New Deal for Ontario Doctors

new dealDoctors got an unexpected surprise this week: The Ontario government offered doctors a tentative contract, in the middle of July.

The board of the Ontario Medical Association (OMA) voted to support the new deal and share it with members.

People have asked what I think about the contract.

The Board voted to let the doctors of Ontario decide. As a Board member, I support the wisdom of the Board in this decision. If I absolutely could not support the Board’s decision, I would have to step down.

I found this decision very hard. I keep learning more about the deal each time I look at it. I’d love to hear what you think.

New Deal

Doctors in Ontario are desperate. After 2 years of attacks, cuts, and slander from this government, doctors beg for stability. This new deal seems to offer that.

Why Doctors Might Like It

No more unilateral cuts – Doctors will cheer for anyone who offers to end cuts. Doctors cannot run clinics, when government cuts payments without warning. No business could handle such caprice.

Co-Management – This contract promises to welcome doctors back. Many find this irresistible. Government has usurped control and progressively shut doctors out of healthcare governance, over the last 40 years.

Modernization of the Schedule of Benefits – This deal proposes to fix relativity (Some doctors bill high fees for easy work; others bill low fees for hard work). Doctors have failed to fix this since the 1980s.

Charter Challenge Protected – This requires lawyers to explain, but they say that this contract will not undermine the Challenge.

Better Than the Alternative – Based on current utilization, the negotiated funding for growth, one-time payments, and two Schedule of Benefits modernizations is expected to keep spending within the planned PSB and one-time payments. We shouldn’t need further adjustments. But if government keeps to its current behaviour, it plans over $1.1 billion in cuts over 4 years of unilateral action.

Why Doctors Might Pause

No Reversal of Previous Cuts – The physician services budget (PSB) sits at $11.452 billion dollars, after approximately $700-800 million dollars of cuts.

Enough Growth? – The government has offered to fund 2.5% growth of the PSB. This means that the MOH has agreed to fund 2.5% more physician services per year.

Note: physicians’ fees stay the same. If a fee was $33 dollars last year, it is $33 this year.

A promise to fund 2.5% more services marks a huge improvement over the 1.25% that government funded last year.

However, growth has been around 3.2% for the last 15 years. Each year, 150,000 new patients come to Ontario, and almost 1000 new doctors start practice. Can anyone contain utilization?

One-time payments – These are expected to cover the difference in funding noted above, but only if growth is contained at 2.5%. Doctors could earn an almost 0.8% annual bonus, if all doctors work together to find permanent savings in each year of the contract.

Shifting Risk – This contract seems to give government the predictability they wanted in the PSB. Is that reasonable? Does this increase the likelihood of reconciliation if growth goes beyond the 2.5% + one-time payments? How will this be handled and will there be winners and losers?

Hard Times

Doctors in Ontario have faced cuts of up to 30% net, since 2012. At the same time, they struggle to find care for their patients.

For example, patients wait up to a year just to see an orthopaedic surgeon, in my area, and another 9 months to get their hip replaced. On top of this, government has cut hospital funding for the last 9 years and also cut over 1400 nurse positions.

Doctors are tired. They want a contract. A contract seems to provide predictability and lets doctors apply for loans to purchase equipment that patients need for care.

Members Decide

Doctors need to ask: Does this contract offer something good for patients and doctors in Ontario?

Doctors will not get a raise. Inflation will eat into their earnings. But doctors will get certainty for 4 years. Doctors will not get unilateral action.

What will patients get?

Do the pros outweigh the cons?

What will government do if doctors do not accept this deal?

What options do doctors have?

Doctors face a huge decision, possibly the biggest decision of their careers. They need to ask hard questions about: certainty, growth, rationing, and relativity.

Doctors need to do whatever they can to inform themselves.

Doctors needed something concrete from government. Members needed to see this contract, and the Board is wise to trust members with the decision.

The OMA Board has committed to inform members through special meetings and information sessions. Physician leaders across the province should be able to answer questions from their colleagues.

The current situation was unsustainable. Can doctors trust government again? Please ask hard questions. Let’s hope patients like how this turns out.

photo credit: www.brittanica.com

Note: OMA communications and negotiations reviewed a draft of this post. They offered helpful edits and re-focussed the content on the deal. I added a few comments and made final edits after that. I assume responsibility for all errors.

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167 Replies to “New Deal for Ontario Doctors”

  1. Thanks Shawn for this. The “informing” being done by the OMA looks an awful lot like propaganda. Disguising $ 200 M of cuts as an item on the positive list “$200 M in modernization” is completely disingenuous. If the OMA board really think this PSA is our best shot then let it speak for itself- send summary emails that contain both pros and cons- instead of all pros. The current emails do little to restore my faith (already much shaken) in the OMA as our representative organization.

    1. Thanks for taking time to read and share a comment, Lauren!

      Ultimately, doctors will inform doctors and make their decision based on debate, discussion, and trust. Can doctors trust what they hear? Can they trust government? Docs have been beaten to a pulp and now they face a very tough deal. It’s very risky to present such an offer in the face of all that docs have gone through….or maybe it’s political brilliance? Beat them down then offer?

      Regardless, docs need to ask, probe, and dig into all the dark corners of this one. In the end, members will decide.

      Thanks again!

      Best regards,

      Shawn

      1. Dr. Whatley, the OMA board is only giving doctors a little more than two weeks in which to analyze the PSA and vote. I think this the shortest period of time ever. That alone is pretty good evidence that the OMA board ISN’T primarily interested in educating doctors, but just wants to push a yes vote. The OMA’s ACTIONS are indicating that they DON’T want us to think, just blindly trust them.

        1. Jonathan,

          You raise a very valid point about timing. I think many doctors will question the rushed nature of this, especially in the dead of summer (maybe August would be worse). As you can imagine, the OMA is not the only party in negotiating the timing. I, too, do not like feeling pressured after such a long time without a contract. I guess many people feel that government has no money to spend, and this offer seems to spend a little more than what they were spending last year. Not a great reason, but I understand. If you are given the choice between losing and arm versus a finger, and you have to choose quick, you probably wouldn’t dither on the timing. But none of this discredits our right to feel frustrated about it!!

          Excellent thought.

      2. Hi Dr. Whatley,

        Excellent post making an excellent read. I understand your conflict of interest and loved your bipartisan discussion. No new questions for you here except to commend you on your discussion and echo Dr. Lapointe-Shaw’s criticism on the biased information coming from the OMA. OMA should represent their members needs and not be trying so hard to convince them what they need. I feel the OMA is heavily invested on having a “yes” majority from the members that they are skewing the truth in some areas, a characteristic reminiscent of Hoskin and the MOH. I would wish the OMA could send out discussions written in the same manner you wrote this one or send no biased analysis at all.

        Cheers,

        Mathew Nicholas

        1. Thanks Matthew!

          I’m really glad you enjoyed the post. I will pass only your thoughts.

          I sure appreciate you taking time to read and share a comment!

          Cheers

          Shawn

  2. I haven’t read the agreement yet Shawn and I value your opinion and comments. I am currently feeling selfish because I have fewer years left in the profession. If I vote in favour of this because of fatigue from previous and current fights that seem to have only led to further status quo, am I going to harm future generations of physicians? Since you are a Board member, I have to believe you are less cynical about the ‘agreement’.

    1. I feel that the OMA has let down the physicians of Ontario again. It has also let down the patients who depend on their physicians for the highest quality care.

      I felt this way even before I read the following two posts on the COD Facebook site a few minutes ago. I will post them one after other.

    2. Hey Nick.

      As a board member, I cannot speak against the board’s decision on this, unless I was to resign. I DO support the contract going out to members. I tried my best to lay out the issues and plead with docs to dig in with hard questions. The details will come out clearly, and doctors will decide.

      Feel free to give me a call. Just email me and I’ll give you my number.

      Thanks so much for reading and commenting!

      Shawn

      1. Why can’t you speak against the contract? Now the OMA controls free speech? What is going on there?

        1. Great question, Phil.

          The time to debate a decision happens before the decision gets made. Once a board has come to a final decision, Directors must stand behind it, or step down. I support the decision to let doctors decide on this offer. Many people believe there are some good parts in it….at least better than the alternative. Many people have deep concerns. Ultimately, it’s up to doctors to dig deep and make a very hard decision.

          This is not about freedom of speech. It is about doctors being allowed to make the decision on their own. I support that.

          Thanks again!

      2. Hi Dr Whatley. As an OMA naive front line physician, who spends all of the time working hard and never bother with politics, I couldn’t help but wonder how can you NOT go against what the Board has decided without resigning? It is a very disturbing detail. So it is either an all yes or all no situation at the board? Don’t you guys have diversity in opinions and obliged to listen to your members? Can’t you say NO to a proposed deal when you see all the flaws in the process without being an outsider, like the rest of us? So correct me if I am wrong : You say YES to this proposed agreement, because you are a member of the board.
        If you shed that title, can you truly tell us what you think? You guys are in a position that influence the opinions of hundreds if not thousands of apathetic doctors. When you say a YES that you do not believe in, you are literally inviting many peers that look up to you to vote yes.
        Respectfully.

        1. Great questions, Julia!

          The government offered a tentative contract. The Board got a chance to debate it, and there was extensive debate. After everyone expressed their opinions, there was a vote. The vote supported the decision to endorse the contract and send it to members. The Board had only two options: turn down the offer and members never see it, or endorse the offer and let members vote on it. Once, in 2004, the Board sent out a contract without endorsement. George Smitherman went wild.

          The Board has had a chance to debate and express opinions. Now, the Board is trying to inform members. Not sell. Not convince.

          All boards must speak with one voice. This is not evil or new. It is a fundamental fact of good governance. It should not sound shocking or unusual. We need good governance at the OMA. I support the concept of solidarity after a decision has been reached. Most votes are not unanimous. This is normal. Supporting board decisions is part of what it means to be a board director.

          It is now up to members to debate and express opinions. I already had my chance. If I was violently against this and thought that members needed me to help them make the decision by expressing my personal opinion, then I would have to step down from the Board to share it. But I believe doctors are smart. They can make up their own minds without my help. They will make BETTER decisions without my help. This is not the time to push and influence, but to inform.

          Highest regards,

          Shawn

          I support the Board’s decision; members can now decide.

          1. Shawn:
            I read between the lines what you mean.
            However, with all due respect, the statement “Now, the Board is trying to inform members. Not sell. Not convince.” is not entirely correct. From what we have seen in the past few days, and the roadshow/townhall sessions, OMA is HARD Selling the yes vote.
            I think you are right on “I believe doctors are smart.” However, lots of them are fatigue and don’t think anymore. Some will even have the blind faith that OMA suggest YES vote and so be it !!

            1. Again, you make a very wise point, Michael.

              I worry about how energetically this contract is being promoted. We should focus on a ‘just the facts’ approach, but it looks a little to rosy. I still believe that doctors will see through this. But your point is well taken. We should be informing, not persuading.

              Thanks so much for this, Michael. You have been an advocate for front-line physicians for years. I hope all your colleagues know how hard you work for them!

              Highest regards,

              Shawn

    3. don’t forget even if you don’t work in this field you may be using health care in this field. what you vote will determine if the government will fund your care or not.

    4. Yes Nick you will be harming following generations of doctors because it agrees to nullify our ability to seek compensation for the unilateral clawbacks. It also sets the budget further and further from reality creating a gap between supply and demand which is always closed by physicians providing service for less and less compensation or no compensation at all.

  3. “I had a long talk with a member of the negotiating committee this week. S/he informed me that this was the best deal they could get. S/he said BA will never be offered by the MOH and, even with the court challenge, reparations would be unlikely. S/he instructed me that this path was the best way forward to eventually get BA.
    I asked: “why would the liberals or MOH bureaucrats insist on having a clause that prevents the chance of seeking damages or costs”
    S/he then told me that the OMA had offered this…..WTF?
    I had to have him/her repeat this twice.
    I simply am at a loss why we would give up the chance to seek back pay, interest or at least legal costs…..it is amazing to me.
    Worse still s/he told me that the OMA believes that the membership is hurting so much that they will agree to these cuts to prevent further and deeper cuts. The OMA expects 70 percent ratification.
    Feel free to share this information but not my name.”

  4. And the most damning indictment of the OMA Negotiating Committee from a member of the Negotiation Advisory Committee

    MESSAGE TO ONTARIO DOCTORS
    Dear Medical Colleagues:
    As a member of the Negotiations Advisory Committee who sat on the “negotiations second table”, I urge all members to vote NO in the upcoming referendum.
    My position on this OMA advisory group gave me an inside perspective of process, transparency, and outcome that I feel duty bound to report to you, my colleagues.
    Process
    Council gave clear direction to secure binding arbitration prior to a return to negotiations. This was not respected by the OMA leadership despite a clearly stated commitment to this principle.
    The Negotiations Advisory Committee was not consulted in any meaningful way. The PSA was presented to us as a finished document only hours before it was presented to the Board. We as a group representing the interests of the profession had NO input into the document.
    2. Transparency
    Despite numerous direct requests as to the status of negotiations, I was told that there were no ongoing talks. My last query came after bumping into Dr. Bell, the Deputy Minister of Health at the OMA offices. Once again, I was assured that there were no ongoing talks. It was as if the American tanks were rolling by in the background as the Iraqi Minister of Information declared that there were no Americans in Baghdad.
    Another point of transparency is the language of the document. Much of it is vague and refers to future committees with promises of consultation. Given my experience on the Negotiations Advisory Committee, I have no confidence about the degree of input any doctor will have outside of those in the backrooms of the OMA.
    To that point are issues already discussed and now openly denied. I was on the calls when significant cuts to new physicians entering the Ontario workforce and to medical school spots were discussed as part of the PSA presentation, yet it appears nowhere in the document except in the most vague language. A precise number was discussed as alluded to by Dr. Nadia Alam. How can we be sure that other major system changes are not also hiding in what is more of a pamphlet than a contract? Six-page contracts are between, friends, family, and fools, not between governments and professional associations.
    3. Outcome
    Make no mistake that this is a hard cap. Based on growth estimates, THERE WILL BE CLAWBACKS.
    This is not a 2.5% raise. The increase refers to an increase in total funds available to a fixed pool of money. This will be instantly consumed by new physicians and increased utilization by our aging and growing population.
    This is a massive cut. There will be a minimum of $200,000,000 cut from the physician pool. This is a permanent cut that will disadvantage all groups. This is in addition to the permanent cut that all physicians have experienced since 2012. It is also uncertain where this money will come from. How will this be titrated to ensure that the cuts don’t become $300,000,000?
    The PSA does not address many of the major issues, including relativity, that we expected a binding arbitration process to deal with in a fair and transparent manner. There are no specifics in the PSA that any doctor can reasonably hold either the OMA or government accountable to.
    We have been disparaged by a government in its dying days. We have been witness to an unprecedented increase in demands for our services and unprecedented decay in our healthcare system. Wait lists grow. Patients go untreated. Clinics close.
    The PSA breaches process, lacks transparency, and has negative outcomes for both physicians and our patient. For these reasons, I ask you all to vote NO!
    Sincerely,
    David Jacobs, MD, FRCPC

    1. Thanks for posting this Gerry!

      I’m watching it all unfold on FB right now. WOW!

      Waiting for an official response from the prez

    2. Dr. Jacobs: Thank you for your insightful comments. I will be voting no. I am disgusted this vote is proceeding at a time when many physicians will be on vacation. Like many physicians in this province I feel completely betrayed by the OMA.

  5. Doesn’t this all of a sudden government a huge incentive to increase utilization. Open OR time for underemployed surgeons, create incentives for new doctors in rural communities. None of the actual physician resource costs of these actions would cost them anything. Total pay to doctors would be capped. Adding Physician utilization would cost them nothing. It would also greatly improve their appeal to voters, all on the back of doctors. Doctors would be powerless to stop such actions at the expense of looking greedy. With a surplus of unemployed and underemployed specialists, there would be massive clawbacks.

    Long term, this strategy would backfire, with doctors leaving the province en masse due to clawbacks, but we all know government cares about spring 2018, not the long term sustainability of the system.

    1. Great point, Matthew. Capping physicians lets government open the floodgates on everything else, comfortable in the knowledge that docs will pay for the overage.

      Brilliant comment!

  6. I am aghast…but I am not surprised…and I am not speechless.

    One would have hoped…could have hoped…that the OMA had learned from the egg on their face debacle of 2012. Promises were made…platitudes were preached. And it all blew up in their, and the profession’s, faces. Doctors in Ontario got what they deserved. 81% fell for the OMA propaganda show and marched the whole profession, like lemmings, off the cliff.

    After 18 months of unilateral annihilation at the hands of the MOH (a nice consequence of 2012, thank you), the profession is abused and demoralized. They are battered in the media, while having to deal to deal with a CPSO run amok. They are working harder for less gross income while expenses of running a business continue to skyrocket.

    The OMA Board, and the negotiating team, were advised by Council to proceed with no further negotiations with the MOH under binding arbitration was agreed to. The president of the OMA came out in the media saying that this was how the OMA was going to proceed. The actions of the negotiating team, and the blessings of their efforts by the OMA Board, shows nothing but disdain and contempt for the profession. OMA knows best…trust us.

    The OMA has taken advantage of the position of a drained membership by outdoing itself and making 2012 look like the greatest thing since sliced bread. It has brought forth a travesty…an abomination of a contract proposal that enshrines and legitimizes the unilateral cuts of the MOH and agrees to a hard cap on physician services. It is not just put forth for the membership to vote on…it is done so with the recommendation of approval from the OMA Board. It is sold as the ‘one thing’ that the profession craves…STABILITY…when it is anything but. It promises no further unilateral cuts but ignores that there will be cuts…just that the OMA will have a voice in where they will go. OMA will have a hand on the knife that cuts membership billings.

    And so now it is time for another propaganda show. I will attend and listen to the usual OMA platitudes to sell the deal to those on the fence…to those who have not bothered to read the contract word for word (twice). I will spend far too much time at the podium again spewing hot air while the OMA Brass chortles and rolls their eyes like they did in 2012 (“Quite frankly, we don’t believe that is going to happen”). And we know how that turned out…just like it will again.

    How the OMA can dress up this pig and say it is beautiful is beyond me. But they have done it so often for so long with a tried and true formula to get that “yes” vote that they can do it in their sleep.

    I am mortified…

    1. Paul, you have been around and have seen too much!

      While I agree with so much of what you’ve written, I want to push back on one point. Would you rather that the members never got to see this offer?

      No one believes this is a great offer. An OMA MD leader on one of the teleconferences called this a ‘treading water’ agreement. I suppose even that’s debatable if utilization goes up and there are further cuts through reconciliation.

      I agree that the current messaging does not contain a strong description of any dissenting opinion. But the messaging does offer the facts. And the roadshow will answer all the tough questions. If docs do not like the answers they get, then they should vote accordingly.

      The scariest thing for those who really dislike this contract is that all the members get to vote on it. What if members vote strongly in favour? Does that give government licence to do even worse next time? But if members turn it down, does that give government licence to slash with abandon?

      We are between a rock and a hard place. But I am confident that doctors will make the best decision possible.

      As always, thanks for sharing such a great post!

      1. Shawn,

        Could the board not have chosen the 3rd option and sent it out without endorsement – then at least its a true let the members decide, not let them decide but the Board says vote YES..

        Also, is there any way to know who voted how during the board meeting – was it a 90/10 split or a 51/49 split ??

        ..rob

        1. Hey Rob,

          The option you suggest was explicitly excluded.

          I do not believe that there was a formal count called. You could ask the board chair whether they can remember and whether it is something that can be shared. I attended by teleconference.

      2. I believe that if we vote No then it will be the government that will be between a rock and a hard place. They will continue to be exposed by Ontario physicians as rationing health care. The government will have to tell the voters whether they choose more money for health care or more rationing. In a nutshell that should be our strategy: expose the government’s rationing to the voter. The rest will follow.g

  7. Thanks Shawn!

    How can we believe this agreement will give us predictability? When have we or the Ministry ever been able to contain utilization? Without major cuts to the fee schedule, likely to predominantly affect higher billing specialties or physicians, which will not be redistributed to lower billing groups, but instead used to stay below the hard cap, we will continue to go above the proposed budget year after year after year. And then the next cut will occur. We will again be told that this was a process we agreed to. But likely this won’t become horribly obvious until after the next election! This agreement will not offer stability to physicians in the end, and the hard cap needs to go unless there can be an open converstation about ways to control utilization of physician services.

    1. Brilliant questions, Crystal!

      Why should doctors trust anyone at this point? Shortfalls could be compounded. I don’t think anyone expects that docs will get any increases out of this; they will only get (hopefully) protection from more cuts.

      I guess that’s what makes this whole thing doubly hard for doctors. Do we have any stomach to give something a try, or is this offer just not worth it? What do we believe will be the likely outcome of deciding either way?

      Thanks for sharing!!

  8. Great post Shawn! We are asking members to make a difficult decision that will affect us all. We need to be asking the tough questions that will inform our decisions. We need to keep probing until it is time to vote. Then we must make an informed decision and vote. I encourage everyone to remain objective as they gather the information they require to make the best decision possible for the physicians of Ontario.

    1. David, have you not read what Dr. David Jacobs has written? The OMA has committed a travesty. We must vote No. If you haven’t read what he said then you didn’t read my comments above on this blog.

      1. Hey Gerry. I think David just called for members to dig in and ask hard questions, no? Your post(s) contain information that doctors need to make their decision. It sounds like you both want as much detail and transparency as possible.

        Thanks for keeping in touch with all the comments and adding your own! Brilliant.

        1. Frankly, Shawn, after the two posts on Facebook that I reposted here, the OMA “leadership” itself must be taken down by a No vote.

          1. All leaders are elected. They all can be voted out.

            Docs need to focus their energy on the contract, first, then attack the OMA, if they wish. In my opinion…

    2. Shawn, this is a good post but I sense that it is incomplete.
      I understand you have constraints as a Board member to perhaps not speak your the entirety of candid thoughts.

      Sorry, David, but it is not a difficult decision at all for the great, great majority of physicians that I have spoken to – especially those who are informed.
      The bigger question in my mind is WHY did this PSA get released to the members in its current format.
      I don’t believe that you have a mandate to expose the membership to the potential liability for the financial costs of increased utilization in the health system.
      I don’t believe that you have a mandate to agree to PERMANENT reductions in the physician services budget.
      I KNOW that you did not have a mandate to trash or jeopardize our Charter challenge on Binding Arbitration.
      You did not have a mandate to even discuss negotiation with the MOH without first obtaining a commitment to binding arbitration.

      Why were negotiations kept a secret, even from the nogotiations advisory committee?

      You will excuse me if I ask whose interest the OMA has as its priority.

      1. Ken,

        As always, you ask GREAT questions! Your years of experience inside the OMA gives you an informed voice, that I hope others listen to carefully.

        I love that you asked about mandate. It’s a critical question. We do not have a refreshed mandate. The last time we built a solid mandate was in late 2011. The clearest ‘mandate’ we have now is that doctors want the cuts to STOP.

        But let me push back a little. Every offer includes things that never showed up on the physicians’ mandate. That’s because government has its own mandate. If OMA only every showed members offers that only included features from the OMA mandate, there would never be any offers to show doctors, ever. All tentative contracts include things that doctors never expected to see. I’m sure the ministry feels the same, when they see what doctors want in the contract, too.

        Again, you ask great questions. They all need answers.

        I leave you with this question: Would you rather that the OMA Board never showed this contract to doctors? That was the only choice that the Board could make: share it with endorsement, or turn it down. Government refused to let the Board send it out to members without endorsement like it did in 2004. Overall, I’m glad that doctors get a chance to tear into it. It opens the Kimono on everything to date.

        Thanks for taking time for this, Ken. Brilliant!

        PS And you are also right: I can only say so much. But maybe it’s best that my opinions stay low to leave room for members to express theirs. I’d be happy to chat on the phone anytime. You have my number. Cheers

        1. With all due respect Shawn, I think that the OMA board should have either rejected this offer outright or presented it to members with a statement that they did not endorse it but are presenting regardless.

          By presenting this (awful) offer with an endorsement, the OMA has played into the MOH’s game with publicity etc.

          Very naive and poorly considered in my opinion.

          1. Solid point, Chris.

            The Board did not have that option. It could only reject it on behalf of all members, or endorse it and share it with members. There was ‘no deal’ if the board shared it with members without endorsement.

            1. That is bizarre. In order to share this deal the Board must endorse it? That sounds manipulative at best. The government is the puppet master and the OMA is doing it’s bidding. They have been bullies for the past 4 years and continue to behave this way.

            2. Shawn, could you please explain why the Board would have to endorse a deal before presenting it to members?

              1. GREAT question!

                It seems a bit odd. It goes back to George Smitherman days. A non-endorsement is interpreted as a signal to vote no, to many members. That sends a message to government to withdraw their offer. At least that’s how I think the reasoning goes.

                Do we need a new process? Suggestions?

            3. Shawn, does endorsement include releasing public statements from the OMA saying that this is a good deal for doctors and ON patients?!?! There is a difference between endorsing it so that members may see the proposed contract but the media dog and pony show is galling for most members to see I’m afraid.

              1. You make a good point, Tina. Where’s the line between informing and influencing? Should the board try to influence a vote either way?

  9. Shawn — thank you for posting. My greatest concern is the potential effects on patients; the funding envelope increases, but not enough to match historical trends, and with each passing year, more Boomers reach the ages of maximum health care utilization. Yet the contract, in its imposed mandatory cuts to overall physician services (the only way I get a fee is if I see a patient), is guaranteed to force a choice of using a diminishing resource meant for 100 people on 90, or 80, without being able to tell in advance the 80 people who need care, and the 20 others who just want care. Accountability is a three-way street (doctors, government, and patients); yet this contract seems to force physicians to accept responsibility for utilization that they have no mechanism to control, and to become the insurance underwriter for any overshoot in OHIP-related spending with no hope of recouping those costs. All on a warp speed time scale. I would greatly appreciate your insights.

    1. Graham,

      I think you have nailed the most important point in this whole contract. I, too, worry about how this will impact patients. Furthermore, what will patients think of doctors accepting a contract that does not fully fund growth and deal with wait times? With the media spinning it as a big raise, maybe patients will never know the inside details?

      Great point!

  10. “If I absolutely could not support the Board’s decision, I would have to step down.”

    Shawn, I worry about you. You have too much integrity.

    1. Thank you, Gerry!

      I really liked David Cameron’s approach to the Brexit vote. He had campaigned hard, and voters chose to go against what he wanted. In this case, I did not have time to campaign hard either way. And once the board has decided, I cannot debate it all over again, in public. I respect that. Every member of every board has to ask, every time a decision does not go the way they thought it should, “Do I need to step down over this?” “Does this decision mean that I simply cannot function here at all?”

      I believe members benefit from seeing this contract. I think the board was wise to release it. Now, doctors face the enormous work of digging into it. Not easy.

      Thanks for your thoughtfulness on so many levels, Gerry. I am thrilled to see your passion after decades of this. Impressive indeed!

  11. Thank you for your blog Shawn. I believe you are truly torn. You have presented the facts without trying to gin the yes side up too much. St the same time there really is no stability in this contract. There will be cuts just the amount will be different. Problem is that the OMA will be responsible and complicit in further overages in the PSB.
    The charter challenge,even if won,after this means nothing. The government will set PSB growth after”negotiation” and this will, again, likely be under utilization. The arbitrator will look at cihi and say, well utilization is expected to grow at 1.9% let’s be generous and give 2%. The OMA will be bound to look to cut again with further “modernizations”.
    As for listening to members and deciding best interests how can anyone now really believe the OMA will follow due process. They just negotiated a deal without that process, now I’m expected to believe if thus deal is ratified they will listen to the sections and “modernize” thoughtfully and without bias? Saw that happen in 2012 with how the “agreed”upon cuts took place heavily on certain specialties.
    Our own OMA president just gave credence in the Star’s article yesterday that one group should be made to pay. I am now expected to believe that the OMA can represent groups fairly at the comanagement table?
    I appreciate that you eant to stay on the board but this blog lacked the heartfelt passion of previous ones. Just wondering did you have to vet it through OMA central before posting it?

    Brad

    1. Great comments, Brad.

      You are very perceptive. I put a disclaimer at the end of the post stating that, yes, I had the communications and negotiations departments edit a draft of the post. Having said that, their edits added precision and focussed the blog more onto to the deal, away from my personal thoughts.

      As you can imagine, I cannot offer much of my own commentary. However, I think I can encourage doctors to ask great questions, to really dig into this. There’s much more to the contract that you see in a quick read. I believe that the truth will come to light, and I believe that the OMA truly wants that to happen.

      Very often, people desperately want you to ask them something that they could not offer on their own. It takes your kind of insight and wisdom to ask those questions and to inform yourself and others.

      Brilliant thoughts!

  12. Of all the ‘Pros’ listed, not one of them has any mechanism to ensure the government doesn’t ignore these clauses as they have done many times in the past. The government has shown us over and over and over again that if it suits them they will ignore any clause in an agreement. This contract ‘allows’ us input in Schedule of Benefits cuts – input does not mean they have to listen to what we say.

    This is a bad deal with a Trojan Horse clause in item #7. Vote No.

    1. Solid point, Ernest. What reason do doctors have to trust anything that government says they will do? This contract asks for a tonne of good faith after years of showing no reason to offer it. However, doctors tend to be very forgiving people….

  13. CMPA Sept 2012 – ” Physicians have a duty of care to patients. This duty may extend to resource allocation, and ensuring patient care is not compromised. ln an environment of constrained resources, or when faced with an unexpected shortage of medication or supplies, physicians should engage with hospital officials or health authorities to request resources to meet patient needs.”

    It does not mean comanage or assist in rationing. It does not mean receive $100 million by contractual agreement for rationing. Accepting this PSA without immunity for the consequences of rationing is unwise.

    1. Excellent comment, Edwin.

      Most people do not hone in on the potential/risk of rationing in this offer. Either they do not see it, or it is not as important to them. I believe it is critical.

      1. I have spent a fair amount of time thinking about how a physician may change their practice in response to being responsible for a fixed health care budget. How do we respond to being in charge of rationing health care. Does it affect ordering of investigations and consultations? Does it affect the decision to take that extra family into your practice? Do you decline an extra urgent care shift? To be clear I don’t think individual physicians will be thinking about the fixed cap as they decide on a individual’s treatment plan. But physicians are human, and we all respond to subtle pressures, financial being one of them. I think being responsible for overall health care utilization does alter the physician-patient relationship. In some ways positive, some ways negative. Some ways subtle and likely unpredictable.

  14. Hi Shawn

    I hope I don’t put you on the spot too much with this one, especially after a very thoughtful blog, but……….

    My sense from watching this thing unfold is that the OMA Board was under the impression that the Negotiating Committee was meeting with the MOHLTC to agree upon a Framework to Resume Negotiations. However, it was only the Board Executive and the Negotiating Committee that was aware that the discussion suddenly veered into a framework for a PSA (and yes, I’m willing to concede that it was fairly recent and sudden). The PSA announcement was therefore a surprise to the rest of the Board as well.

    Can you comment?

    1. Great questions, Sohail!

      I think everyone was surprised that the government agreed to offer a contract. I do not know anyone who could have predicted this.

      I see this like a dating relationship: two people spend time together, get close, then all of a sudden they’re having a baby. No one expects it to move along so fast at the end.

      The real question is: What do we do with the offer before us? What do doctors think of the latest baby?

      Thanks for asking!

      1. I somewhat disagree. Yes there is a baby, but who’s the father? The process doesn’t seem right to me. I think the process should be investigated.

        Let’s say the government did offer a contract out of the blue (which would be the best case scenario) while the team was negotiating a “Framework for Return to Negotiations”.

        – why didn’t the team tell the OMA Board there was a sudden contract offer? (I’m guessing by your response that it was ONLY the Board executive that was told

        – why didn’t the team say “Thanks for the offer, but we don’t have a framework, let us go back to the membership and let them know this happened before we accept?”

        – why didn’t the team consult with the Negotiation Advisory Committee?

        A skunk died in my back yard the other day. It smelled less than this.

        1. All valid points, Sohail.

          Are you suggesting that the team should have refused to pass along the offer until the ‘framework…’ was done, even if the team thought it was worth having the board see it?

          Breaking process is a different issue than a poor process.

          These are great questions. My sense was that this came to a contract rather quickly and was offered to the board ASAP instead of filtering it with consulting the NAC, etc.

          Whatever happens, we should review the process and learn from it….just like we’ve tried to do in the past.

          Tough times. Tough decisions!!

  15. Shawn

    I think one of the main outstanding questions that has been left unanswered is why all of this seems to rushed.

    Are you able to comment on why this process seems to be being pushed through so quickly?

    Is this at the request or demand of the MOH? Was the negotiation made on the condition of the limited timeframe to ratify? If so, any comments on why the timeframe would be limited?

    1. Excellent questions, Matthew.

      I do not have a precise answer to whether the exact timeline was a condition of the contract. All negotiations have a life of their own until agreements get signed. Just like when you buy a house, you have to weigh whether to move quickly, or to stall and let the other party sweat a bit. You should ask these questions at the roadshow. My sense was that time was of the essence. The government wanted to get this done before the fall. I am not certain how rigid the timeline had to be…or if it had to be rigid at all. I know that there was some urgency to make a decision. Great questions!

      1. My I humbly suggest the by-election dates are looming and this imparts a certain urgency to the government to put out political fires.

        There is great advantage to the Liberal party to settle this by August. I do not see an advantage to OMA to agree to this.

        I am troubled by some of the OMA statements the allude to “the government would not accept binding arbitration” so we moved on. I don’t see the recipicol “the MOH was informed physicians will not be responsible for health care utilization” so they moved on.

        Each party in these negotiations holds considerable power. I don’t see this balance in the agreement. I see an unbalance in multiple places, right down to the timing.

        1. Good point, Kevin. The unbalance of power continues. Will it ever go away in a monopsony?

  16. Watching this process unfold this week has been better than reality TV. Secrecy, incest & a rising up all in a matter of days. I can read between the lines that you are not endorsing this tentative PSA Shawn. My question is why are other board members trying so hard to sell this to the membership like its the best thing since sliced bread? To date I’ve thought your blog posts have been spot on but this one lacks the usual oomph. If board members like yourself felt this was a bad deal then why not just present it to membership & say so? Why endorse it? Who cares if MOH wanted you to endorse it? What love or good faith have they shown us in last 2 years?

    1. Great comments, Natalie!

      First, no one should be selling anything. Doctors need to know the pros and cons. They need information to make a decision. ALL contracts have good and bad parts…..even the really, really bad ones.

      I am glad you noticed a change in tone from my previous writing. To date, I tend to write articles designed to influence opinion. This blog was an attempt to stick to bland facts and questions. This was hard for me. I would love to editorialize on the issues, but even more, I want doctors to make up their minds based on information.

      I believe doctors will make a great decision. I support giving this to members to decide on it. We need to encourage all physicians to do whatever it takes to inform themselves and then vote accordingly.

      Thanks so much for sharing your thoughts!

      EDIT: I just learned that there could be a risk of being accused of not bargaining in good faith if one of the parties does not endorse the contract enough.

  17. I know its been used excessively for various causes, but the Franklin quote is so relevant here, as it the term “liberty” was actually (historically) referring to having enough money to do the job:

    “Those who would give up essential Liberty [money], to purchase a little temporary Safety, deserve neither Liberty [money] nor Safety.”

    This was the first time in my 25 years of following the OMA/government shenanigans I thought there might be true leadership, given the ad campaign (as bad as it was) and the Charter challenge. I was ready to ride it out 10 years if it took to get the justice we deserve. But, of course, the same old secretive games come out yet again.

    Shawn, your openness and insightful thoughts are valued , given the secrecy of the OMA. But in the end, you are either for this deal, or are against it, and need to rise above personal gain and ask yourself if you are really doing the right thing for the physicians of Ontario, who have been dumped upon for 4 years (and are being offed a deal that will do the same thing for 5-6 more years!- remember, the Government game is to negotiate a new deal that takes 1-2 years to do after the old one expires…so we are now talking about agreeing to 9-10 years of ongoing loss in income, below COLA or inflation…). Since you have brave enough to chat online about it, if you are against this deal, the physicians of Ontario need you to stand up and say so- if you have to resign, then be a true leader and do so..your actions alone could finally open the door to the truth of the OMA.

    Otherwise (frankly), you just become, in my eyes, another OMA career-ist, enjoying hanging out in the (still inexplicable) Yorkville offices and cafes while we pay the rent. How many Board members have spent most of their careers like the thousands of us who are up at 4 am, on weekends too, manning the battle stations in the ERs and hospitals? And our President? Our bodies and families have been broken by this- but thankfully, our OMA dues have managed to secure yet more income loss, but at least we are paying for really good anti-smoking campaigns…

    I have never been so deflated about being an ER physician, who is “represented” by the OMA in 25 years. (I am , of course, a “member” who has followed, and therefore refused to join, the OMA for 25 years, but has his money taken every year by the very government you negotiate with and who hands it back to you; on paper, of course, you get to claim I am your “member”). The OMA, and Ontarians, can kiss my 25 years of experience goodbye. I am just so done with you and your OMA politburo. Time to look for another job…Thanks OMA…

    1. There’s a tonne of passion in that note, Ksy11. Thank you for sharing it. It made me sad reading it….I wish I knew who you were…

      As I’ve said elsewhere, I support the board’s decision to endorse this contract and share it with the members. I support the board’s decision; it takes precedent to what I think. I believe that members are smart. They will inform themselves. Doctors will make a good decision.

      As for calling for my resignation, I review whether THIS is the time, or not, at every board meeting. I think every Director needs to serve in such a way that they are ready to step down at any time, given the right situation. We need to be brutal with ourselves. If I am no longer adding value to the physicians I serve in my district, I will step down.

      Thanks for sharing your thoughts!

  18. So the deeper question to decide is – Are we self employed businessmen and women or are we contracted employees?

    My parents and I’m sure many of our parents were proud when we got into medical school. I’m actively discouraging anyone from going into medicine today.

    OHIP is simply put, an insurance company. We submit claims and get paid for them. Where else in any similar insurance industry has the fee not changed in the last 10 years ? Where else are there so many other “penalties/fines” added to you fees such that they are even paid at less than 10 years ago.

    If the insurance company can’t afford to pay the fees, either raise the premium, add a copay or GET OUT OF THE INSURANCE BUSINESS!

    The OMA schedule of Fees has become increasingly separated from the OHIP schedule of benefits. No other profession would allow their fees to be held in such disdain. The new grads have no concept of what the profession use to be like 25 years ago. Slim pickin’s seems to be the norm for the day.

    Like much of the auto industry now, it seems we are no better that hired contract workers – This is what you get: Take it or leave it…

    Guess what my choice will be…

    1. Don’t forget that we pay HST on every expense and don’t get it refunded like vets dentists plumbers. My u/s machine was 60,000 that’s 7800 in Hst

  19. Need to be TTC driver or postman to get binding arbitration. I don’t understand how anyone in our profession could believe that only our group does not deserve fair bargaining. If we agree to this deal all the negative impacts on patients will be responded by governments that doctors agreed to this. Fair deal or no deal. Don’t accept 1.25% less cuts for 4 years and make our profession responsible for overutilization in perpetuity without any mechanism in place to control it. And I am referring to overutilization by both patients and doctors. Governments job is to govern and control costs but that would be political suicide so let’s make doctors pay.

  20. Dr. Whatley, thanks for your balanced and thought-provoking post. You mention several times that the TPSA is presented to us to make our own objective decision. But all communication from the OMA has been very one-sided. As others have pointed out, it seems like a hard-sell, complete with high-pressure sales tactics like tight timeless and threats that “this is the best offer you’ll get”. If the TPSA is so good, then why can’t the OMA present it to us in a more balanced fashion, such as you have here? I appreciate that you answer all questions asked to you, instead of repeating the same things over and over again.

    1. Thanks Michelle!

      I don’t like being rushed either. I’m not certain there was a need for so much rush, other than scheduling issues.

      No one should be selling anything. Members should be getting tonnes of information, but not a hard sell. I will share your comments at the board this Wed.

      Hard sells will turn off doctors…

      Thanks for reading and commenting!

      EDIT: I’ve been told that there might be a legal risk if one party in a negotiation does not promote a contract. They might be accused of bargaining in bad faith. I did not know this. 🙁

      1. Thanks for your response Dr. Whatley, and for passing on my comments. I think I’ll be sending a letter to all my District 5 reps. At one of the OMA meetings in the fall you said that the OMA needs to hear from its members, so you (and all District 5 reps) will be hearing from me :).

        I believe that the OMA can promote something while still providing a balanced presentation of the information. For example, I will talk to my patient who has rectal bleeding about the risks as well as the benefits for colonoscopy. I will talk about the risk of infection, bleeding, and even perforation. I do not hide these facts when I then STRONGLY recommend that they proceed with colonoscopy. If they refuse, I will try to convince them why they need it. But I still present them with pros AND cons. Don’t Ontario physicians deserve to make informed decisions regarding the TPSA? The OMA is in a position of power, and for some physicians, the only source of information about the TPSA. As a physician if I didn’t give an opportunity for patients to make informed decisions, I’d be negligent.

        1. Well said, Michelle!

          Did you see Mike Goodwin’s comment he posted here recently? He offers and excellent analysis of the unspoken pressures we feel at the OMA. I am embarrassed that I had not thought about the ‘bargaining in bad faith’ angle. I know that there is no reason to accuse this, but just the threat of it makes me a bit ill.

          I look forward to your communications! 🙂 Thanks for all you do!!

          Cheers

  21. Shawn, please explain why you would have to resign the board if you disagree with their decision even if you had voted against the majority on the Board? Is your presence on the Board really at the pleasure of the Board itself? You were not appointed by the board, you were elected by your constituents.This makes no sense to me. How can you represent the membership properly if you are forced to tacitly or openly endorse an agreement that you might not agree with?

    1. Great questions!

      Board governance dictates board solidarity. However, you make the great point that our board is NOT like a corporate board. We have an elected/representative board. This is where the confusion enters. But even in government caucuses, elected members have to support a caucus decision after the vote unless explicitly stated otherwise.

      You ask WHY? Because that’s considered ideal governance. You can imagine the confusion it would create otherwise.

      1. “All boards must speak with one voice. This is not evil or new. It is a fundamental fact of good governance.”

        Shawn, you know I love you but I must comment a little more harshly here.

        First, it IS evil.

        I found the following with a quick Google Search:

        http://www.carvergovernance.com/faq3.htm

        “A board member who disagrees with a decision made by the board has every right to do so. Indeed, there would be something wrong with a board that always agreed unanimously with everything. It is usual that important issues are issues about which people disagree. In the Policy Governance board, this disagreement is thoroughly expressed and considered before the final decision is made. This enables everyone to say that the process used was fair, open and inclusive. The board then requires that the dissenting board member who announces his or her dissent also announce that the process used was proper.”

        Shawn, there are weird things going on so maybe just don’t reply to this comment. I just want it out there for others to see. Don’t even answer.
        Sincerely, Gerry

        1. Hey Gerry,

          I love your posts! You posted this same comment in 3 different places, so I deleted the other two. I have never done that before. I hope you are okay with that!

          It was getting confusing for readers to see the same post in 3 different places.

          Cheers

          1. The multiple posts were a function of the posting not appearing at first. My bad? No internet’s bad.

  22. Docs have serious concerns, feel betrayed and manipulated. Govt misspent taxpayer $ and now are cutting fees and hurting pts all to cover their empty ,bankrupt financial mess. From a patients point of view, we are the ones that govt is knowingly causing harm by unreasonable wait lines to see what govt calls …overpaid specialists. Hospitals close operating rooms, beds etc etc. Docs are still paid, albeit, below their expenses. Patients are at the bottom of this mess. When Docs lose money, have to limit services….who suffers physically and emotionally? I for one, support docs in their fight to maintain their income and not cut services to patients. My job is to maintain my health by being able to visit a doctor when needed, not months later.

    This mess isn’t going to be corrected until Wynne is retired.Financial responsibility is govts job, they screwed that royally….now we all pay for their mess. As a province we must decide what our priorities are. Is it people’s health or their misguided money losing gambits?

    Hope docs don’t role over because if you do it’ll be years to recovery, if ever.

  23. Shawn,
    I hope you are well.
    This agreement is a farce.I graduated in 1987 and in every agreement since we were told of the poor economic climate in Ontaro.
    When HM Hoskins announced he wanted to re-open negotiations a few weeks ago, the only reason I could think of was a fear of the charter challenge. Clearly briefs had been read and word had gotten back to the Wynn gov’t that the ruling would not be in their favour.
    By ratifying a four year agreement we are giving the courts an out of ruling against the gov’t.
    They can say there is no need to rule if an agreement was ratified,gov’t doesn’t take any blame, no binding arbitration, and no reparation. The gov’t already knows this or they wouldn’t agree to this deal.
    Also should Oma executive members be prevented from working at MOH as consultants once leaving the OMA?
    It would prevent a very obvious conflict of interest.
    KC

    1. Hey KC. Great to hear from you!

      You make a string of good comments. The Charter Challenge won’t settle for another 2-4 years, apparently. I don’t think it scared the government that much, yet. They don’t like it, but probably aren’t too scared of it. The lawyers say this contract does not impact the Challenge (they will explain why).

      Interesting thought on future jobs. I think someone mentioned they might propose a council motion like that.

      Thanks again for reading and commenting!

      1. Already tried a motion at Council about the COI ie OMA Board members moving to gov’t/MOH jobs without a cooling off period.
        I tried to bring that motion forward in 2006 or so.

        Board members pretty much scoffed at it. Never made it to above.

        Look back and see where former OMA presidents go….often towell paid government positions or government funded agencies.

        Many of the “physician Leaders” go there too.

        COI

          1. I have talked to my councillors more than once about a voting issue. They reply was that the Board will not even consider it.

  24. The last 2 years of sitting around the table should have been spent modernizing the SOB. Then the results of that modernization is what should be submitted for our ratification. This TPSA has this backwards. It is essentially a contract that allows ongoing contract (modernizing SOB) negotiations.

    Lastly, my own field has been beaten to a pulp (Hospital based anatomic pathology). Our unique situation has no comparable in medicine (we’re salaried with no ability to bill OHIP, no control of workload which keeps increasing, no pay for being on call, no pay for tumour board presentations, I could go on…), and not one of our negotiation platform requests was addressed, either in this proposal or in 2012, not a single one. How exactly has the OMA represented me?

    1. WD, you give another example of why the OMA should not be negotiating for physicians in Ontario. The sections can protect us all better from the government. I keep alluding to my blog piece on Healthy Debate after the 2012 agreement because events have confirmed my feelings at that time.

      http://healthydebate.ca/opinions/is-the-oma-an-appropriate-vehicle-for-negotiating-doctors-fees

      2016 has confirmed my opinion that the OMA is not an appropriate vehicle for negotiating doctors’ fees.

      Sorry, Scott, but I am posting some of your comments to my 2013 blog piece here for all to see.

      Scott Wooder February 11th, 2013 at 12:53 pm
      -No Section of the OMA and no specialty is represented at the negotiations table. Members of the
      negotiations committee have a fiduciary duty to represent all OMA members fairly and in good faith.
      -Family Doctors may bring some special knowledge of family medicine issues when they served on the Negotiations Committee, but they certainly do not represent family physicians. The Executive of that Section is consulted, as are other Sections, on matters that directly affect them. Each OMA Section can present information to the Negotiations team prior to negotiations starting and the Committee seeks out advice as the process proceeds.
      -The fact that there were no members on the Committee from Ophthalmology, Cardiology and Diagnostic Imaging may be related to the fact that members of those Sections did not apply to join the Committee.
      -The OMA has negotiated for all of our members dating back to the introduction of medicare. It is not new and it has served our members and our patients well. Doing anything different would be new. That’s not to say that we shouldn’t think about the process and re-examine it from time to time. But let’s do so with a clear understanding of the facts.

      Scott Wooder, MD
      Co-Chair OMA 2012 Negotiations Committee

      There are a large number of comments and discussions after the article. In the context of 2016 “agreement”, the following response to Dr. Wooder’s comment is very important:

      “Being represented does not mean having influence. In a letter to its members dated January 14, 2013 the Ontario Association of Radiologists states that:

      ‘Evidence uncovered following a detailed review of diagnostic radiology section priorities submitted and discussed with previous OMA negotiating teams [shows] that none of [Diagnostic Imaging] negotiating priorities have ever made their way into a final OMA/MOH agreement.’

      I repeat: NONE OF RADIOLOGY’S NEGOTIATING PRIORITIES HAVE EVER MADE THEIR WAY INTO A FINAL OMA/MOH AGREEMENT.”

  25. The Governance of most Boards requires a fair process when voting to make decisions. A majority vote should not infer the Board is unanimous in their decision. If this is implied, then this is incorrect as transparency and accountability are lost. It is made worse when this OMA Board’s Negotiation Advisory Committee may not have been fully involved in this TPSA as per the supposed statement of Dr. David Jacobs.

    Co-management just means we are now the government’s agent of rationing patient care which is contra to the CMPA mandate of ‘Physicians have a duty of care to patients’. Co-management is the classic ‘suck & blow’ dilemma……….they both can’t be done at the same time.

    There is no retroactive fee increases and the proposed 2.5% increases is too a hard cap on the PSB. Given the fact the Ontario’s government is the most indebted institution in N.A., that the Federal gov’t may reduce the 6% Healthcare Transfer, expected healthcare growth is 3.2%, etc, and even with one time yearly payments, we will surpass the hard capped PSB which will again initiate further fee cutbacks (offset by Co-management rationing and OHIP relativity which will create a further divide among our profession).

    The Charter Challenge will become a lame duck if we allow the MOH request to remove the numerous clauses which holds the MOH and its representatives responsible and accountable for their prior unilateral actions and misleading propaganda.

    The urgency of passing this TPSA during the summer months is a classical negotiating tactic. The spin-doctors will have a field day if we reject this TPSA…………offered the Doctors a 2.5% increase yearly over four years, offered the Doctors the ability to use their insight to help improve patients’ lives, etc…….and if we accept this TPSA the spin-doctors will say that it is the Doctors who are imposing their views (for monetary reason) when patients are being negatively rationed to healthcare access.

    1. Thanks for sharing, Gordon!

      Good point: board decisions are rarely unanimous on difficult issues. Otherwise, they wouldn’t be difficult issues. Board solidarity does not mean unanimous votes.

  26. Having read through this extensive Forum it is evident that the OMA has become a dysfunctional shambles with the left hand not knowing what the right hand is doing and with the government playing it like a violin.

    “Every battle is won before it is fought” ( Sun Tzu)

    ” All war is based on deception” ( Sun Tzu).

    ” Let your plans be dark and impenetrable as night, and when you move, fall like a thunderbolt” ( Sun Tsu ).

    ” The supreme art of war is to subdue the enemy without fighting” ( Sun Tzu).

    The government has revealed itself to be cunning and Machiavellian ( Sun Tzu being the Chinese Machiavelli)…it has a strategy and the tactics that go along with it…the OMA seems to have neither.

    I will Vote No even though I suspect I will be in the minority….sad to see how a once mighty and proud ( in the good sense) profession has been brought to its knees….at the end of the day it is the citizenry, our patients, the government’s clients that will suffer and I want no ownership of that.

    God help our patients because no one else will.

    PS: I have no faith in the reassurances of the OMA’ s legal department….they reassured us in 2012…and see where that led us.

  27. Hi Shawn
    As I’ve told you before, I admire every thoughtful word you write. You are that “noblest work of God, an honest man …. ”
    To further the pursuit of knowledge I offer something shared by me with the Exec of the SGFP this morning :-

    ” Hi everyone
    Some random thoughts, to help clarify things a bit ….. things not well understood, which I learned while on the Board ….

    First, some facts to keep in mind.
    We are the OMA …. and we can’t strike … and the employer hasn’t locked us out, and is still paying us ….. rather poorly, I concede ….and we’re still working ….
    and at no time since 2012 (until now) has the OMA placed a tentative collective agreement (PSA if you like) before us (very important, see below).
    Even retired Chief Justice Winkler urged us to accept the 2014 tentative PSA, but the OMA declined to present it for ratification, for reasons well explained.

    So ….

    When a labour negotiation gets to the point where the employer side says this is their final offer, the employer is also entitled to put a reasonable time limit on the offer. The bargaining agent then has two choices:-

    1) The agent can decide that the deal is not good enough and refuse to present it to members for a ratification vote. In this situation (rejection by the bargaining agent), both employer and employee group are then free to do whatever is permitted by law and the rules of the process ….. like nothing, or strike, or lock out, or return to work at the same or reduced pay (which the Minister did to us twice in 2015) ….. or take the matter to mediation and/or arbitration if law or contract permits.
    or
    2) The agent can decide that the deal may be ratifiable, and agree to bring the offer to the members for a vote. In this circumstance, the agent is expected/required by the employer to present and explain the offer to the members, and to endorse the offer. Not to do these things is in law considered to be acting in “bad faith”, and may cause the bargaining agent to be penalised ( fined or worse) for the bad faith behaviour. Penalties are enforceable by the Labour Board where it has jurisdiction, and/or by the Courts.
    Having made the decision to bring this deal to us, I imagine that if the OMA does not present this offer with a suitable degree of “endorsement etc “, the MOH would consider that to be ‘bad faith” and record the information to be used as argument in any future legal action.
    Reality is, because of the Relationship Agreement to which both parties are signatories, both sides have legal obligations to each other.

    This still begs the question “why did the OMA bring this offer to us in the first place, rather than rejecting it” ….. which is a different question from the one we’ve been focussed on …. and it got me thinking.

    My first reaction on reading the tentative PSA was that, on balance it was a poor deal. It does have some positives, which the OMA leadership emphasise as they are required to do. But it is still a bad deal for me, and the OMA is being self serving, and the negotiators are acting in their own narrow self interest, and all the other conspiratorial thoughts one indulges in at times like this.

    But here’s the thing. These are people in leadership who I have worked with, smart hard working very motivated people whom I know well, and admire, and people who my gut tells me would not normally act in such a blatantly self serving way. So why would they bring such a poor deal to the membership.

    A possible alternative explanation occurs to me.

    The answer, I suspect, may be in part that our expert adviser (Mr Burkett) believes that the MOH can justify this offer as reasonable (in present economic circumstances) before the Superior Court when our future Charter Action finally gets there. And that the MOH can and will also argue that the OMA has been acting unreasonably and in bad faith all along by not putting this or the 2014 final offer before members. Remember, again, that the highly respected Chief Justice Winkler recommended to us in December 2014 that we accept governments offer! The MOH would further argue that the OMA has from the beginning acted unreasonably with the sole purpose of getting binding arbitration, rather than what should be the bargaining agent’s primary purpose, which is to get a fair and proportionate collective agreement for its members.

    The other part of the explanation may be the politics, and the media spin which government would have used had the OMA declined to put this new “final” offer before its members.

    A bit speculative, I concede, but I think it’s plausible. And it doesn’t mean that we the members can not reject this offer.

    If we do reject, and if we do so without recrimination against OUR OMA, we send a powerful message to government which the OMA can voice on our behalf. That doctors are consistent: That we support a publicly funded health system. But that the system must be adequately funded. And that we do not, nor should we have the tools to control utilisation. But that we are prepared to suck it up on behalf of patients (even if patients don’t seem to care much) until we have both government respect …. and independent binding dispute resolution.

    We can do this, without blaming the OMA for the dilemma which it is in; a dilemma, I observe, which was deliberately created by an unscrupulous and manipulative government.

    One thing is sure.
    This Minister and his Premier are going to be right pissed if we refuse this “generous” offer.
    They will want to be vindictive, but they have already cut our pay by so much that they’re having great difficulty deciding where to make the next cuts without starting to have a significant effect on service provision.
    And the election clock is ticking.
    And soon, tongues will wag about liberal incompetence and their inability to manage healthcare.
    Politicians really really hate being thought incompetent.”

    Mike

    1. Hello Mike,

      I am so pleased to see that you posted your email here! What a brilliant piece of writing. Someone shared it with me just a few hours ago. I am embarrassed to say that I had not considered the ‘bargaining in bad faith’ part. It puts far more pressure to endorse. I believe we should avoid a hard sell on anything. We should share both sides. But if, as you suggest, the courts think that we cannot, then we are in an odd position indeed.

      As always, Mike, you open your mouth, and everyone learns something in the process. I wish you had time to write more often. Thank you for your kind words. They mean a great deal coming from you, especially.

      Warm regards,

      Shawn

    2. Very interesting and helpful…the OMA has to present the offer ” in all sincerity” as you explained…we still vote No.

  28. Thank you for your eloquent comments. More will vote NO than you expect. We need a resounding NO. This is not an agreement , but a tactic to accept the lesser of 2 evils.
    We will stop beating you if you accept these controls, that basically removes the need to keep beating.
    This is the end of the road for the OMA as representing the members with transparency and acting in their best interest. They have surrendered without our consent. We cannot limit utilization unless a chunk of us retire now – most organizations to save money give a “package” to get costs reduced.
    Maybe 2 years of last gross billings – which is now an apt term may be more appropriate. This government is not able to afford the health care of the population. We are being shafted. Would teachers agree to teach more for less pay to appease the population? What makes us so different? This is such a farce I cannot believe what I am reading in the PSA. There are no assurances or limits to what we are to be exposed to. The legislation will be adjusted- not defined. We will have to work stat holidays with no reference to reimbursement in primary care.
    There are so many vagaries in this agreement that it is obvious it was crafted by the MOH , not by our negotiating committee. We are given a take it or leave it deal and Told if not ratified by the board the board cannot present it to the members. The members have been bullied and now the board has allowed themselves to be bullied into how it is transmitted. Please see the MOH press release on this tentative deal and compare to the OMA press release. We are basically capitulating and the carrot of the FHO , which is fast being eroded is too little and too late. It basically want to get the GP vote and expose specialists to a greater share of cuts. This was the photo opp presented by the health minister. Taking from the high billers and sending it to the rest of the members would not do anything tangible and is punitive without recourse to representation. I am not in that category of earning , but this is not justified and we cannot sacrifice our colleagues to get less of a pay cut.
    Fascism is the mode of operation of a bankrupt government , to placate the majority and paint doctors as overpaid. We have a short window of time to earn productively with no defined retirement income. We cannot sustain an overhead that does not drop. Can we go to landlords , staff and suppliers and say we want a 10% cut in these costs. When will the collusion with this insanity stop? The OMA and the MOH are colluding to inflict more pain. Once we agree to this agreement we are silenced and have no voice. We will soon have to have a tip jar to cover overheads and collect donations and issue tax receipts as we should be called the OMA charitable organization and I would be fine with that! This economy has 350B$ of debt. Residents attend doctore 3 times more than equivalent developed countries. MOH want same or next day service, that they refuse to pay for. We have complied with primary care reform and still that is not allegedly fast enough. This whole process should be aborted and the deal sent to the negotiating committee for comments from the membership. Who cares if the MOH would not agree to allow to be released to the members if not voted ratified by the board. They should not dictate how our representatives act – we no longer have autonomy of our own destiny and even the board has assured us of that by complying.

    1. Well said, Anonymous. You certainly explain the No side very well.

      We also need to explain the Yes side in its strongest form. Some doctors think this is ok. Are they uninformed? Are they placing hope that an undefined process will turn out well? Are they just tired of continual cuts?

      And as always, dishonest opinions and ideas will sprout on both sides of the vote. Hopefully docs will dig in enough to identify bias, where it pops up.

      Thanks so much for offering a comment. I hope we work in a system where, someday, you feel free to offer your comments with your real name attached.

  29. School bully keeps taking a kids lunch money and punches him in the head every day.
    The victim says hes had enough and says hes going to the principle.
    Bully says OK, I wont punch you in the head anymore if I get to keep the money I took, and you give me a “small amount only” each day… and you have to do what i tell you once and a while…and you can’t tell the principle for 3 years (when I’ll be gone anyway…)…but I won’t punch you in the head!
    Victim meekly agrees…losing his money is better than being punched in the head, and he really needs to try and keep a relationship with this bully to survive…
    Seems like a “reasonable” arrangement, just to keep the peace…the bully gets to remain top dog, gets some money, and does not get in trouble… and the victim doesn’t get punched in the head…

    1. Presumably we have all been bullied during our childhoods….bullies are essentially cowards and they don’t like getting hurt…. I recall launching myself against one as a boy knowing that I would get severely knocked about as a consequence….I was….but he never touched me again….the word got out and potential bullies backed off.

      This government requires a bloodied nose , yes it will bloody ours, yes it will , but if we do a good job it will never try to bully our profession again.

      The alternative is submission to the bullying and then, as George Orwell put it, it is a matter of the government grinding its boot in the profession’s face…for ever.

      Those bullying the medical profession today don’t seem to appreciate the fact that those that they bully today are those to whom they will turn to when they themselves need their lives and that of their loved ones, saved….we should remind them.

      1. “This government requires a bloodied nose , yes it will bloody ours, yes it will , but if we do a good job it will never try to bully our profession again.”

        Yes. yes. yes.

        In the mid 80’s, Federal Health Minister Monique Begin told Marc Baltzan, head of the CMA, that the doctors of Canada need not worry about being abused by government because politicians fear the power of physicians.

        Time push back and bring that fear back to politicians.

        1. Great comments ksy11, Andris, and Gerry.

          Like any social environment, unwritten behavioural codes guarantee that people who always refuse to push back must put up with being walked on. Even the nicest people in the world must stand up for themselves now and then. Groups of doctors do not seem to understand that these days. In most hospitals, for instance, they need a very large majority of outspoken people before anyone actually stands up strongly against oppression.

      2. Andris is correct.

        The bully also managed to make a deal with the OMA without the full knowledge of it’s own negotiating team members.

        Time to hurt the bully.

        From now on, until binding arbitration is secured, never accept any contract unless it ends prior to an election year. This will give the bully incentive to play nice when it is time to talk.

        Since the bully likes to pull one sided stunts, the OMA should do the same. We should refuse dealing with the bully until they learn to play nice.

        The OMA should prepare the public to pay for their elective services and we let the patients sort it out with their OHIP. We no longer deal with bully insurers.

        We should refuse to deal with the bully until it learns to treat us fairly. When teachers, police, MPPs, Hydro and others start having clawbacks for not meeting their global budgets, then we will join them. Until then we start embarrassing the bully every chance we get till the situation improves.

        Time for the OMA to lead

        1. Well said, Dr. Hadenough. Every decision risks setting precedent….in both directions, unfortunately.

  30. Why sign a 4 year deal? There is enough opposition to at least make the government think twice about further clawbacks. So with an election in 2018 and several byelections before then, why sign a seriously flawed deal that benefits only the government. The longer we hold out,the better our position. Very little downside risk to rejecting the agreement.

    The cuts to date have already decimated our profession and have made Ontario noncompetitive. Any further cuts will have profound effects and the government can own them. I say bring them on. We’ll see you in 2018.

    1. Fair point, Jeff!

      Calling a bluff works as a solid tactic. We just have to be sure of our call.

  31. This is a great comment that readers will find helfpul. Providing an analysis can help one make an informed decision. An OMA roadshow will not balance like the following. The MOH is hoping we will capitulate. Personally I am voting NO and appreciate the thought all members place into helping analyze and dissect this agreement. I think because the OMA board is supportive of this agreement we need a counterbalancing group to represent the growing silent majority, who do not believe that this is in our best interests or that of our patients. The NO lobby has little voice through the OMA media source, and this is a concern in this process. For those who find it hard to decide please listen to the NO side opinion , otherwise you will be swayed by the YES side out of battle fatigue and OMA promotion. This should be a neutral presentation with the pros and cons presented as follows. We have not had a board present such a summary and wish the OMA should present these excellent analyses to their members and let us decide our future. The NO side will have to become more vocal to counteract the OMA voice. The writer has allowed to pass it along. Thank you for this excellent piece.

    Analysis/Summary of 2016 OMA Tentative PSA
    Pros, Cons, and Unknowns/Value Judgements
    Dr. Jesse Wheeler, MD, CCFP

    Some members of the OMA Board have acknowledged that both what IS included in this tPSA, and what ISN’T included in this tPSA are important. The below items summarize ideas presented both by the OMA Board during Town-Hall/live events, by members in feedback to the OMA at such events, and by members in private discussion/social media. This is not intended to be an all-inclusive list, but is my best effort to provide a view of both sides.

    Acknowledgement: Like many, I am undecided, admittedly somewhat skeptical about the tPSA.

    Permissions: Please feel free to pass this along to anyone who you feel would benefit.

    Pros:

    – No NEW unilateral action (for the term of the agreement)

    – “Stability”/“Lesser of Evils”/Everything is Relative: Many members are just wishing it would all stop, and we could get back to doing what physicians do, rather than worrying about politics. On the surface, a planned, stable 2.5% Physician Services Budget (PSB) increase seems better than the government’s current 1.25% planned increase.

    – Clawback Prevention: No reconciliation for 2015/16, and maximum $50M reconciliation for 2016/17 – Despite the unilateral action thus far, Physician Services Spending went $240 million over the “budget” for the current fiscal year. This agreement forgives that component. For fiscal 2016/17, the only amount the government can claw back is the planned $50M one-time payment for that year.

    – Co-Management: The concept of the OMA via the Sections helping to determine where there is waste in the system seems like a good idea (but see counterpoints below). This also allows the OMA to once again partner with the Ministry to help direct the health care system, which is what many members are looking for. Unfortunately, it appears based on the numbers in this PSA that the co-management process is likely to be used solely to determine where cuts aka “modernization” occur, since it is unlikely that there will be any substantial revenue increases, based on historical utilization data (OMA Economics estimates that this tPSA keeps up with, but does not substantially exceed, estimated a 3.1% annual increase in health care utilization). There is mention in this clause that the parties are considering “progressive discounts on fee-for-service billings above $1M per year”.

    – Charter challenge: Leaves the fundamental portion of the Charter challenge open i.e. asking the Courts to agree that binding arbitration is a right of physicians in future negotiations. It is expected that the Courts will rule on this by the end of the 4 year agreement, which would help inform the next set of negotiations.

    – FHN/FHO Entry: Reopens managed entry into FHOs (20 slots/mth in any community first-come, first-served; 20 slots/mth dedicated to designated underserviced communities), allowing newly-trained residents to practice in the style they were taught. Also may allow existing FHGs to convert to FHO/FHN if desired.

    – Best Government Offer?: OMA notes that this deal is, in their estimation, the best that we are ever going to get – “we haven’t left anything on the table”.

    – Outdated Codes: I think most specialties would admit that there are fee codes that probably aren’t up to date – some are codes that are far too low for the work involved, and others may be codes that are higher than they should be on the basis of attainable volume and other factors (it is acknowledged that the “relativity” issue is very complex, and many physicians feel that the OMA’s approach to relativity is fundamentally flawed).

    – Bill 210: Removes some dangerous clauses in Bill 210, including those that allow the LHINs to act as an agent of the Minister to police physician services, and require physicians to provide reports to the LHINs.

    Cons:

    – Locks in Existing Unilateral Cuts: This agreement “locks in” the existing unilateral cuts (average 7%, but varies specialty to specialty) as the “new normal”; everything else in the contract starts from that point.

    – Inflation – Keeping up with clinic costs: There is no provision in this PSA to help physicians cover the ever-increasing costs of running a practice in this province, and providing high-quality care. Thus, as a result of the the 4 year term of the agreement, there is an effective inflation-adjusted “cut” of 6-8% (assuming 1.5-2%/yr inflation). For the “average” physician with OHIP revenue $360k, this amounts to inflation-adjusted losses of an additional $5400 (yr 1)+10800+16200+$21600(yr 4)=$54,000 over the course of the agreement. This is on top of the background acceptance of the existing unilateral action as the baseline (7% x $360K x 4y = $108,000 over 4 yrs), and does not include year-over-year changes in things such as CMPA fees, which may increase at rates greater than inflation. So while the OMA has cited the “stability” this provides compared to unknown future unilateral action, it is also quite certain that, unless “modernization” brings us in under budget, net income will continue to fall over the 4 year term as office costs rise and revenue is flat.

    – No Binding Arbitration: No guarantee of binding arbitration (though “co-management process” has a binding facilitator component). The government simply won`t agree to this, and continues to oppose the Charter Challenge.

    – Open-ended: $200M in yet-to-be-determined “modernization” (read “cuts”) to fees/fee codes. No mention of whether this is FFS, capitation, AFP, etc – all are options. No mention of specific specialties. Relies on a vague statement about “relativity, appropriateness, and value for money” – there is no description of WHOSE definition of “value” is used – This is CRITICAL, because patients, governments, and physicians often perceive value very differently, and because government will often with voters. Can we trust the government to act reasonably in this process?

    – Capped Budget, Uncapped demand: Places the issue of sticking to the budget squarely on the backs of physicians – no Ministry responsibility if patient demand rises out of proportion to the 2.5-3.1% planned/expected (except in the case of something like an epidemic, which the Ministry agrees to fund, though there is again no dispute resolution process for determining how much funding might be required). Physicians have minimal (but not zero) control over how much health care patients use.

    – Hard Cap of 2.5% (excluding one-time funds) to approximately 3.1% (including one-time funds): If physician services spending exceeds the amounts in the, then ADDITIONAL “adjustments” to fees will be made jointly by OMA and Ministry through the co-management process(with a facilitator, who can issue a binding recommendation). The Ministry can then say (as they did after the 2015 cuts) that we “agreed” to this process.

    – Public Sector Precedent: No other public sector profession has, or likely ever would, accept “locking-in” existing cuts to its salary/benefits, or subinflationary increases in salary/benefits to help the government meet its fiscal pressures. (The converse to this is that the PSB is, by far, the largest public sector contract. A 1% change in the PSB amounts to MUCH more money than a 1% change in teacher or police salaries, for example.)

    – Ontario Precedent: Will we show that a hard-capped Physician Services Budget can, in fact be done? Does this contradict the OMA’s previous, very public statements around a hard cap? How does this bias future negotiations or binding arbitration requests?

    – Canadian Precedent: Does this agreement set a precedent for other provinces whereby physicians in those provinces will also be required to adhere to a capped budget, despite uncapped demand?

    – The Other 80%: Physician Services Spending is “only” 20% of the health care budget in Ontario. This contract does nothing (and maybe it can’t anyway) to address, or even force the government to EXPLORE, the waste that physicians see in the other 80% of the system. Some doctors feel that physicians are the only professionals in the health system who are being held personally accountable for the costs of their profession.

    – Primary Care Unknowns: Promises that by Nov 2016 “amendments” will be “negotiated” to primary care contracts around 24-48h access for urgent issues and “improvements in” evening/weekend service. The specifics of these amendments are unknowns. Some members question why such amendments could not have been negotiated as a part of the tPSA, rather than being left for afterward. No additional funds are allocated for such “improvements”. The process of negotiating these is unknown. Whether the government will “negotiate” in good faith vs. “negotiate” like they have in the past 2 years is unknown. No dispute resolution mechanism around this is included in the agreement. Conversely, OMA notes that these amendments are specifically targeted only at those physicians who are not already meeting the expectations of their existing agreements (but if this is the purpose, then why not say this explicitly; why use the phrase “improvements in evening, weekend and holiday coverage”, if what you really mean is “ensuring providers comply with existing requirements for evening, weekend, and holiday coverage?). Shouldn’t terms of work be part of any employment agreement?

    – Bills 119/210: Doesn`t address LHIN/Sub-LHIN bureaucracy, or other physician concerns with the Act, and the way it may affect their Family Health Teams or other organizations. The tPSA contains nothing at all about Bill 119, which allows Ministry officials to access patients’ electronic records without patient consent.

    – Transparency: Concerns have emerged about the process through which this agreement occurred, and the speed with which it emerged and is being voted on. One member of the Negotiations Advisory Committee (NAC) was concerned that the NAC had no input into the final deal. Other members have expressed concerns that their Sections should have been consulted on key issues/terms within the agreement prior to it being sent to the Board and the membership.

    Unknowns:

    – Who is responsible for budget?: Allows the OMA, via its Sections, to contribute to the determination of where cuts should occur to achieve a fixed budget – Should physicians be responsible for determining where cuts occur? Is that our role? To what extent, if any? Is this a conflict of interest with our duty to protect our patients?

    – Health Human Resources: Promises to study (and issue recommendations by March 2017) issues of physician supply and specialty vs. provincial needs. The implications of this for current medical students and residents are unknown. How the government acts on these recommendations is unknown. It is unclear whether a student currently in medical school may get to the end of medical school or first part of residency only to find that the new HHR policy no longer “requires” their specialty of interest or no longer allows them to practice in the community where they were hoping to practice?

    – Allied Health Resources: Reopening FHO entry may be a good thing, however, it is also reasonable to assume that there will be little to no additional FHT Allied Health funding for these doctors; so allied health providers may be divided among more and more physicians, which may in fact worsen service.

    – Changes to Charter challenge: Gives up Charter claims that the government violated the Charter via its unilateral cuts; giving up the right to damages (OMA Legal Dept. reports that, even in the best case scenarios across Canada, damages have been at-best $2M, which goes nowhere close to making up for the cuts). However, OMA Legal has been very clear that the goal of affirming a right to binding arbitration is unaffected by the removal of these claims, or the ratification of this agreement.

    – What would a “No” vote cost?: In worst-case, if this agreement is rejected, government could decide to continue on its path of 1.25% increases for the next 4 years, resulting in further clawbacks to physicians totalling an estimated $1.1 billion. There is an over-shoot of $240M (above the 1.25% cap) for the current fiscal year, which may be reconciled in the very near term if this contract is not agreed to. The Ministry would also have the political spin that the OMA membership could not agree to a “10% increase over 4 years”. HOWEVER, several assumptions are made by the OMA, including: this government not feeling additional pressure as fall 2017 byelections and the 2018 general election approach; this government being reelected at all (though a new government could be better or worse); this government not feeling increasing pressure to get a deal done as time goes on (otherwise, why is this happening now, and why did the full process take only a few weeks?). The $1.1B theoretical cost also ignores the fact that this agreement, if ratified, requires “modernization” cuts which total $400M anyway ($100M by Apr 2017, continuing 2018; $100M more by Apr 2019).

    – What would an Arbitrator do?: Is this PSA any better than what an arbitrator would have awarded? And does that even matter? (Some argue that it would be better that physicians are forced to cut than that they CHOOSE to cut). OMA notes that this is likely as high as the government will go on any offer.

    – Patient Accountability: This concept is noted in a single line (2 words) in discussion of the budget co-management process. No further details are provided. No accountabilities are outlined. No further action is outlined. No government commitment is obtained. Should this be more explicit?

    1. Thanks for posting this here, Sean!

      I agree that we need to educate from all angles. I am confident that the information is there in all the work that the OMA puts out. Members will find the balanced opinions more easily at the roadshow than in written material. In the end, doctors need to do whatever they can to inform themselves fully.

      Thanks again!

      1. I have been hearing from members who have attended the road show that balanced opinions were not presented.

    2. Best review of the contract I have seen. If govt wants to limit monies paid to me with an individual hard cap I’m all for it. We all know that for every docs limiting service there will be docs ramping it up to keep income the same. This promotes bad care. If the govt wants to promote good cost effective care they need to govern. Look south to how HMOs control docs.

      You can excellent cost effective timely care pick two

  32. So Drs Wooder and Bonin negotiated this by themselves? With no professional negotiators in the room??
    And strategize by themselves???
    How does that happen????
    Hmmmmm! I wonder who might move to the gov’t sector?????
    KC

    1. Actually, that’s not true, KC.

      Dr. Wooder sacrificed a tonne of time in the early stages, initially all by himself, speaking with other leaders to try to see what needed to happen before both parties could come together again. He kept the board informed, and the group slowly grew and evolved. You remember that all the media announcements since last fall said that a small group was meeting to try to get the parties back together.

      By the end, the group included the co-chairs of the negotiating team with support from our negotiators and senior staff. It was not negotiated as you describe.

      I suggest that you ask this question at a roadshow when Drs. Wooder and Bonin are present. They would love to be able to address this openly and clear it up.

      Thanks again!

      1. Thanks Shawn,
        This info was from a post from someone who attended a roadshow.
        My other question was, “if the gov’t was afraid of the court challenge, why we’re all the clauses holding them accountable for their actions dropped?
        It seems counter intuitive to me.
        The obvious answer from the OMA would be “as a sign of good faith from the profession”.
        My follow up would be ” then why didn’t we give them something that mattered”?
        KC

        1. Great questions, again.

          The parts about being held accountable for their actions would have given us the pleasure of being right, if we won. The biggest award for being right, so far, has been $2 million. Divide that by almost 30,000 docs, and it looks like we didn’t give up too much. It was a trade-off for other things.

      2. OMA COMPENSATION

        All of my life I naively thought that OMA elected positions were basically voluntary positions of public service. I thought that OMA physicians got a small honorarium to make up for part of their lost income away from their offices. At least for some positions this does not seem to be the case. Because of all the time and energy spent by the OMA recently on the current deal being discussed, I checked out the following document. It is the Financial Matters Policy effective January 1, 2016 For Council, Board and Committees Expenses. Here is the link:

        https://www.oma.org/Member/Resources/Documents/2016FinancialMattersPolicyCouncilBdComm.pdf

        I will highlight some of the information that I gleaned from reading this document. I suspect that many who read this will find parts of it as galling as I did. These honoraria are paid to the Negotiations Committee members as well. These honoraria are also paid to those on the President’s Road Show.

        -Honoraria for time spent in meetings, face-to-face and teleconferences
        -Nine or more hours per day are paid as 1½ days.
        -Travel time is paid at the SAME RATE as meeting time
        -Transportation and accommodation
        -$100 per night for staying as a guest in a PRIVATE HOME!
        -Use of a SECOND RESIDENCE IN TORONTO on OMA business. Peter Shurman, my MPP, recently resigned for doing something similar to this. Senator Mike Duffy, although eventually found innocent, was prosecuted for doing something similar to this.
        -CAREGIVER EXPENSES for dependent
        -Time worked outside of formal meetings is paid at 25% of the hourly rate. Do other physicians get paid outside of the office for patient related work and paperwork?

        -“Members WILL BE PAID honoraria and nonrecoverable out-of-pocket expenses when a scheduled MEETING HAS BEEN CANCELLED or members are prevented from attending by meeting-related circumstances, such as travel delays” Do you get paid when your office is cancelled because of a snowstorm?

        -The President is paid for your Road Shows and as well SPOUSE AND/OR FAMILY EXPENSES will be reimbursed when it is advisable that the president be accompanied by spouse or family.”

        To me the stipends and travel expenses for Road Shows stand in sharp contrast to the volunteers trying to get other opinions out about this deal.

        -Honoraria rates and stipends will be indexed to the Ontario Consumer Price Index in Ontario average weekly earnings. Do practising and dues paying Ontario physicians have their pay INDEXED TO INFLATION?

        -Delegates to Canadian Medical Association General Council Meetings, selected by the OMA Board of Directors are paid honoraria AND will have “ticket costs for the Delegate and SPOUSE/GUEST for the Welcome Reception, Fun Night and Presidential Dinner/Dance.”

        -Negotiation Chair be paid to any meeting attended in the course of the chair’s duties a chair, including attendance at the President’s Road Show.

        Honorarium meeting rates as at January 1, 2016

        Daily rate ranges from $800-$1125 per day
        hourly rate ranges from $114-$161 per hour
        President’s daily rate $1695
        President hourly rate $242

        How many Ontario physicians make LESS THAN THAT after expenses?

  33. “By the end, the group included the co-chairs of the negotiating team with support from our negotiators and senior staff. It was not negotiated as you describe.”

    Simply unbelievable. Why, why , why do we continue to let the egos of OMA doctors make them think that with their years of medical practice, they are ready to negotiate with professional bureaucrats about a multi-billion dollar budget of immense complexity and wrought strong public opinions?!

    It should have been a negotiating team (i.e. professional labor negotiators and lawyers) with support from the co-chairs, not the opposite as you describe above.

    And the same lawyer who promised us the deal was a safe one, and the best we could do (uh, except for the 2 years of cutbacks that followed, of course) is now giving the same BS analysis.

    The utter incompetence of the OMA (what else could it be?- retrace the history of every contract since the illegal Randing process was formed, compared to any other working group’s contracts) must be declared openly , frankly, and honestly. If that is not an explanation, then the self-serving (i.e. monetary support the government gives the OMA) can be the only other explanation.

    1. YIKES!

      I’m so sorry to have confused this issue: Professional labour negotiators – possibly the best labour lawyers/legal team in the country – helped with this from the beginning.

      Please attend a roadshow to ask your questions and present your concerns. They need to be aired where other docs can hear them too.

      Thanks so much for taking time to clear this up!

      Cheers

  34. I have tried to avoid posting something that would come across as angry…wore me down.

    ksy11 and Ken Lai have it right. Membership has lost confidence in the OMA leadership. The lawyer providing legal analysis of the contract is the same who has provided us with similar opinions in previous contracts. I would suggest that he was wrong in his analysis/advice and I am certain I would be told that he never told us there would not be cuts….There are many other lawyers in this field…I think we need new blood seeing how we have steadily been losing ground under his legal advice leadership while other health care professions, who are part of the 80% of health care costs, have done far better.

    I voted no in 2012, part of the minority, and while I can say I was right that it was a bad deal, we have all suffered with it. The tPSA 2016 is a bad deal and I will vote no on this one; I hope not to be part of a minority again. I would prefer to remain without contract than to agree to entrenched cuts and such potentially punitive conditions. The less details in the contract, the more open interpretation is enhanced, the kind that will force us to reduce services, work more for less, and fight amongst ourselves for a larger piece of the shrinking pie.

    Disrespect for the OMA has never been higher amongst the membership. Obviously, social media allows us to voice these opinions instantly. Mutiny is in the air no matter what the outcome of this referendum, the outcome of which the OMA Board is free to ignore. No amount of weasel words will excuse or explain how the vast majority of the membership of the OMA feels betrayed with the mere presentation of this agreement to the membership for ratification. We understood and supported the president of the OMA when she publicly stated that there could be no negotiations until binding arbitration is granted, with the analogy of rules to a game being agreed to before starting play.

    Now we learn that one physician, a former president and past president of the OMA, essentially started the ball rolling to achieve an agreement with MOH, enlisting the support of a Board member to pursue the goal. And then it extended to include the rest of the Board, legal team, etc. One would not be impolite to ask who gave him/them the authorization to do this? And why were they not stopped as this was clearly a deviation of the agreed to process. What exactly is Scott Wooder’s role at the OMA currently? Now that there is an agreement of sorts, it had to be presented for membership vote unless to be seen as negotiating in bad faith…Heaven forbid, why that could be used against us in a court of law…

    The more radical among us may have to rise and make a stand, the kind the CPSO won’t like. Sometimes, you just have to do what you have to do…

    1. Thanks Monique,

      Just to be clear: Dr. Wooder did us a HUGE service by working to get some dialogue going between the OMA and MOH. Until that point, there was zero talk, literally nothing happening at all. He stuck his neck out to try to get two waring parties to start talking. For that, we need to show our appreciation and profound thanks.

      Looking forward, we need to do exactly what you have been doing: digging into the contract. We need to ask hard questions. We need to look to the future, not look for someone to blame. Our job, right now, is to decide how to vote and help our colleagues to inform themselves, too.

      Thanks so much for writing! Love your passion…

      Shawn

      1. “Dr. Wooder did us a HUGE service by working to get some dialogue going between the OMA and MOH. “

        I totally and absolutely disagree agree with this statement, Shawn. Whatever his intentions, good or otherwise, his going to the government has done the physicians of Ontario a HUGE DISSERVICE. The government needs an agreement more badly than the doctors of Ontario do. The pressure from the grassroots doctors of the province, especially Concerned Ontario Doctors, through the involvement in the Oshawa by election, the recent Queens Park Rally, the exposure of very long waitlists, lack of infrastructure, the 800,000 Ontarians without a family doctor, an unpopular Premier and an upcoming by election has had the government on its heels. Evidence of this are the blatant falsehoods that the Health Minister has been putting out about physician incomes and the fee schedule. The 6 million dollar man is a desperate attempt to demonize all the physicians of Ontario during fee negotiations.

        As well as the above, the Media has been on our side like never before. The Toronto Star initiative to reveal high billers is just a red herring to sell newspapers. The Star editorial policy with regard to physicians has never been this good. I have never seen the Star lambast any provincial government about the health care system and be supportive of physicians during any contract dispute. I would like to tell those who only read the Toronto Star that the other newspapers in the province are very supportive of the doctors’ position. The supportive articles have been posted on Twitter and the COD Face book page almost daily. I have never never in my 40+ years in medicine seen so much support from the media against the government.

        In 2012 there was also an impasse in negotiations. The grassroots physicians put pressure on the government via radio, television and especially patients. The government needed an agreement as they had violated the Canada Health Act by imposing the fee schedule in 2012. The government had to be desperate! The government came back to the OMA. Then the OMA agreed to a bad agreement that cut all doctors, some more than others. I discussed the non-binding arbitration that the OMA had agreed to with a very experienced lawyer. He said, “What idiot lawyer would let a client sign a non-binding arbitration agreement?”

        The OMA was able to push that deal through by appealing to the sections that were cut the least and the medical students who were not affected by that agreement. The 2012 agreement with its precedent of cuts and with no binding arbitration set the stage for the current fiasco for doctors and patients.

        Going back to the government in 2016 was a huge tactical error by the OMA as the government should have been made to come back to the OMA and not the other way around. The government needs this deal much more than the physicians of Ontario. By voting No to this horrendous deal the physicians of Ontario can put themselves back into the strong position that we had a few weeks ago.

        1. As always, I love your thoughtful debate, Gerry.

          The process of mending relationships started in the fall, 2015, long before government needed anything out of us. I hear what you are saying. I guess I always think it’s worth trying to talk. We need to judge this offer by the quality of the offer itself.

          Thanks for taking time to write!!

  35. This proposed PSA fails in many ways:
    It ignores that the majority of contracts negotiated by the government have left members with an average of a 1.1% pay increase (Website of Ontario Ministry of Labour)
    It doesn’t roll back the 5% clawback and likely will add to it as growth is at least 3.2%/year and the PSA funds 2.5%
    It doesn’t allow “remedy” if we win the Charter Challenge meaning the Government won’t have to pay anything back if we win. Lawyers have argued that this is meaningless as the Government is unlikely going to be forced to give back any significant amount of money.
    Why not 2 years instead of 4 years. Then we would be near the end of the Wynn mandate and more likely have more leverage. In addition, we would likely be close to a Charter Decision.
    Overall, this is a poor proposal by the OMA leaving the Doctors of Ontario suffering over the 4 years likely 10% in loss of take home pay (inflation at 1.8%/year times 4=7.2% plus 5% clawback which may be worse=12% loss of purchasing power over the time frame of the agreement. No other group that negotiated with the government accepted a 12% reduction in their pay!

    1. Eric- well said…and don’t forget this will be a 5- 6 year deal!!! The Guv has always, conveniently, stalled out at the end of every contract…the OMA also dilly-daddles with them , usually for a year or more (why not negotiate in the year it is ending? Even though there is always a new “partnership” touted in each deal, there is always brinkmanship that starts at the end of every deal)…so there is always an extra 1-2 year gap without a deal before a new deal comes in (what a surprise, we’ve been in a gap now)….it always guarantees the Guv a year or 2 of savings, ON OUR BACKS, sanctioned by the OMA careerists…this could mean a (now) total of 8-10 years without any increase, and only cutbacks/clawbacks. But hey, it gives physicians a sense of “stability”, especially the ones working at 4 am all of their careers…it feels even better when you get about a 40% pay cut as you bring experience and hard work over a decade, but the Minister is allowed to get away with sayimg we’ve had a 60% pay increase over the same period we’ve had about a 30% decrease. Thanks OMA….

  36. Shawn:
    I think I finally got it.
    The Board, specifically Dr. Wooder, was given the offer to take to the Board. Dr. Wooder, whom I have great respect( just like you), saw how insulting it is. With the time frame imposed by the gov’t., had to present to the executives. He recommended that the only way to let the profession to see detail of such an inadequate offer is to accept it and let it be vote down. Only then, that the details can be release to the public too. However OMA has to appear that it endorses the offer. Up to this point , I fully understand. However, why such a hard sell ? Then Andris just reminded me about Sun Tze’s tactic. The hard sell is to make people angry enough to vote for NO at the end !!

    Vow: I am a simple person and did not think of all this before. If this is true, then OMA is very successful. Am I giving too much credit to OMA ?

    Michael

    1. Thanks Michael,

      Actually, Dr. Wooder, and the whole team with him, thought that this was a good enough contract to present to the board. I never heard him say or imply that it was ‘insulting’. IF people thought the way that you suggest, the OMA would be accused of speaking in bad faith to its own members.

      I think it is much simpler just to take the offer as it is and accept that the board endorsed it. We had just over 24 hrs to consider it. Now the membership and board has had much longer to consider and explore it. We all need to keep informing ourselves and then decide how to vote.

      Thanks again!

      1. “I admit that the Wynne Government’s strategy will work in the short term to reduce spending. But it will make impossible rational system changes that could maintain current spending levels and patient care. The current strategy of a hard cap and claw-backs will do nothing to improve or even maintain quality.”

        Scott D Wooder, MD September 9, 2015

        https://drscottwooder.wordpress.com/2015/09/09/game-theory-the-prisoners-dilemma-and-ohip-clawbacks/

      2. Shawn, what are the consequences of being accused of negotiating or speaking in bad faith? I have seen this mentioned recently by the OMA. Is it really that big a deal? Is the punishment firing squad or excommunication?g

        1. Great question, Gerry.

          I do not know. I heard that perhaps the other party could sue. I am not a lawyer. I am not even sure this worry applies in this scenario. Like all threats of lawsuit, it got me worried. Perhaps, I worry too much. 🙂

          Thanks!

  37. Well, you can’t have it both ways…either the Board of OMA truly believes this is a good offer and this is why it was presented to the membership (albeit with most of details to be agreed to in the future), or it does not and it should not have been presented at all.

    Sorry, but I agree with Gerry Goldlist here and disagree that Dr Wooder did us all a great service by re-starting the talks with the government. By essentially begging for a deal, we end up having to vote about a ridiculous contract, that is actually worse than the 2012 deal because it enshrines the cuts we have suffered since then.

    A bad deal is not better than no deal, unless you are the OMA leadership, it seems.

    1. I think the Board endorsed this offer because it looks much better than the alternatives right now. Does that make it a fair choice?

    1. Its NOT a 4 year deal…we need to stop saying it and letting the OMA say it. It is a 5-6 year deal, with net losses (not zero gains), which will end with 1-2 years with no contract, therefore even more losses, with the current recent roll-back already in there. WHAT on earth is there to debate here? We are voting on a pamphlet that says , essentially, the Government wont break the law anymore, treat us like crap as bad as before, but they can if they really want to, but (thankfully), the OMA gets to keep co-mangaging our decade of losess forever with them.

      “We are taking things away, but we’ll let you stay and help us decide which ones, as long as you don’t complain about we’ve already done to you, and we might be nicer to you.”

      Vote YES for sure…

  38. latest panic propaganda from the Prez:

    “The OMA has a wealth of experience and positive outcomes working collaboratively with our Sections and OHIP specialty groups in the co-management setting.”

    Name ONE positive outcome in the last decade, and if you can, compare it to the number of negative ones.

    Outcome can only be measured by numerical facts, and we’ve had over 30% docked from us in the last few contracts, with real estate up (insanely) and the economy having growth during that period.

    The OMA can simply NOT claim to have achieved anything meaningful despite all the effort and money. We have been assaulted as a group, and the OMA has “co-managed” it. This is irrefutable if you look at real numbers.

    Oh wait, I forgot: we reminded Ontario smoking in cars with kids is bad. Who knew?….just thought of another: we have a great monthly magazine we pay for which serves 2 purposes: remind us of how awesome the OMA is (no negative letters to the editor allowed, please), and remind us we probably need more of their insurance, and if you’re not sure, here’s 3 articles on it…

  39. Shawn,
    I simply don’t get you. You agree with many of the comments about how bad this is, all the problem this deal can potentially cause, and what a bad precedent this is setting, but that you support it. I’m sorry I think you are convincing yourself and not being honest with yourself. That is human nature to some extent. But I strongly disagree and don’t respect your position as I don’t believe it is a position of integrity which is a human ‘s highest value. This is a terrible deal and you know it.

    1. Thanks for calling me out, Leo! I hope I haven’t disappointed you too much. Perhaps, I can try to explain the gordian knot I’m in:

      I try to see the pros and cons of accepting, as well as the pros and cons of rejecting. This offers a much more difficult challenge, but one that is more realistic, too, I believe.

      You have had 10 times as much time to consider this tentative contract than we had to decide at the board. Our decision was essentially: turn it down so that doctors never get to see it, or endorse it so that the MEMBERSHIP could make the final decision. I believe it was smart to give this to members. I believe members will inform themselves and make a great decision. I continue to support the boards’ initial decision to endorse this contract and send it to the membership.

      I realize this sounds messy, but I see it as the only way to give YOU, and all the other doctors like you, the power to decide. I hope you can find a way to understand the convoluted position that many of us find ourselves in. I am certain that doctors will make a great decision if they think about this issue fully. Please encourage all your peers to dig into this, too.

      Best regards,

      Shawn

    2. Leo, Shawn is caught in a legal conundrum. As a Board member he is legally obliged to agree with the decision of the Board and promote the ‘deal’ to us, whether he believes in it or not. Organizations are supposed to show unity. That is the level of integrity Shawn has to face. I really have never understood that point; in a Supreme Court decision, we get to know the vote, and which justice provided a supporting or dissenting opinion. Business models are not set up the same way, but it should be that way at the OMA who are supposed to be representing our interest. But I am no corporate expert.

    3. Leo – of all the Board Members, Shawn has been the most open about the workings of the OMA, and the most willing to help. I appreciate that you may not like his stance, but given the internecine and tortuous bylaws/obligations he has to deal with, I’m impressed that he’s gotten as much out as he has. He’s acting appropriately, and should be respected for that.

      1. Whether he is totally bound by Board unity and confidentiality may not be straight forward. It does not necessarily have to be the rule of any specific organization. I checked online and there are some places that encourage Minority Reports. Either there is an OMA rule against it or Shawn has been incorrectly led to believe by someone at the OMA that he must strictly follow the party line. If it is the former then OMA Members should try to change that. If it is the latter then heads should roll at the OMA.

        1. Thank you Nick, Sohail, and Gerry!

          I sure appreciate your understanding. Board solidarity is a pretty standard principle; it’s not unusual for the OMA to adhere to it. For the future, we need to help the organization figure out a way to avoid turning complex issues into black and white dichotomies. I am certain that we could find improvements on the current process. It has created bizarre choices that should never have to be faced; corporate Sophie’s Choice(s).

          Regardless, I am so pleased that this decision rests with members. Regular working doctors will make a great decision, if they take the time to get informed and think things over for themselves.

          Highest regards to all of you!!

          Sincerely,

          Shawn

  40. Shawn
    I know that you are restrained regarding giving opinions on this negotiated deal but as a board member I would like your opinion about recent ad campaigns by the OMA. I have recently received an email with the OMA logo and it has the slogan “vote stability. Vote predictability. Vote yes”
    This is a blatant one sided advertisement that biases any objectivity from the OMA. This association is supposed to represent all doctors and provide objective facts so that we can make an informed choice. I would hesitate to say that if this was the way a doctor informed a patient before a medical procedure (informed consent) this would be grounds for reprimand by the CPSO.
    Brad

    1. I agree. Shouldn’t the OMA be sending out information that is a little more balanced? Makes me wonder what’s in it for them ( the board members) that they are pushing one side only at the expense of being perceived not “fair brokers”.

      1. Great comments, Brad and Eric.

        Doctors spend their lives talking about rare complications of treatments they endorse. We go out of our way to highlight all the possible negatives. We trust our patients to see the negatives as important, but unlikely. We let our patients make up their minds, with full knowledge of the worst of the worst. We do not sugar coat our advice.

        Doctors, especially, need a different presentation, in my opinion. No doubt, docs feel the pull of marketing. But docs are too steeped in science to stop thinking at the punchline.

        It’s great to see thoughtful people, like you two and many others, taking time to reflect on all this. These are very unusual – and unusually straining – times for everyone. I am sure many people are doing their best to follow advice from experts. I am not an expert on campaigns. Personally, I favour less rhetoric and more facts. The flavour, tone, and content of the advertisements are not details that the board decides. Having said that, since you (and others) have raised the concern, I will continue raising it with the board.

        In the end, we must trust that doctors are smart, thoughtful, and diligent enough to do whatever it takes to inform themselves and make a solid decision, regardless of what they read from either side of the vote.

        Thanks so much for taking time to share your thoughts!

        Best

        Shawn

  41. Thank you Shane for sharing this with the rest of us in District 5. I had not commented earlier because I have been away using rural internet and did not access your blog for several weeks. Once again your honesty and insight is appreciated and your opinion clearly valued given the quality of the comments. Please allow me to reshare this on Concerned Ontario Doctors given the events that have postdated the intial release of the tPSC – including the upcoming general members meeting on August 14. And the upcoming 3 question proxy vote.

    1. Thanks so much, Sandra!

      I can take no credit for the letter from D5. The delegates came up with the idea, did all the work on it and approved the final copy. Please thank them and our Chair, Dr. Ananth!

      Great hearing from you!

      Cheers

      Shawn

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