Not About the Money

Hand holding fanned out Canadian money.The Canadian Press Images-Mario Beauregard
The Canadian Press Images-Mario Beauregar

Almost 50% of couples divorce, but 90% never fight about money, according to a new study.

Government has fought with doctors for almost 50 years now, and it looks like all they do is argue over money. This assumption is reasonable, and wrong.

Money is a Distraction

Most grownups pay attention to their accounts. They limit debt and make payments on time. They know that money runs out.

Government takes a different approach. In part, government does not need to worry; it can always raise taxes. But voters will not tolerate anything. Taxes run out, too.

When doctors and government fight about money, observers often miss an important point: Government does not really need to worry about the money it spends on doctors. Continue reading “Not About the Money”

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Distract Doctors, Gain Control

distracted-parentSmart kids learn to distract and stay out of trouble. They know Mom won’t bother about overdue homework, as long as she stays stressed about something else.

Politicians do the same. They distract voters with new handouts, or even better, stoke anxiety about Zika, Global Warming or some other ominous event.

Just do not let voters ask about things that government can impact, like patient wait times.

How to Gain Control

If government wants to shape society, instead of just serving it, politicians need the power to tell people what to do. Continue reading “Distract Doctors, Gain Control”

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Unspoken Debates – 1st Step to Recovery

kids-ask-questionsDysfunctional families sit down for dinner and dance around old feuds. They trip over unspoken debates and pray the kids don’t ask awkward questions.

The same thing happens in healthcare. Doctors sit down with patients and try not to think about why healthcare works the way it does.  Hopefully no one asks an awkward question.

How to Create a Mess – 101

In theory, healthcare works like this: Doctors care for patients and leave funding to the government. If patients need specific care that no one offers, some doctors retrain so that they can open clinics to provide the needed service.

Doctors fill needs and niches. They form an organic network of medical services and referral patterns around patient care.

Everything would work fine, if government could just let it happen and step in only when doctors and patients asked for help, for problems they cannot solve themselves.

Instead, government jumps in with its own ideas, even when no one asks. Continue reading “Unspoken Debates – 1st Step to Recovery”

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Our Medical System Needs Choice to Survive – National Post

private_health_20160901national-post-logo This must read, 700 word editorial from the National Post sums up the issues with Canadian healthcare and the BC Supreme Court case.

Read the original article here, or in the full text below.

Our Medical System Needs Choice to Survive

National Post, Sept 7, 2016

Defenders of public health care in Canada should welcome Dr. Brian Day’s constitutional challenge to Canada’s health-care system, which has finally reached British Columbia’s Supreme Court. The system needs choice to survive.

Day’s critics clearly don’t see it that way. Predictably, they warn that a victory for the former Canadian Medical Association president will sentence Canadians to “U.S.-style health care” and an inevitable decline in standards or access. The claim suggests a curious myopia. First, there is no reason to assume the only alternative to our current system is 100 per cent private medicine Continue reading “Our Medical System Needs Choice to Survive – National Post”

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Doctors Need a Common Enemy

common-enemyMy son’s hockey team kept losing, even though they had one outstanding player. They got an early win when their superstar was away. The team started passing, worked together and won.

Team unity beats divided talent every time.

The OMA presented a contract to the doctors of Ontario in July. Even at first glance, people could see that it would divide doctors.

We should not fear dangerous ideas. But ideas must come out at the right time, in the right place.

Tackling divisive issues in a tentative contract is like starting a team brawl in the locker room, just before a game. You will lose.

Divide and Conquer works well. Politicians know that.

Government is Not the Enemy

Doctors need government. Teams cannot play without goal posts and referees. Doctors cannot provide care without government to enforce contracts and maintain order.

As much as many of us hate to admit it, we need a little government bureaucracy.

But sometimes, government is the enemy.  Continue reading “Doctors Need a Common Enemy”

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Identity Crisis – Whose Side are We On?

luke skywalkerWhether in war or the Super Bowl, anyone who tries to cheer for two opponents gets called a traitor by both.

Serious opponents wrestle over fundamental differences.  Dreamy relativists dismiss debate and sing, “Why can’t we be friends.”

Although peace costs less than war, sometimes you must pick a side and fight. Peace-brokers risk becoming irrelevant to both sides, after the war ends. Those too eager for peace could incite civil war in their own ranks.

That’s not to say we should never call a truce. Calling a truce means, by definition, that there are two sides. You cannot deny differences and hope to win favour with both opponents.

Identity Crisis

Doctors are not on the same team as government. Politicians are on their own team. As soon as their interests do not align with ours, doctors often lose. Continue reading “Identity Crisis – Whose Side are We On?”

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Dreams of Co-Management

Blond Boy CryingWe start life ruled by passion. We clench our fists, howling at hunger pains and wet diapers. We swing from elation to rage, driven by desire.

Eventually, we grow up. We learn to control emotion. But passion continues to fuel our dreams throughout life. Life absent passion is death.

Dreams of Co-Management

Doctors have audacious dreams. They want a say in how patients receive medical care. They want an equal voice in decisions about medicine.

Some call these dreams arrogance. Continue reading “Dreams of Co-Management”

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Crisis of Trust – Doctors Vote No

harry-potter-philosophers-stoneOrphans make great fiction. Harry Potter leads a long list with Tom Sawyer, Anne of Green Gables and Oliver Twist.

Children need someone to trust. They cannot be children and fight the world at the same time. Abandonment is held with universal disdain.

Doctors feel abandoned. Over 61% voted No to a tentative deal that promised cuts and underfunding for 4 years.

The Wynne government has squandered money for medical services, by gambling on windmills and pension plans. Health Minister Hoskins makes a point of belittling doctors for working hard in the system his government created, while every other public union gets contracts, with raises.

Doctors feel abandoned by government.

Many doctors feel the same about the Ontario Medical Association (OMA).

No one can accuse the OMA of bargaining in bad faith. The OMA was determined to promote the 2016 Tentative Physician Services Agreement and spared no expense in advertising.

Robocalls, personal phone contact on the weekends, slick campaign ads by email, video interviews, dozens of roadshows, tele-townhalls, local medical meetings, letters to the editor and a massive social media campaign pushed doctors to vote Yes.

No one knows, but people guess it cost between $1 million to $3 million. This ignores hours of OMA staff time, as other work got put on hold.

The OMA has never tried so hard to convince their members to ratify a contract.

And that’s the problem.

The board endorsed the New Deal. It was wise to share it with members. But endorsement morphed into promotion and desperate advocacy.

Desperation creates blindness and drives odd behaviour. Superior Court Justice Perell ruled that the OMA Board’s Executive Committee had “abused the authority provided to it” and created an “unhelpful, unclear,  unbalanced, and unfair” voting process.

Perell called the Exec “sneaky”.

Addendum: One physician leader insisted that Perell called the “OMA” sneaky. Legal opinion did not back up that statement, although it is not 100% clear. Regardless, whether Purell referred to the Exec, the whole Board or the OMA writ large, his comments are damning. We must get on and face the fact that the comments exist and stop blaming people for drawing attention to them. 

We must not judge too quickly. Passionate beliefs make people double down and pour in more energy, precisely when they should step back. Double or nothing seems logical at the worst time.

A wise friend said that, People with weak arguments hold the bitterest resentment for those who do not support them. People with strong arguments do not need endorsement. Their case stands on its own merit.

The OMA bet everything on promoting a Yes vote and lost doctors’ trust in the process. Many of us might have made the same mistake.

Crisis of Trust

Warren Buffett said, “It takes 20 years to build a reputation, and 5 minutes to ruin it.” It takes years of effort, sacrifice and principled behaviour to earn the trust that creates lasting change.

Doctors need someone to watch their back, so that they can focus on patients. Doctors cannot provide care with one hand on their sword.

Many believe that the massive No vote is a vote of non-confidence in the OMA.

How to Rebuild Trust

Healing starts with taking other people’s beliefs seriously, regardless of our opinions about those beliefs.  Denying a crisis of trust guarantees more failure.

For leaders, staff opinion must trump leadership ‘facts’. When staff members firmly believe that leadership betrayed them, leaders cannot fix it by proving their staff has no right to feel that way. Leaders win trust with behaviours and outcomes, not arguments and facts.

Doctors know this. When grieving parents attack us, it does not help to debate the best way to resuscitate a dying toddler. We want to run away when lawyers show up, but that is exactly the time to engage with compassion.

Leaders must deal with beliefs and emotions before process and projects. We must take the accusations of our most passionate critics with utmost seriousness.

If government is a reckless, absent parent, then the OMA must be the dependable one. The OMA must win the right to be trusted. It can be done. But it will be costly, in many ways. We need the courage and humility to start.

The OMA must prove to doctors that it values its members before anything else; that it will never abandon them. That might require painful sacrifice. But it’s essential. Orphaned doctors do not provide great care.

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General Meeting of the Membership

AllStream CentreAnyone who has ever video taped an event knows that important things  happen off screen. The camera lies.

Historians write history long after collecting all the details and stringing them together. They interpret events and find meaning. They might even use video clips.

General Meeting of the Membership

Eight hundred doctors attended the General Meeting of the Membership, on Sunday, August 14, the second one since 1880.

The first one took place at Maple Leaf Gardens in Toronto, in 1991 over a rotten contract. That time, around 1500 doctors sat in hockey bleachers and left disappointed; the OMA President had collected thousands of proxy votes and crushed the uprising easily.

The contract was ratified. Doctors endured almost 10 years of ’Social Contract’ abuse that ended with 2 million Ontarians without a family doctor.

Almost Perfect

This meeting was different. The OMA pulled together one of its best-organized meetings, in less than 6 weeks.

No expense was spared.

Attendees stretched out in a room prepared to seat 4000, plus overflow. Everyone else watched it live online, from the middle of their summer vacations.

Hartley R. Nathan policed the meeting. He wrote Nathan’s Company Meetings Including Rules of Order and is the expert on parliamentary process in Canada.

Mr. Nathan whispered to the Chair all afternoon, until the Chair closed the meeting with: “This meeting is now terminated.

Doctors loved the opening speeches, an ersatz debate almost. They cheered as the underdogs approached the stage, brave upstarts challenging the establishment.

A reverent hush filled the room, while the next speakers assembled. No one dared whisper or fidget as the Co-Chair of Negotiations adjusted the mike.

The army of security guards had an easy day. Fearing the worst, organizers thought of everything. They made speakers line up at separate microphones, labelled ‘For’ and ‘Against’. It helped the Chair alternate sides and prevented shoving in the lineups.

Squabbles

Only once, a group of medical students and trainees swarmed the microphones.

One doctor had questioned whether trainees knew much about running a medical business in their ‘naiveté’: Did their opinion really matter?

With good reason, students responded. A few went too far. One said most working doctors could never get into a modern medical school.

The issue was not settled. Students do not get to vote on residents’ contracts.

Thankfully, the fracas ended quickly.

Many doctors said they wished that biannual Council meetings could be as fair and open. They loved debate that ran as long as necessary and only ended after speakers ran out of words.

The crowd discussed 3 motions over 5 hours. At that rate, Council might complete business in 7 days, instead of the usual Saturday – Sunday meetings.

Existential Impact

Now we wait to hear from the official counters-of-the-vote. As memories fade and blend with official records, we will decide what this General Meeting means, if anything at all.

Will it prove that activism can never change a nationalized industry?

Will it show that doctors cannot change their own organization from the outside?

Or will it mark a watershed in medical politics, the point when the populace rose up and said, “Enough!

In the tangled meaning that emerges, one thing is certain: healthcare in Ontario is in trouble, and this marks the start of change.

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Minister of Monopoly (Nat’l Post Article)

CorcoranTerence Corcoran, journalist at the National Post, captures the bigger issues going on in Ontario healthcare, in his article today: Minister of Monopoly

Regardless of where you land on the doctors’ New Deal, please take a few minutes to read Mr. Corcoran’s article (posted below).

Patients do not benefit when government holds all the power in healthcare. Even if doctors vote YES, let’s hope they keep the power imbalance in focus. 

Enjoy!

Minister of Monopoly

National Post
Thu Aug 11 2016, Page: A10, Section: Issues & Ideas
Terence Corcoran

This coming Sunday, Ontario’s doctors will meet and vote on a proposed compensation agreement between their ersatz union, the Ontario Medical Association, and the Wynne Liberal government. It is shaping up as one of the most important events in the modern history of health care in the province.

The new agreement, known as the Physicians Services Agreement, has been superficially portrayed in the media as just another typical labour skirmish over cash between greedy overpaid medical millionaires and do-gooding politicians protecting the public good and the sanctity of universal health care.

Similar confrontations have been raging since the 1980s when the OMA was transformed into a mandatory Rand Formula organization and doctors lost the right to practice outside the system. But this year could – or should – be different. The Sunday vote is much more than a simple decision on whether doctors – along with nurses the only people in the $50-billion government funded system who actually deliver health care directly to patients – will be paid more or less over the next four years. The answer is less, but that’s not half the story.

The new compensation agreement (negotiated in secret unbeknownst to members before it was announced by the OMA in July) is the high-profile tip of a giant low profile health-care menace known as Bill 210, legislation that bears the unbearably cute title “The Patients First Act.” The objective, officially, is to improve primary care in Ontario and repair the bureaucratic shambles that currently exists.

Bill 210 was tabled in the Ontario legislature in early June by Dr. Eric Hoskins, Minister of Health and Long Term Care. It received minimal media coverage, perhaps because it arrived surrounded by vaporous clouds of bureaucratic babble, management consultancy jargon, impenetrable legalese and ideological sleaze. What can one say about a plan that promises a new system that “focuses on performance management and continuous quality improvement” and aims to improve “population health” and serve “community needs” based in equity and the delivery of healthcare “where people live”?

Underneath the sleaze and behind the clouds is the Ontario government’s attempt to put in place the power apparatus it believes it needs to install the next phase in the ongoing multi-decade effort to reconstruct the province’s perpetually failing healthcare system and install a more centralized top-down perpetually failing healthcare system.

When government holds monopoly control over any system, and the means of production of key suppliers have been nationalized, there’s no market to help patients, doctors and health-care managers make decisions. The only option for the system is to constantly increase bureaucratic control and progressively reduce the freedom for everybody else.

If doctors vote Sunday to accept the agreement, they will be pulling the first string that will allow the Wynne government to bring in reforms that will, among many other things, greatly reduce the already constrained freedom of doctors, hospital managers, and other organizations and individuals. As the OMA itself said in response to Bill 210, the legislation gives the minister of health and the government-controlled Local Health Integration Units (LHINs) “a significant increase in their command and control of the health system and many of the providers within it.”

To get that command and control, Ontario is using the oldest legal dodge in the command-and-control handbook: give the minister the power to do anything the minister wants so long as it can be said to be in the “public interest,” an undefined legal grab bag that provides command-and-control freaks near-unlimited power. “This is problematic,” says the OMA in an understatement.

As the all-powerful commissar of patient care, the Minister of Health (MOH) can reach high and low through the system in search of the public interest. The Ontario Hospital Association, in its response to Bill 210, calls the MOH’s new public interest powers “quite broad” – another understatement. It would, for example, permit the minister to issue direct orders to hospitals to lower parking fees – something the government has tried to do in the past but had no legal authority to enforce. Now it will. Moving up the chain of decision-making from the seemingly trivial business of parking fees, Bill 210 lays out a dozen instances in which the “Minister may” act in “the public interest.” One example:

“The Minister may issue operational or policy directives to a local health integration network where the Minister considers it to be in the public interest to do so.”

And on it goes: The Minister may in the public interest issue “operational or policy directives” to the board of a public hospital. Private hospitals “shall carry out every directive of the Minister” and such directions could be “general or particular.” The Minister may appoint investigators to “enter the premises” of a local health network “without a warrant” to inspect records and “report on the quality of management and administration.”

The MOH needs all these new command and control mechanisms to help it impose Bill 210’s major objectives, which is to expand the powers of the 14 local health networks that currently plan, fund and oversee health-care delivery across the province. Under the plan, the local networks – through which most of Ontario’s $50-billion health budget flows – are to take over another branch of the system, the province’s dysfunctional community and homecare operation. Also to be submerged under the centralized control model are local medical health officials. Even experts who support some of the power consolidation have their doubts. Michael Decter, a veteran of Canadian health policy, said the group he chairs, Patients Canada, supports the goals of Bill 210. But he said “we are unable to see how a major restructuring of boards and more bureaucratic management and oversight of health providers and health organizations will result in more responsive, effective, compassionate delivery of health-care services to patients.”

Most agencies and associations have adopted a wary wait-and-see attitude toward Bill 210, which will come up for detailed review and amendment in the legislature later this year. The OMA has many clear concerns. Requirements that physicians report their office operations to local authorities, including practice policies, profiles, wait times and coverage, is “intrusive” and “erodes physician self-regulation.” Other parts violate agreements the OMA has with the government.

A recent commentary by lawyers at Osler Hoskins portrays Bill 210 as a “sweeping expansion” of government and local health networks over physicians and other health-service providers. Bureaucrats will have the power to identify and plan for “physician resources” and unilaterally impose accountability agreements. The bill will impact physicians in family health teams, individual hospital departments, entire services in a single hospital, and emergency services. None of this is directly on the proxy ballot doctors will be completing for tabulation on Sunday. But it is clear the new compensation agreement is part and parcel of the Wynne government’s Bill 210 master plan.

The OMA’s position is that while the new compensation agreement may not be all that great (“Not a perfect choice. Far from it.”), they say doctors will benefit in the future because the OMA has negotiated certain clauses that will mitigate some of the worst aspects of Bill 210.

For example, to help alleviate the fact that many Ontarians have no family doctor, the OMA has agreed to work with the government “to ensure that every Ontarian who wants one has a primary care provider.” To meet that objective, the OMA will work out improved evening, weekend and holiday coverage, and produce reports on physician resource and access issues. If the OMA meets these commitments, then the government will amend a couple of clauses in Bill 210.

But that clawback still leaves physicians under increasing government control. In another concession to Bill 210, the last clause in the compensation agreement says government and the OMA “are committed to ongoing engagement … regarding health system reform and design.” Four decades of fractious government-doctor relations suggest cordial engagement between doctors and demagogic politicians over health-care reform is a political long shot.

On the other hand, Virginia Walley, president of the OMA, said in an interview this week that the compensation agreement includes an “ironclad” legal commitment from the government “not to take unilateral action” to reverse or impinge on the compensation agreement the doctors are debating on Sunday.

That would be a step forward, but how far does it go?

Enhancing bureaucratic power can only come at the expense of the people supplying the services. The last Ontario budget called for healthcare spending to increase by about 1.5 per cent a year over the next three years. With rising health-care demand, growing population and inflation alone running at 1.5 per cent, something is going to have to give within the healthcare envelope.

The OMA’s members account for 23 per cent of Ontario’s health-care spending. Doctors took unilateral cuts of up to seven per cent in the past, and the new compensation deal to be voted on Sunday suggests doctors will collectively see their real incomes fall over the next four years.

A new analysis of the proposed agreement by University of Toronto economist Jack Carr on behalf of doctors opposed to the deal concludes that as health-care demand rises, doctors will have to bear more of the costs. Carr says that under the agreement “doctors implicitly accept financial responsibility for increased utilization.” If utilization rates rise four per cent a year from three per cent currently, doctors will be forced to face reductions of almost $1 billion. If utilization rises five per cent a year – not an improbable proposition – doctors will face payment reductions of more than $2 billion.

Should Ontario’s 42,200 OMA members (including 3,000 medical students) say no to the agreement, it would send the province’s bureaucratic central planners back to the drawing board. If they accept the compensation agreement, the OMA will have helped advance the Wynne government’s imposition of its massive interventionist Patients First command-and-control healthcare system.

The hallmarks of central planning are maldistribution of resources, inadequate supply, shortages, waiting lists, lineups, price controls and breakdowns. If the economic history of command and control teaches anything, it is that you can’t put patients first by putting the suppliers of patient care last.

 

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