24 thoughts on “Should We Splinter the OMA?”

1. Interesting take Shawn as always.

   1. Thanks Hiro!

      Times are desperate. We need everyone’s help to hammer out the best possible solution. Let’s stand together for a bit longer. We can discuss radical options once we have a contract in hand.

   2. Wise comments, but I fear the horse has already left the barn.

2. Excellent piece. Do you really think the issue is relativity? Do we care about gross earnings or units served? Does a radiologist actually make more than an FHO doc? I think the problem is, we don’t know how to define how much a unit of physician time is worth. We also don’t know how to determine the adjustments for complexity. So, let’s start by looking at the fee codes…the top 10 per specialty. Then let’s determine if those fee codes are reasonable. Let’s compare jurisdictions etc. Once we settle on cost…the gross earnings are irrelevant. Gross revenue is just that…says nothing about units serviced or how many of an item was sold. In terms of the association split..I think the government is just angry that they can’t get a deal. Ford wants a deal. He thinks he can get one if he works with specialists…who can find cost savings in a resource driven health sector. If fewer echos, CT’s, tests etc are done in expensive environments like hospitals, they will find the savings. I also think Ford feels fee for service GP’s are cheaper than FHO’s. I don’t think this government is stupid…they have demonstrated that they will do anything for a deal.

   1. Good comments, Concerned Doc!

      I agree. Fee based or relative value units seem to offer a good option. Many people have concerns about an income based relativity. In fact, income based approaches seem destined to create the kind of divisions we see.

      Thanks so much for taking the time to read and comment!

      Cheers

3. This is why the high billers stay high billing: they’re proactive.

   In life there are victims and there are perpetrators. Both of those roles are a choice.

   1. Thanks Dr. Harambe. It’s always good to be proactive, for sure.

      However, I don’t think dividing will allow anyone to conquer.

      Thanks for taking time to read and post a comment!

4. Although I think that high billers are probably smart enough to see through the implausibility of starting a new rep rights body, I think their sentiments are a symptom. Psychiatrists being at the opposite end demanding rapid paced parity is another symptom. The commonality between the two symptom extremes is the underlying disease – The Schedule of Benefits. I don’t think you could find a single doctor who is not on the Govt’s payroll who thinks the SOB is rational or fair. It is the underlying cause of income disparity as the government uses it to “adjust” the fees which is often politically motivated for the problem de Jour in the media. It is the schedule of benefits that needs to be shredded, not the OMA. The OMA must not accept negotiations on the Physician Service Budget where the goal is to fit us into an arbitrary number that is determined by political goals. We must fight and negotiate for our WORTH/VALUE. We must never accept a SOB that sets services at $0. Time increments must take into account income minimums. Consults for medicine and Surgery and Family Medicine, ought to be the same value. Technical fees have to be based on actual costs including overhead. The old OMA jumped into bed with the MOH so as to “co-manage” healthcare, they were dupes, sucked in by a mere veneer of power and prestige. There would be no need to splinter if we all had our needs med according to OUR needs and not an arbitrary political budget that is actually flexible enough to hide a mere 9 Billion.

   1. Hi Ernest, I agree with a lot of what you say except re: consults. Time is a huge issue. If a surgical consult takes 10 minutes and involves looking at an image and surgeon says “I cut or sew here” and discusses the risks and benefits, or a cardiologist takes a 10 minute history on the location of chest pain, it’s very different and takes much less time than a history of everywhere you have travelled to determine where an infection came from or what you have breathed in over a lifetime to determine what is going on in someone’s lungs. This is where time based units come in, or complexity. Good luck, as someone else mentioned, the horse is out of the barn.

      1. Great comments, Ernest and Effie.

         I totally agree with your comments about the Schedule of Benefits, Ernest. It’s a fifty year old document that’s stayed the same more than it has changed.

         Effie, I really like what you said about consults and the different of time required for different issues. I’ve always been bemused by the 3 sentence surgical consult that really captures everything and the 3 page internal medicine that does the same. It requires 3 pages to capture the internal medicine information. We should admit that and compensate accordingly. But that’s fee based relativity….not income based.

         Thank you both for GREAT comments!

         Cheers

5. Shawn, old strategies are not working, on that we likely agree. The government is not willing to negotiate by the rules for a long time – so why do we still hold to that old frame of mind? It seems to me having the OMA represent all doctors is like the old British idea of volley firing in the nineteenth century.

   It wasn’t until WW1 that volley firing became obsolete – you know troops line up kneel shoot all at once then go to the back of the line and load and await their turn to be at the front again. It was an excellent strategy when tools were different and people didn’t know any better. As weapons and tactics improved the rigid strategy became obsolete. It was not a negotiated solution.

   The war metaphor is perhaps not too far off when the government is so belligerent. Let me explain. As they changed the rules, some doctors have adapted by gaming the system with procedures and asymmetric political sway while others have fallen further and further behind. The OMA was too cumbersome to adapt to that quickly.

   MD-patient relationship has been progressively undervalued which has led to increases in dissatisfaction with the system associated with a dramatic decrease in MD satisfaction, and practice changes that focus more on finance and less on patient care out of necessity. This had been very expensive. Some say relative value will rescue us, but of course, it does not work to take food from one sibling to give to another when everyone is cranky.

   The government and OMA strategy seems too rigid – They will spend a lot of time and money to cap MD salary. and use up OMA resources in the meantime. The OMA is complicit in accepting the government strategy as a reality, choosing to focus relative value is an important work-around. What other unions would agree to a relative value for professionals? None!

   A friend once said, “many MD’s are trained to be racehorses but are now being treated like mules by the government and their own professional organizations. ”

   A disbanding of OMA would provide chaos in the rigid system, that may help professionals break free from the wrong-minded micromanagement strategies now offered. Individual hospitals may need to negotiate with individual MD’s to provide service, just like the on-call debate when the government’s cut back income. It will be much more expensive but may have to happen for the profession to get more respect at the table.

   Individual towns may opt out of OHIP, rogues may try extra billing – oh that already happening just call it executive care or fees for noncovered services – let the government deal with that diaspora strategy. Maybe CPSO regulations would have to adapt, disintegrating professional expectations.

   Not sure chaos is ideal but sometimes it is necessary to get people to listen, to care, to realign with priorities that make sense. A disbanding of the OMA will lead to chaos, but maybe a little revolution is needed?

   1. Thank you, Concerned MD about to Quit.

      You make solid points. Doctors are selected from the hardest working, most altruistic, most conscientious students available. Then the system treats them as ‘mules’ as you say.

      The system has run out of money. All socialist systems collapse after 50-70 years max. Medicare will collapse without substantial change. In some ways, we might even be furthering a dysfunctional relationship by agreeing to work harder and harder for less and less.

      But I do not like Trotskyite solutions. Revolution as a tool to create change ends up destroying more than necessary. Sometimes it’s the only solution, but I hope it is extremely rare indeed.

      I worry about you and the hundreds of other doctors who are losing hope in our system. Those who can retire do. Those who can generate income outside of OHIP jump at the opportunity. If there was some easy way for doctors to work clinically, or non-clinically, outside of OHIP, I bet up to 50% would explore the opportunities. That does not speak well for Medicare.

      Thanks so much for your thoughtful note. I do hope you find something you can feel passionate about. Don’t feel guilty about it.

      Best regards,

      Shawn

      1. Perhaps you misunderstand, a “Trotskyite solution”? We are not orthodox marxists here, quite the opposite. There are systemic insults that make the system near collapse., this is not a Bolshevik revolution.

         This could be an integrity revolution. I defy you to find a doctor in the system who couldn’t save his life time costs to the system by pointing to nonsense expenses born out of adversarial compromise (legal solutions are far from ideal) or local political waste preached by SJ warriors who are neither “social” nor “just” in their approach if you are looking for Trotsky, look there!

         Connect billing directly – consumer and provider. Wouldn’t that open the eyes of the public? An honest hospital bill and how little of it that goes to the actual care givers. 140 dollar meals of jello, and a drab room that costs more than their house! The information is readily available.

         No, instead the system enables hiding behind privacy and bad business practices. The system is broken because the people who built it are broken. It’s just human nature. Treat that reality by giving back to the profession, autonomy and accountability to consumers, Maybe extra billing could be allowed as a percentage of the bill, so the consumer knows exactly what the professional fee is.

         The point I am making is the OMA is shackled by mixed interests and has been ineffective in promoting professional autonomy.

         Imagine a billing manual over a thousand pages long that is then not even honoured, just used for administrative types to micromanage their control.

         Complexity theory, out of Plato Alta, predicts this better than the communist manifesto.

         1. Well said indeed, Concerned MD!

            I apologize for mentioning Trotsky. I did not mean to imply you agreed with his ideas or sympathized with Marx. I only expressed worry about the modern rebirth of the ‘revolution as a way to create change’ movement.

            You make excellent points. The public does not know. I just shared a lunch table with a lawyer who works with patients on mental health rights. She made comments about physician incomes. I said that I get around $30 to see, diagnose, and treat her for pneumonia (including ordering and reviewing labs, X-Rays, etc), and my fees have been cut every year since 2012. She said, “This is first I have heard of it. I had no idea.”

            The public does not know about ‘March Madness'(spending sprees before the fiscal year end). It does not know about unlimited sick days for some union workers (they just have to take classes on how not to miss so many days). The public has been kept in the dark intentionally. The only thing they hear is people like former Minister of Health, Eric Hoskins, telling them to get their “Free” flu shot at the pharmacy.

            You comment about complexity theory needs expansion for sure. It is exactly what we need. But complex systems – e.g., imagine an ecosystem, a swamp, a family relationship – cannot be controlled with programs, legislation, and oversight. So system controllers will never give up their levers and admit that complexity will always sit beyond reach of their designs.

            Again, great comments. Thanks so much for taking the time to share them!

            Cheers

6. https://torontosun.com/news/local-news/greedy-doc-loses-licence-after-scamming-ohip-for-2m The Ministry of Health and Long-Term Care/OHIP ” probes for fraud regularly and finds” some as opposed to “none”. Here is the most recent case where fraud was found.

   1. Great correction, Perry.

      I will change the text. Thanks again!

7. The only reason that ‘relativity is an issue,is because we allowed normal market mechanisms that control pricing to be eliminated by gov’t when they eliminated balanced billing. True value of a service can only be determined by the people that receive that service…..and the fees follow accordingly.
   I am sick and tired of those colleagues who think surgeons ‘just cut and sew’ …. do they have any idea of the responsibility/accountability of suggesting/performing surgery … the stress/exertion/risk involved ….. as opposed to talking about peoples ‘problems’?
   This is one of the reasons there is a schism within the OMA …. DOCTORS don’t understand/support each other any more,because they are all fighting over the limited pie.Enough…. end RANDING and let people go !!!

   1. Great comments, as always, Ramunas.

      I agree with everything, except division at this point. I would welcome a debate about RAND after we have a contract in hand. I have said before that I do not agree with forced dues for any association, union, or guild. However, at this crucial time, debating RAND is a toxic distraction.

      Thanks so much for taking time to post a comment! I’m sorry I was 36 hours late. I had to close up the cottage yesterday.

      Cheers

8. The OMA and its membership deserve whatever happens them…they both sleptwalked into the present situation …much like that proverbial frog that found itself in a pot of cold water that failed to detect ( ignoring warnings from other frogs in the pot) ,the subtle increases in the temperature generated by the political class and the health care bureaucracy and egged on by the frog hating media …the water is now nearing the boiling point and some of the overheated frogs are declaring that they want to get out and found another pot of cold water…of course they face criticism…”give it more time “ they’re told…”those turning up the dial will come to their senses”….” we are working on it”.

   The sad aspect is that quisling frogs have been advising those manipulating the dials all along and are still at it in the name of social justice.

   It’s now every frog for him or her self….no one cares about their stresses and strains, their burnout, depression , suicidality and marital breakdowns…they should ignore the comforting and reassuring words from those manipulating the dials, they give more credence to their bean counters that warn them of the dangers of turning the dials down.

   The road to our present health care system “ hell” was paved by good intentions….also with candies strewn along the path to draw the gullible into the abattoir.

   1. Stimulating comments, as always, Andris!

      I agree with much of what you said. If your thinking sparks action and inflames passion for solutions, then I think we should continue on this vein. Which would lead me to ask, What do you think we can do about it?

      However, I worry that your thought line leads, logically, to nihilism and despair. I think it was Dee Hock, who I believe was the CEO of Visa, who said something like, The times are too tough and the situation too dire for negativity.

      So, if we take your comments as a brutal honesty about the facts of the situation which will inspire action, I like them. We need even more. But if your sentiment makes us all want to lay down and wait for death, then we need to focus on better paths.

      I have always liked, “We will fight them on the beaches. We will fight them on the landing strips… We will never surrender.”

      But again, I always love your comments!

      Cheers

9. We have to have an honest all too goodness autopsy / analysis of how we got into our present predicament.

   The OMA and the membership through its voting ( often misdirected/ manipulated by the OMA ‘s own leadership caravan tours) made mal decisions and allowed itself to be outmanoeuvred time after time by the various governments.

   One strongly suspects OMA had government ‘ undercover agents’ within its ranks leaking information to the government and misdirecting the organization…one strongly suspects that the government had actors on both sides of the negotiation table allowing them to see the OMA ‘s cards even as it successfully hid its own.

   The one argument for a new representative group or splinter groups is that they could purge themselves of such double dealing agents…no one on the government’s side of the negotiating team should be a member of the OMA or of any of the proposed repreentstive groups….and no representative member of the OMA should be allowed to move to a government sinecure for 5 year plus.

   1. I second your call for an autopsy of how we got here. I don’t know what to say about ‘double agents’. With the former DM and Minister of health both on the email list, I don’t think there were too many secrets about what went out to members.

      I hear what you are saying about non-compete clauses. I do not know how you would enforce it. I believe the anti-lobbying rules for political staffers required legislation.

10. For years I have been suggesting the negotiations should be done through smaller homogeneous groups than the OMA allows for in dealings with the government.

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

    Historically the pursuit of relativity has kept all physicians down. In some past deals with the government money had been allocated for across the board increases to all sections with extra money being allocated to the underpaid sections. The catch-up was funded by the government and not other sections but this has not been the case for a long time with some sections being coerced into giving from their own pockets to other sections,

    A smaller more homogeneous group is more cohesive and even at times more collegial. Ophthalmology has always been able to resolve its INTRA- specialty relativity with little if any acrimony. The pursuit of inter-speciality relativity within the OMA has often boiled down to a tyranny of majority alliances within a democracy.

    I think that each section, and that includes family doctors, pediatricians and psychiatrists, should be able to deal directly with the government. The more homogenous and smaller the group, the more likely sanctions are to be supported. This might seem paradoxical but in the case of fee negotiations with the government I believe that smaller will be more powerful.

    “Even if the government agreed to give rep rights and BA to multiple groups it would have to justify an exponential cost to deal with sections individually.” I say that would be the government’s problem as each section could justify its own increase. We must force the government to increase the pie instead of our agreeing to taking a shrinking pie/service given.

    Your make the point that “if some doctors feel marginalized now [within the OMA], imagine the Toronto Star publishing the average income in the high billers’ group?” I don’t think that publishing billings of physicians is that big a deal but I do commend the OMA’s pursuing this in support of physician privacy in general. Even this issue, however, shows that there is membership disagreement about whether the OMA should even pursue this further in the courts as it is only in the interests of the high billers and it costs the unaffected OMA members money. I think that this is less likely to occur within a smaller homogeneous group.

    I commend the current OMA board for entering negotiations with the principle of never robbing Peter to pay Paul. Although this is the Board’s position, it appears that a significant number of individuals and sections have not accepted this principle. Relativity has been attempted many times (RBRVS, RVIC, CANDI 1.0, CANDI 2.0, RAANI, and now the RAC . Unhappy members have time and time again called for new algorithms while saying that the previous attempts at relativity were not done correctly. It is like pointing out that Socialism has always failed and getting the reply that it has never been implemented right. I think that the current specialist/section uprising is a logical reaction to having to keep explaining and fighting the failings of the pursuit of Relativity over and over again.

    I am only privy to what is public information and what I have seen on social media. I have been a huge proponent of Binding Arbitration and by persistence we finally have it in Ontario. I have been urging my Section of Ophthalmology to stick with the OMA and make our case directly to the arbitrator. If this unfortunately is not going to be the case, then I can understand why some sections are looking to break away from the process.

    As I advocated in 2013, I envision the OMA as an umbrella organization under which negotiations could be done by section. The OMA seems to have had better direction in advocating for physician welfare and rights under your leadership, Shawn. Nadia from day one has always advocated for all physicians and patients and I am still hoping that the OMA can remain as a vibrant organization for physicians but because of other OMA leaders, sections and members, this may finally be the time when the OMA has to allow sections to negotiate for themselves.

    1. Great comment, Gerry!

       I share your vision for an umbrella organization. A federated model. Indeed, this is how the organization was designed with sections, districts, and a council. We need to recommit to federalism (or republicanism if you like) to give people maximal opportunity for self determination within a unified country of medicine.

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