The Tenative Psa Agreement

[thestar10]

Just curious what thoughts other residents/Meds have. The online reaction in COD seems very extreme. I think rejecting it is akin to cutting off the nose to spite the face.

 

Personally it's not a great deal but probably a deal I think we should take.

 

Thoughts?

[5th time the charm]

I will vote No, the MOH is going to do what they want anyway and this is no way to treat docs/learners/residents. difficult times to be a doctor in ontario these days and some clinics won't be able to stay open will be my prediction. 

[ralk]

The details of the deal got better, but the core structure - which is the main problem - stays the same.

 

A global physician budget, even one increasing at a more reasonable rate, is not a feasible approach given the way physician services are currently managed and paid for. They've deferred a number of decisions that, if they turn out well, could make this deal a reasonable one in the short-term, but the structure they're proposing is ripe for misuse. The agreement to work in tandem with the OMA seems like an empty promise which could be broken on a whim, not something with legal force. Even if the power-sharing is respected, the efficacy of this set-up depends on the willingness of the Ontario government and the OMA to put patients' and physicians' best interests at the forefront, something neither party has seemed to do recently. Frankly, I don't trust either group to make informed, practical, evidence-based decisions.

 

They've also left open a lot of potential for political influence on practice management, particularly in family medicine. I'm generally in support of some sort of centralized planning for healthcare delivery, but I want the politicians at arms-length for the main decisions, as political preferences are often far removed from best practices. It's also a dangerous set-up with a global physician budget, as it maintains all the responsibility and liability for care with the physician, while providing little guarantees for compensation levels or any sort of labour rights. That's not a very stable arrangement moving forward, even if there's not too much that's immediately concerning.

 

I don't think a better deal will be coming anytime soon. However, the best way for physicians to get past this was always going to be to wait things out for a change in government, one that would have been eager to find fault with the Liberals' moves on healthcare and wouldn't take their approach. By agreeing to this deal, even tentatively, the OMA has killed that option. Rejecting the deal looks petty, even if it has serious long-term flaws, and makes it harder for opposition parties to back physicians. Accepting the deal makes it seem as though the long-term flaws are acceptable in exchange for the short-term concessions on income, removing the pressure for future governments to eliminate those flaws. At this point, I'd say take the deal - and then make considerable efforts to reform the OMA, if not lobby to have them removed from the equation entirely. They don't seem to be working in physicians' or patients' long-term best interests at all.

[NLengr]

My short opinion: The deal is garbage. It's caving to government. The government will never share power or decision making with the OMA or physicians. That's true of any political party. It does nothing to address the root of the problem, which is lack of binding arbitration (like the majority of the provinces have). Without a clause for binding arbitration, this deal will be a failure.

 

The OMA has once again proven they are incompetent.

[NeuroD]

So it seems there is a lot of discontent in the OMA, especially from younger, and some very articulate physicians and students. Why don't we do something about it? Why don't work towards reforming it, or competing with it via another physicians advocacy group?

 

It might take effort and time, but being the younger generation, we have those on our side.

[ralk]

So it seems there is a lot of discontent in the OMA, especially from younger, and some very articulate physicians and students. Why don't we do something about it? Why don't work towards reforming it, or competing with it via another physicians advocacy group?

 

It might take effort and time, but being the younger generation, we have those on our side.

 

Unfortunately, the younger generation, for the most part, has neither. Residents working 80 hour weeks with minimal control over their schedule and studying on top aren't going to be able to be intimately involved in OMA business. Same goes for new physicians fighting to land a job or establish a fledgling practice. It's the older, more established, even partially-retired physicians who have the time and flexibility to do that sort of thing.

[ploughboy]

This is an incredibly important vote.  Don't think that "I'm just a medical student" or "I'm just a resident".

 

Read the text of the TPSA itself.  Read the OMA's supporting documents.  Read the analysis by COD. 

 

And please, vote.

[NeuroD]

This is an incredibly important vote. Don't think that "I'm just a medical student" or "I'm just a resident".

 

Read the text of the TPSA itself. Read the OMA's supporting documents. Read the analysis by COD.

 

And please, vote.

How do we vote as medical students? I start in September, and I'm not familiar with the OMA yet. I'm sureaure many others readings this are in the same boat.

[thestar10]

How do we vote as medical students? I start in September, and I'm not familiar with the OMA yet. I'm sureaure many others readings this are in the same boat.

You should be able to register on the OMA website as an incoming medical student.

 

If you go to https://www.oma.org/MEDICALSTUDENTS/Pages/OMAMembership.aspx

you can register now.

[thestar10]

This is an incredibly important vote. Don't think that "I'm just a medical student" or "I'm just a resident".

 

Read the text of the TPSA itself. Read the OMA's supporting documents. Read the analysis by COD.

 

And please, vote.

Unfortunately, the referendum is not a binding vote. Really it is just a poll of the membership.

 

Council's votes are the ones that actually matter.

[NeuroD]

Unfortunately, the younger generation, for the most part, has neither. Residents working 80 hour weeks with minimal control over their schedule and studying on top aren't going to be able to be intimately involved in OMA business. Same goes for new physicians fighting to land a job or establish a fledgling practice. It's the older, more established, even partially-retired physicians who have the time and flexibility to do that sort of thing.

 

I was talking about the long game, not this current situation. By having "time", I meant we're going to be in the game a lot longer than those who are currently in power. If we're strategic and organized now, in a few years (maybe 10?) we could really control the OMA, or build our own organization to get more bargaining power.

[ploughboy]

Unfortunately, the referendum is not a binding vote. Really it is just a poll of the membership.

 

Council's votes are the ones that actually matter.

 

While technically correct, the precedent is for Council to abide by the results of the general membership vote.

[thestar10]

It's a large organization that actually only employs one doctor (the president). The rest of the OMA is non physician employees. It's governed by elected representatives either through district or through specialty.

You have to either be elected by the physicians in your district or be elected by your fellow specialists. Those are the voting members plus the board members who are elected by council.

 

When your young and new it's frankly harder to get elected and lower on a lot of people priority list unless you have an interest in medical politics. I have an interest in medical politics and while I commit some time to it, it really consumes your life when you let it making it toxic and unfulfilling.

 

Med students and residents are represented at the Oma by OMSA and PARO respectively.

 

People aren't happy with the conservative approach the OMA has taken. Frankly the ads that they have purchased are really terrible. People want the OMA gone emotionally but obviously doctors need someone to represent them and that will require money, which will probably be taken through the Rand formula. There will always be a union/association that doctors will complain about.

[thestar10]

While technically correct, the precedent is for Council to abide by the results of the general membership vote.

With the OMA board is pushing this deal as it is, I wouldn't be surprised if there was a general No vote with a council Yes vote.

 

The No's have been very vocal online but they also seem very ignorant and hateful towards those currently in the OMA.

[ploughboy]

With the OMA board is pushing this deal as it is, I wouldn't be surprised if there was a general No vote with a council Yes vote.

 

The No's have been very vocal online but they also seem very ignorant and hateful towards those currently in the OMA.

 

I dunno.  I think if Council voted "yes" after the general membership voted "no", an unholy shit storm would result.  Guess we'll see!

 

Agree that some people on the Facebook group are letting their emotions get the better of them.  I don't follow The Tweeter, so I don't know what's happening there, but I'm guessing it's similar?

 

I just hope that it isn't a split vote, and that there is a solid majority on one side or the other.

[ralk]

I was talking about the long game, not this current situation. By having "time", I meant we're going to be in the game a lot longer than those who are currently in power. If we're strategic and organized now, in a few years (maybe 10?) we could really control the OMA, or build our own organization to get more bargaining power.

 

This current situation is not a short-term problem, it's been building over the last decade. Yes, there is turnover in the organization, but it tends to be established practitioners being replaced with other established practitioners. Perhaps slightly younger ones, but still closer to retirement than medical school.

 

I'm all for the younger group getting involved and organized, but that's far easier said than done. As I said, for someone just starting medical school like yourself, the next decade leaves very little time to get involved in the politics of medicine - mostly in your preclerkship years. I started off medical school trying to get more involved on this end, but got blocked out of a few initial opportunities to do so and then quickly got busy with other obligations. We can all only focus our efforts in a few directions and most learners understandably choose to spend their limited time developing their careers or exploring interests while they have that flexibility. Efforts I've seen (or made) to organize action or generate discussion tend to do alright for a while, but eventually fizzle due to inattention or apathy - most people in medicine are simply too busy to get involved and see things through over the longer term.

 

Even for those who put an emphasis on being involved politically, potential impact is pretty limited. There's OMSA and PARO, but a lot of their efforts naturally go towards issues specific to medical students and residents respectively. Efforts to get involved in the broader political process often fall on deaf ears, while students, residents, and their respective groups are often hesitant to take strong stands. The hierarchy in medicine is rather well-entrenched. How can you stand up for what you think is right when the people you're standing up to have the real potential to negatively impact your career?

 

Yeah, we'll be in this longer. But, by the time we have the time and freedom to speak with a full voice, we won't be the younger generation anymore and it'll be far too late to address the current issues, which are rather pressing and could have a significant impact on our future practices. Frankly, political and culture change in medicine seems to move at a snail's pace. I won't say no to opportunities to move things in a positive direction, and I try to take advantage of the chances I do get, but I'm not hopeful.

[kbinners]

How do we vote as medical students? I start in September, and I'm not familiar with the OMA yet. I'm sureaure many others readings this are in the same boat.

 

Hi PhD2MD,

 

As mentioned above, it's easy to register online. I just joined last week myself because students on other forums recommended membership in the OMA and CMA for the discounted car insurance, access to online textbooks and clinical databases, cell phone plans, etc. It was all of $22 to join both the OMA and CMA together.

 

I am feeling a bit like 'Oh shoot I'd better start reading up on these issues' regarding the vote though. Glad to see it being discussed here.

 

Kathryn

[kbinners]

So I just sat down with the TPSA, OMA's supporting documents, and the various pieces by Concerned Ontario Doctors.

 

A global physician budget, even one increasing at a more reasonable rate, is not a feasible approach given the way physician services are currently managed and paid for. They've deferred a number of decisions that, if they turn out well, could make this deal a reasonable one in the short-term, but the structure they're proposing is ripe for misuse.

 

...

 

They've also left open a lot of potential for political influence on practice management, particularly in family medicine. I'm generally in support of some sort of centralized planning for healthcare delivery, but I want the politicians at arms-length for the main decisions, as political preferences are often far removed from best practices. 

 

The global physician budget worries me, because I have recently had to wrangle with the homecare system, and it's horrifying what happens to patients as the end of the fiscal year approaches. This can't happen with other health services.

 

At the same time, health care costs, and especially physician payment schedules, are not fixed costs (as you note). I continue to read that the physician fee schedule needs to be modernized, and this agreement seems to suggest a move to do so -- potentially to cut some of the highest fees and to add incentives for after-hours care, which both sound like good ideas to me. I wonder, tentatively, because I'm such an outsider, whether some kind of funding limit might be needed to force more active examination of the current system and funding priorities by physicians. No one wants to voluntarily take a pay cut, but I'd like to believe that most doctors would, ultimately, if it meant doing so would allow more patients to be treated. (Eg if the choice was between treating 500 patients at fee $X or treating 1000 at fee $X/2.)

 

I am worried by COD's list of clinics and practices being forced to close. I don't fully understand why this is happening. Can someone explain the mechanism here? At what point is it more expensive to run a practice or clinic than to close it? Are doctors literally reaching funding caps and choosing between shutting up shop or working unpaid? Has anyone seen this happening?

 

I am also worried by the COD's numbers suggesting that Ontario family medicine grads are increasingly choosing to work outside of the province. Does that maybe have to do with the managed entry policy? Isn't that off the table now? Could adding incentives to primary care, as hinted at in the TPSA, potentially help to reverse this trend? Unfortunately, one of the issues with having a province-by province health system is that there are going to be shifts in the popularity of each province for each specialty as each tries to update their funding schedule (unless they all do it at once, haha fat chance), but that's not a reason not to update the fee schedules.

 

I'd second your opinion that I'm generally in favour of some central planning for health care, especially looking to history for the line taken by government vs doctors on major health system restructuring (notably medicare). Unfortunately I don't think physicians always organize their work according to best practices either, and I'm not sure which of the three groups (OMA, government, individual doctors) I would trust most. Really, I'd be happier if some patient advocacy groups were involved... Given all the misgivings, a co-managed system doesn't seem like a terrible idea to me, from out here...

 

Honestly, if I had to vote this second, I'd vote for it. BUT I'd love to have more information. I'd be happy for further resources and/or opinions if you folks can take the time to share them.

 

Kathryn

[ralk]

So I just sat down with the TPSA, OMA's supporting documents, and the various pieces by Concerned Ontario Doctors.

 

 

The global physician budget worries me, because I have recently had to wrangle with the homecare system, and it's horrifying what happens to patients as the end of the fiscal year approaches. This can't happen with other health services.

 

At the same time, health care costs, and especially physician payment schedules, are not fixed costs (as you note). I continue to read that the physician fee schedule needs to be modernized, and this agreement seems to suggest a move to do so -- potentially to cut some of the highest fees and to add incentives for after-hours care, which both sound like good ideas to me. I wonder, tentatively, because I'm such an outsider, whether some kind of funding limit might be needed to force more active examination of the current system and funding priorities by physicians. No one wants to voluntarily take a pay cut, but I'd like to believe that most doctors would, ultimately, if it meant doing so would allow more patients to be treated. (Eg if the choice was between treating 500 patients at fee $X or treating 1000 at fee $X/2.)

 

I am worried by COD's list of clinics and practices being forced to close. I don't fully understand why this is happening. Can someone explain the mechanism here? At what point is it more expensive to run a practice or clinic than to close it? Are doctors literally reaching funding caps and choosing between shutting up shop or working unpaid? Has anyone seen this happening?

 

I am also worried by the COD's numbers suggesting that Ontario family medicine grads are increasingly choosing to work outside of the province. Does that maybe have to do with the managed entry policy? Isn't that off the table now? Could adding incentives to primary care, as hinted at in the TPSA, potentially help to reverse this trend? Unfortunately, one of the issues with having a province-by province health system is that there are going to be shifts in the popularity of each province for each specialty as each tries to update their funding schedule (unless they all do it at once, haha fat chance), but that's not a reason not to update the fee schedules.

 

I'd second your opinion that I'm generally in favour of some central planning for health care, especially looking to history for the line taken by government vs doctors on major health system restructuring (notably medicare). Unfortunately I don't think physicians always organize their work according to best practices either, and I'm not sure which of the three groups (OMA, government, individual doctors) I would trust most. Really, I'd be happier if some patient advocacy groups were involved... Given all the misgivings, a co-managed system doesn't seem like a terrible idea to me, from out here...

 

Honestly, if I had to vote this second, I'd vote for it. BUT I'd love to have more information. I'd be happy for further resources and/or opinions if you folks can take the time to share them.

 

Kathryn

 

You're right, what happens with home health care an other services towards the end of the fiscal year is, well, horrifying. However, the global physician budget is another beast entirely. Home health care, as well as hospitals, have a set budget. They know how much money they as an organization have to spend for a year, and if they go over it, there are consequences. So, as the end of the year approaches, any organization at risk of going over their budget starts cutting back, hard. These organizations know what their limit is and can plan accordingly.

 

With the global physician budget, we don't know what the limit is. Sure, they specify what the collective maximum spending on physicians will be, but since individual physicians know only what their own billings are, and not what billings for the whole province are from physicians, they really don't know when we hit or approach that limit. Even if we did somehow know that, there's little incentive to stop working because the clawback mechanism hits all physician income, regardless of when it was earned. To give a simple example, let's say there were only two doctors in Ontario, Dr. Carl and Dr. Lenny. And let's say they billed to the maximum in November. Dr. Carl decides to stop working, knowing there will be no more money for doctors. But Dr. Lenny keeps working and increases his billings by X number of dollars. Well, now the global physician budget has been exceeded by X dollars, so there's a clawback. However, that clawback doesn't just hit Dr. Lenny's income, it hits Dr. Carl's income too. So Dr. Carl actually loses about X/2 dollars from the clawback by not working and while Dr. Lenny loses X/2 from the clawback as well, he made an extra X dollars, so is ahead by X/2. 

 

The global physician budget is collective punishment for uncoordinated, individual actions, which changes the incentives for individual actors significantly. I doubt we'd see a December slowdown for physician services; physicians would just see a drop in their incomes.

 

The fee schedule does need to be modernized and that does happen on a regular basis, albeit extremely slowly. I would certainly vote for a deal that simple adjusted billing amounts provided it did so intelligently. The government did push for some changes along these lines, with mixed merits to their changes. For example, Radiologists saw their incomes take a good-sized drop with the new fee schedule. Economically this makes sense - Radiology incomes are quite high, even by physician standards and we don't need to pay them that much to fill our demand for Radiologist services. However, Radiologists are understandably pissed that they just lost a good chunk of income. The OMA can't exactly throw Radiologists under the bus, even if doing so would negate the pressure to cut other physician's income - physicians who may make less and have their practices more affected by cuts. Funding limits really don't help on this front because they're a broad-based cut to all physician services and the OMA really has to tread lightly when making specialty- or service-specific recommendations.

 

Many physicians do already accept reductions in their income for the sake of patient care. It's fairly easy to make more money by being a crappy doctor and happily most physicians resist that urge. However, what's being asked of physicians is to accept lower income for doing the exact same job, with no benefit to patient care. In the proposed set-up by the Ontario government, the number of patients being treated doesn't go down for the most part, physicians simply make less for doing the same work.

 

So how does this lead to the list of clinic closures COD provides? Well, in short, it doesn't. That's mostly just rhetoric. Looking at the list, many instances of closures or cutbacks in services due to proposed cutbacks are just non-sensical. There's no reason for a clinic to close 1 day/week for example, something COD lists multiple times, due to these cutbacks - that just reduces clinic income while increasing the percentage of overhead costs. Where the cutbacks could be affecting patient care is where it causes certain services to no longer be economical. Across-the-board cuts mean that some services which barely covered the cost of providing those services now cost practitioners money to provide. Physicians naturally avoid providing these services - no one wants to pay to do work! Likewise, there are a few practitoners who feel that the overall payments they would receive are too low to justify them continuing to work and would rather retire or move to another province. This is a fairly small number of providers, mostly older family physicians choosing to retire a bit ahead of schedule.

 

There is a lot of rhetoric about new FPs leaving the province and that's probably the main concern I share with those protesting current cuts. However, FP income outside Ontario really isn't much better even after the cuts and many Ontario FPs want to stay in the province for personal reasons. There will definitely be some movement, but I wouldn't expect sustained exodus. Keeping FHTs/FHOs available is certainly something new grads would like and as someone hoping to start as an FP in Ontario in 3-4 years, I'd prefer working in such a setting, but there's a decent argument against these groups. They're more expensive to maintain than traditional practices and they tend to serve fewer patients per provider. The argument was that patient outcomes would improve under FHTs/FHOs, but the evidence for that is pretty weak.

 

I'd like to see more patient advocacy groups involved in the process as well, because I don't think they're being properly represented in this fight. The Ontario government, the OMA, even groups like COD aren't really in the patients' corner. They all are proclaiming quite loudly that they want what's best for patients, but the positions each take seem to be mostly in their own self-interest. The government protects their bottom line, the OMA tries to protect their entrenched power, the COD tries to protect physician income. Deeper involvement of these groups in the decision-making process, to me, just means more non-patient interests being served first. Even if one of those interests is technically my own, I'm not a fan.

[thestar10]

The mechanism of the closed clinics relate primarily tithe elimination of the chronic disease code preimium by son IM sub specialties, the elimination of the urine dip (addiction medicines was able to run clinics with this), the general rate of inflation etc.

 

A couple docs have probably left for greener pastures as well.

[ploughboy]

Here is PARO's most recent statement, which is particularly relevant to readers of this board.  If OMSA sends something out, that would also be relevant to this audience.  Please post it here if and when they do.

 

 

---

On Monday July 11, 2016, the Ontario Medical Association announced that they had a tentative Physician Services Agreement (PSA) with the Ministry of Health and Long Term Care. If you are a member of the OMA, you have likely received information about this tentative PSA.

 

Whenever the OMA and the government negotiate a deal, PARO always carefully examines the details to determine the impact on our members. Most PSAs exclusively contain details related to compensation that affect doctors who are in practice. From time to time, the deals have contained components that have a direct bearing on our members and it is the responsibility of the PARO leadership to carefully review the details of any tentative PSA to ensure that our principles are upheld, namely that doctors new to practice do not in some way shoulder a disproportionate burden of any fiscal restraint, nor that there are any measures that may limit entry of our members to practice on the same terms as our established colleagues.

 

In the not so distant past, there have been previous agreements between government and medical associations in Ontario and other provinces, as well as government legislative measures, (under all three political parties) where new doctors were singled out for fee discounts, limitation on billing numbers, restrictions on practice locations and other discriminatory restrictions. In every instance, they were met with vigorous opposition from residents and medical students. Even as recent as last fall, the government attempted to use the New Graduate Entry Program to single out new family doctors with both geographic and compensation limitations.

 

One of the issues that is critical to residents and medical students, as they consider whether to vote in favour of ratification of the current tentative agreement is the implications of the proposed joint committee formed to make recommendations on physician human resources.

 

There have been unsubstantiated concerns that this committee will be used to impose restrictions on new doctors who have trained in Canada. As a result, PARO is following up with the Government and the Ministry of Health and with the OMA to obtain their commitments that they will not consider implementing any restrictive or discriminatory measures on new doctors once they are training in the Canadian medical system. From PARO's perspective, unless we get these assurances, residents and medical students would not be able to support an agreement which, in the context of restrictions on the overall physician expenditure pool, sets up a joint committee whose mandate potentially includes making recommendations or reaching agreement on imposing restrictions on new doctors in terms of compensation and mobility.

 

Please be assured that the PARO Board, senior staff, legal counsel and trusted advisors are all actively working on your behalf. It is my intent to provide you with a brief summary of the deal, as well as a report back on our ability to get the assurances I have outlined, as soon as possible.

 

Sincerely,

Stephanie Kenny MD
PARO President

[FutureGP789]

Personally, I've already packed up and left Ontario for beautiful British Columbia. Fee for service isn't perfect, but I refuse to work in the type of health care system the Ontario Liberals have now created. One less FP in Ontario I guess...

[ellorie]

I am conflicted about my vote.  On one hand, I hate that this deal came about in such a bizarrely hidden way, and it seems like an awful deal.  On the other hand, the OMA seems to feel like it's the best we're going to do.

 

I really don't want to leave the province and frankly the province should want to keep me given the state of my specialty, but geez.

[Let'sGo1990]

My vote is undecided. It'll likely be a "no". A two year stink... and this is the outcome. It is much less than ideal and will serve as a poor precedent going forward. But news of the deal has hit the media, and the public knows. Rejecting an OMA committee and government approved deal could reflect poorly on physicians.

[NeuroD]

My vote is undecided. It'll likely be a "no". A two year stink... and this is the outcome. It is much less than ideal and will serve as a poor precedent going forward. But news of the deal has hit the media, and the public knows. Rejecting an OMA committee and government approved deal could reflect poorly on physicians.

Yes, but probably in the short term, whereas the effects of the deal are long term. I'd rather wait until the liberals are voted out for a much better deal. They don't have a lot of fans. At the very least, they're likely to be more reasonable around elections (that's assuming they want to get reelected, but given their behavior it's hard to believe that they do).