Making OHIP billings public could alter Ontario’s health-care landscape
TheStar.com – News/Canada – Giving the public a clearer perspective on how doctors are compensated might change negotiations and improve health care, critics say.
Dec 09 2014. By: Theresa Boyle, Health
Making OHIP billings public would give the province a leg up during contract negotiations with doctors, says the former president of the Ontario Hospital Association.
“The government always has one hand tied behind its back in those negotiations because the medical association advertises on behalf of doctors, suggesting they should be compensated well because they are performing an important task,” Tom Closson said.
The Ontario Medical Association (OMA), which bargains on behalf of the province’s 28,600 physicians, has launched expensive advertising campaigns during past negotiations in an attempt to build public support.
“If the public had more information on the way doctors are compensated, they might have a more balanced perspective in terms of giving their views to the government during negotiations,” said Closson, who also previously served as president of the University Health Network and, prior to that, president of Sunnybrook Health Sciences Centre.
The province is currently in contract negotiations with the OMA, and according to multiple sources the talks are limping along.
A conciliator was recently brought in after the two sides were unable to reach an agreement on their own or with a facilitator’s help.
“What I can say is that we are pleased to have the Hon. Warren K. Winkler, former Chief Justice of Ontario, to serve as the conciliator,” OMA president Dr. Ved Tandan said in an emailed statement. “Justice Winkler is internationally recognized for his experience in mediation and dispute resolution, and we look forward to working with him during this phase.”
Negotiations for a new Physician Services Agreement centre on establishing how much doctors should get paid for each consultation or procedure performed, a payment model known as fee-for-service.
Talks started early this year, prior to the March 31 expiration of the last agreement.
There is a media blackout on the negotiations, but sources say Dr. David Naylor, past president of the University of Toronto, was brought in as a facilitator last August. He issued confidential recommendations to each side, but was unable to bring the parties to an agreement, and they continue to dig in their heels.
Winkler’s recommendations will not be binding, but his report will be made public.
Health Minister Eric Hoskins has already let it be known that physicians should not expect a funding hike. “There are no additional funds available for compensation,” he said in an interview earlier this year.
The province spends about $11 billion annually on physicians, most on fee-for-service payments.
The top 100 billers to the Ontario Health Insurance Plan were paid a total of $191 million in 2012-13, according to data the Star received from the health ministry through a freedom-of-information request.
The Star was denied a request to get the names of those top billers, a decision it is appealing.
Tandan has concerns about billings being publicly identified with particular physicians.
“While public accountability and transparency are important, simply publishing a list of individual physician billings could be incorrectly equated as a physician’s salary and requires much more information for it to be interpreted correctly,” he said, noting that overhead expenses are paid out of billings.
Tandan also said some doctors have high billings for good reasons — for example, if they work in underserved communities or are participating in government programs to cut down on wait times for procedures such as cancer surgery.
But Closson argued members of the public have a right to know how their tax dollars are being spent.
“The negotiations between the Ministry of Health and the Ontario Medical Association should be conducted with the public having an understanding of how much their physicians are paid, as it is the public’s money that the government is agreeing to spend,” he said.
During past negotiations, governments have tried to garner public support for their positions by making an issue of what doctors get paid.
In 1996, then Conservative health minister Jim Wilson was forced to temporarily step down after an aide leaked to a reporter that a Peterborough cardiologist was a top biller.
The cardiologist was then vice-chair of the Specialist Coalition of Ontario, an OMA breakaway group that was on strike at the time seeking to force the government to pay them more. He had just held a news conference to criticize the government’s intention to limit doctors’ OHIP billings.
During the last round of negotiations, in 2012, then health minister Deb Matthews made a point of telling reporters that Ontario physicians were the best paid in the country, on average earning $385,000 a year, 75 per cent more than nine years earlier.
The negotiations have a long history of being acrimonious. During the 2012 talks, the government took the unusual step of unilaterally cutting fees for 37 services and procedures.
After the OMA responded with a constitutional challenge, the government relented on some of the cuts.
The government is pushing harder than ever for more accountability from physicians during the current talks, according to multiple sources.
The government feels burned after getting little return on massive investments in physicians in recent years, particularly in primary care, they said. Primary care refers to the entry point to the health system, often the family doctor.
Despite an almost $1-billion investment in family doctors between 2006-07 and 2009-10, many Ontarians continue to have trouble getting in to see a doctor.
A recent report from Health Quality Ontario revealed that 60 per cent of Ontarians can’t get same-day or next-day appointments when they are ill.
Fuelling the government’s hard-line stance during the current talks are the savings targets set out in the last agreement that have yet to be met, according to sources. The goal of limiting spending growth in certain areas wasn’t realized.
The government may want to make doctors more accountable, but the sad reality is it has limited influence on how doctors work, said health policy analyst Michael Rachlis.
“It’s one of dirty little secrets of medicare,” said Rachlis, who is also a University of Toronto adjunct professor. “The government can’t say: ‘Here is a job description, follow it.’”
Provincial governments and their medical associations believe public dollars set aside for physician payments belong to doctors, Rachlis said, and it is up to the doctors to allocate the monies among themselves.
“It’s an insurance-based model where a doctor bills for seeing a patient. There is no other requirement for accountability,” he said.
Physician payment models, especially fee-for-service, don’t give physicians any financial incentive to provide comprehensive care, he noted.
The piecework model rewards quantity over quality. Doctors make more money if they see a lot of patients, each for a short period of time, and send them off with prescriptions for drugs and referrals to see specialists.
“We could have a way better health-care system tomorrow without spending a penny,” Rachlis said, but that would mean changing the government-doctor relationship to make the profession more accountable.
Health policy consultant Steven Lewis concurs. He argues the solution is to phase out fee-for-service. Older doctors should have the option of sticking with that way of being paid, while younger doctors should be encouraged to enter into a new arrangement that ties their compensation to accountability and health outcomes.
“I think there has to be a generational change,” said Lewis, adding that polls have shown that younger and female doctors, especially, are open to change.
Instituting such a huge change wouldn’t be easy, he acknowledged.
“It will take political will, vision and strategy and some tough-mindedness to get it done,” he said.
Dr. Isser Dubinsky, former chief of emergency services at the University Health Network and now a senior health consultant at the Hay Group, said he would like to see far more accountability from hospital-based physicians.
“It needs to shift from a relationship of what I would call credentials to privileges, to a relationship of contracting,” he said.
Contracts should spell out the expectations of physicians, Dubinsky said. That could include, for example, being on-call once a week and meeting targets for average length of patient stays and average cost of patient care.
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