation/treatment, the specialist can't circle that option on his billing sheet... hence no $$$

[apache]

this is so true! medicine isn't so hard that someone who can handle undergrad no prob couldn't excel in everythings, expect maybe in special situations or if the doctor has disability or something (my friends are plastic surgeons and she doesn't practice anymore because of parkinsons )

 

some people think gp's are idiots, maybe they just enjoy the patients, lifestyle, continuity they get in fam med.

 

you could have virtuoso music skills and be a prodigy, but hate music and want to be a gardiner instead.

 

ludwig wittgenstein, a pretty eminent philosopher and genius, as well as obsessive when he had a strong opinion, oppositional and antagonistic, worked various odd jobs for a decade while all the great schools of europe were begging for him to go back into academics. it started by bertrand russel pissing him off, him learning formal logic, destroying russel as well as formal logic in his typical quick fashion (around 70 pages). he went back to cambridge or oxford after he realized there might be a minor flaw in his work, stayed for 17 years obsessively… something tells me guy has weir motivators, lol!

 

There's a difference in ABILITY of doing something and WANTING to do it. And yeah, I think the vast majority of medical students are ABLE to pass in any specialty, if they were interested. The original notion was that specialists hold some amazing skill that others can't obtain and that's simply untrue.

[Wayward son]

If there were free market forces at work, reimbursements would change. Perhaps they'd even go down. But you would know that the value of your work would be determined by what people were willing to pay for it balanced with what you were willing to accept.

 

I assume in your desire for a free-market you are obviously also advocating dropping all barriers to entry. That doesn't simply mean allowing foreign MDs to freely practice hear in Canada, or allowing any other health care provider to perform any current MD task they wish to do (they may do it poorly, dangerously, but that is for the market to decide), but also anyone else anywhere to do any medical task or procedure they feel they can do. Let the market decide how valuable your medical school education is.

[lostintime]

I assume in your desire for a free-market you are obviously also advocating dropping all barriers to entry. That doesn't simply mean allowing foreign MDs to freely practice hear in Canada, or allowing any other health care provider to perform any current MD task they wish to do (they may do it poorly, dangerously, but that is for the market to decide), but also anyone else anywhere to do any medical task or procedure they feel they can do. Let the market decide how valuable your medical school education is.

 

Well you can have safeguards in a free market too in the name of protecting the public. Just because it's a free market doesn't mean we don't have laws against unethical practices such as false advertising, breaking of contracts, etc. even in the business world (Although more shadiness I admit).

 

So while yes, you do have more freedom for people to offer their services, it doesn't mean that Joe Blow can offer to cut open someone's heart if he desires for $200 instead of $20 000 (and may we all hope there is no idiot out there who would agree to that).

[Prince Medward]

Ophthalmologists are getting it from all sides. First fee cuts in Ontario. In BC they are taking away the super-lucrative retail intra-ocular lens market form Ophthals because of price gouging.

 

See this article for the PLoS study on IOL pricing and the BC Ministry of Health press release:

 

http://seeforlife.blogspot.ca/2012/05/are-surgeons-price-gouging-cataract.html

 

This was a source of income that added hundreds of thousands of dollars of income to these guys on top of the $1,000,000 + they bill to MSP. They made the income of one or two GPs just by selling lens implants to their patients.

 

No ophthalmologist should complain about the fee cuts. They will still retire with tens of millions of dollars in the bank. The next generation of ophthalmologists is a different story though. They will not have it nearly as good as the boomers did.

[Blake]

The next generation of ophthalmologists is a different story though. They will not have it nearly as good as the boomers did.

Same goes for radiology. Watch the CARMS applications decrease steadily over the next decade. Maybe it will also make the average ophtho/rad doc more pleasant to work with (I have unfortunately met too many not-so-friendly residents/staff in these particular fields, and I am not the only one suspecting it is largely due to the size of the bank account).

[Wayward son]

Well you can have safeguards in a free market too in the name of protecting the public. Just because it's a free market doesn't mean we don't have laws against unethical practices such as false advertising, breaking of contracts, etc. even in the business world (Although more shadiness I admit).

 

So while yes, you do have more freedom for people to offer their services, it doesn't mean that Joe Blow can offer to cut open someone's heart if he desires for $200 instead of $20 000 (and may we all hope there is no idiot out there who would agree to that).

 

Um yeah, I wasn't talking about that at all. And I think it is pretty arrogant to think that Canadian trained MDs are so elevated that the choices are between them and Joe Blow. They are not. There are thousands of foreign trained MDs who face barriers to entry here. There are thousands of RNs, NDs, chiroprators, pharmacists and so on who could easily expand their scope of practice significantly (sure they may have slightly higher complication rates, but it is not up to you to decide what complication rate is acceptable to other people, it is up to the market). None of this would be false advertising or the breaking of contracts. There are also lots of people with no medical training who could specialize in certain procedures if there were no barriers to entry. For instance suturing. And you can be pretty sure that for more complicated procedures that if people have the choice in between paying 10 times more for a procedure by an MD who has a complication rate of 1 in 10000 vs a non-MD who has a complication rate of 1 in 1000 but is 1/10th the price that a whole lot of people will choose the latter.

 

Calling for a free market while maintaining the barriers to entry is nothing more than the typical free-market rants by rich people who want cheap stuff and more income so they call for a system in which free-market competition exists for the poor, but massive protections from the free-market exist for the rich. It is pure hypocrisy.

[Wayward son]

Irrelevant. Law is a profession that operates on free market principles yet has legal safeguards in place to protect the public from unqualified charlatans.

 

You seem to not know what a free market is. As I have said free-market for the poor, protections from the free market for the rich who like to pretend they are part of a free market.

 

What you are advocating is not a free market, but a regulated one in which regulations that favour you are mandatory, but ones that would not favour you are not allowed.

[lostintime]

Um yeah, I wasn't talking about that at all. And I think it is pretty arrogant to think that Canadian trained MDs are so elevated that the choices are between them and Joe Blow. They are not. There are thousands of foreign trained MDs who face barriers to entry here. There are thousands of RNs, NDs, chiroprators, pharmacists and so on who could easily expand their scope of practice significantly (sure they may have slightly higher complication rates, but it is not up to you to decide what complication rate is acceptable to other people, it is up to the market). None of this would be false advertising or the breaking of contracts. There are also lots of people with no medical training who could specialize in certain procedures if there were no barriers to entry. For instance suturing. And you can be pretty sure that for more complicated procedures that if people have the choice in between paying 10 times more for a procedure by an MD who has a complication rate of 1 in 10000 vs a non-MD who has a complication rate of 1 in 1000 but is 1/10th the price that a whole lot of people will choose the latter.

 

Calling for a free market while maintaining the barriers to entry is nothing more than the typical free-market rants by rich people who want cheap stuff and more income so they call for a system in which free-market competition exists for the poor, but massive protections from the free-market exist for the rich. It is pure hypocrisy.

 

Once you open the gates, then it becomes a slippery slope. FMG's are kind of different than allied health and mid-levels, kind of unfair to lump them all together. At least they have gone through licensing PHYSICIAN exams? That's a completely different story than mid-levels. The problem is that a lot of these things aren't exactly isolated. Suturing isn't exactly JUST suturing. You're not a technician, you have to consider surgical complications, other medical histories, wound healing, etc. And that's why a lot of mid-levels can't act independently (or shouldn't at least ethically).

[lostintime]

You seem to not know what a free market is. As I have said free-market for the poor, protections from the free market for the rich who like to pretend they are part of a free market.

 

What you are advocating is not a free market, but a regulated one in which regulations that favour you are mandatory, but ones that would not favour you are not allowed.

 

Maybe you're not that aware about the legal profession either. I've talked to people in law and they say that that's why para-legals have been under their wing to protect their own interests. Using that analogy, a lot of the work that lawyers can officially do, para-legals can "technically" also do.

[Wayward son]

Once you open the gates, then it becomes a slippery slope.

 

Who cares? Trust the free market.

 

FMG's are kind of different than allied health and mid-levels, kind of unfair to lump them all together. At least they have gone through licensing PHYSICIAN exams? That's a completely different story than mid-levels. The problem is that a lot of these things aren't exactly isolated. Suturing isn't exactly JUST suturing. You're not a technician, you have to consider surgical complications, other medical histories, wound healing, etc. And that's why a lot of mid-levels can't act independently (or shouldn't at least ethically).

 

So what you are saying that as a consumer of health care I am subject to the will of the free market, but at the same time I can't decide that I want to be seen by someone who significantly cheaper, but doesn't consider all those other things like surgical complications and wound healing. I must be FORCED to buy your services, or the services of someone else who meets the non-free market standards that you as group are imposing for the benefit of your group (An oligopoly, almost the exact opposite of a free market in every way). You decide for me that I am not competent enough to decide on inferior, but satisfactory, treatment for a much cheaper price. That is the opposite of a free market. Pure hypocricy.

[Wayward son]

Maybe you're not that aware about the legal profession either. I've talked to people in law and they say that that's why para-legals have been under their wing to protect their own interests. Using that analogy, a lot of the work that lawyers can officially do, para-legals can "technically" also do.

 

I am aware that it is not a free market.