Wednesday, July 20, 2016

Ontario's Doctors Should Take the Deal

No curses, no cracks, no cartoons this time around.

In one of the most unexpected e-mails I've ever opened, the President of the OMA, after reading some of my online comments about the tentative Physician Services Agreement (TPSA), asked if I wanted to become a proper advocate for the deal. Me. The guy who's compared the Ontario government to Wile E. Coyote, the Blue Meanies from Yellow Submarine, and WWF wrestlers. I turned the offer down, because I'm the last person in the world that should be advocating for anything.

But I would urge that Ontario's doctors to vote YES to the TPSA.

There are a thousand reasons to vote NO to the deal. The deal still entails cuts to physician services budget. The Ministry is increasing the pie, but factoring growth in the number of doctors, each slice of that pie is decreasing.

The language in the agreement can be read as overly vague. I'm used to these sort of vaguely-worded frameworks from my days in public health, but I can see why many doctors would find it discomforting, especially in light of the unilateral cuts of the past few years.

The process by which the agreement was negotiated lacked transparency. After reading many thoughts on this issue, I honestly can't make heads or tails of it anymore, but I concede it as a justification for a NO vote.

There's a sense that the membership was betrayed and disrespected by returning to the bargaining table without binding arbitration in place. The OMA had publicly stated this was a precondition for any negotiations.

But as I noted in my last post, there are positive aspects to the deal. Moreover, I don't see that a sensible alternative has been proposed. Much of the argument against the deal rests on an expectation of the public getting behind doctors in principled opposition to government heavy-handedness; or doctors staging a "palace coup" to oust and replace the current leadership of the OMA; or a breakup of the OMA with each section fending for itself; or the government bowing to a more aggressive stance by the doctors; or a strike that will "bring the Liberals to their knees"; or an arbitrator awarding the doctors the money cut and clawed back; or the Conservatives winning the next provincial election and reversing the cuts of recent years. The list of hypotheticals goes on and on. These strategies are all based speculation, not evidence of likely success.

A strike in particular is a spectacularly bad idea. True, past performance is no guarantee of the future, but repeat failure is a pretty solid indication of a bad strategic direction. Like invading Russia in winter bad.

Binding arbitration? The OMA is still going for it, but the deal absolves the government of the cuts. That stinks, no question about it. But the OMA lawyers have cited precedent that the money from the recent cuts isn't coming back anyway, arbitration or not. So arbitration will be there for the next round of negotiations, which bolsters the odds for a better deal.

Taking a stand on principle? I get it, but what's to stop individual doctors or even the OMA from decrying the cuts? As I wrote elsewhere online, my answer to anybody accusing me of being a sellout for voting YES is, "the Wynne government planned to cut more than a billion dollars from health care if this deal wasn't ratified. They intended to sic an army of clueless bureaucrats on family doctors to create more headaches and come between you and your doctor. This agreement will keep the pencil pushers out of doctors' offices, and make sure doctors have a say before any more money is cut from your medical care." Or something to that effect.

As for the OMA? The deal is four years of no surprises and no unilateral action. Get involved. Reform whatever processes and by-laws needed in the OMA so the membership never again need feel like it was sold out. If the leadership of the OMA won’t make changes, change the leadership of the OMA. Overhaul the OMA’s internal structure so there’s no more threats from individual sections to take their ball and go home if they don’t get what they want.

As I noted above, there's no lack of criticism out there for the deal, some of it sound, some of it vitriolic, some of it insultingly or laughably over-the-top. While the allusion to Chamberlain's appeasement of Hitler is out there, I cite this piece that includes a quote from Elie Wiesel as easily the most obnoxious I've seen. Somehow I don't imagine that when a concentration camp survivor talks about "oppressors" and "the tormented", he's thinking of doctors getting a pay cut in a negotiated settlement. But no amount of criticism makes up for the lack of a good alternative. It isn't a vote about whether or not doctors are getting shafted, it's a vote on the size of the shaft.

And that's all I can say beyond what I've posted elsewhere. Absent a sound, realistic plan going forward, Ontario's doctors are better off ratifying the tentative agreement than rejecting it. More importantly, with less anger and anxiety among their doctors, and fewer bureaucrats to make life difficult, the patients will be better off too.

Time to get away from all this stuff about doctors. Next time: TEQUILA!


  1. Sorry no way in hell are doctors responsible for utilization! I vote no

    1. If that's the decision you've arrived at, that's both your right and prerogative. This is just my opinion.

  2. It troubles me that informed people such as yourself use terms like "no surprises and no unilateral action". If you understand the deal as you say you do, then you should know that if funding estimates underestimate utilization, then the deal authorizes and endorses the government to further claw back our wages. So in effect, it pre-authorizes the government to act unilaterally to reduce our compensation if spending estimates are wrong. And from your days in public health, you should be well aware that spending estimates are often wrong. So therefore voting 'yes' is a terrible idea.

    1. The utilization estimates are based on the past few years, where growth has been reasonably controlled. There isn't a compelling reason to expect an explosion in utilization, and there's language in the agreement to explore measures of patient accountability. If the numbers go too high, the one-time payments are there as cushions/fudge factors. And if utilization goes past that, at least the docs have a say in where cuts might be coming from, rather than the whims of Bob Bell and Eric Hoskins. If there's a disaster or pandemic, the government agrees to cover those utilization costs, which isn't all that hard to tease out. And like I said, I get the anxiety around the vagueness of the language. If you think I'm being overly naive, that's fair.

      As I've noted here and elsewhere, the issue isn't that the deal isn't bad. It is, though not all bad. But in the absence of a viable alternative strategy, what's the rationale for voting no? To send a message? To whom - the government or the OMA? What brings the government back to the table if the offer is rejected, now for a second time? The government has made it clear they intend to cut much more aggressively in the absence of an agreement.

      If the rationale for a no vote is one of principle or fear of setting a precedent, I can't really argue against that. It's a personal judgement call for each doctor, and I respect that. But what happens then? We KNOW there will be more cuts, and a whole lot of finger-pointing, but that's pretty much all that's guaranteed if the deal doesn't pass. The OMA will have no leverage on the government to get back to negotiation, and the internal workings of the OMA probably begin to resemble the U.S. Congress.

      If the deal passes, there's 4 years of something resembling stability and predictability. That's a good chunk of time to let the arbitration case go through the courts, and an opportunity for the angry membership to set the OMA house in order.

      It's just an opinion, based on what I see are the pros and cons. That's going to be based on my own experiences and attitudes. For example, I weigh the Bill 210 changes as more significant than other docs might, certainly specialists for whom Bill 210 is not relevant for now.

      Look, I have no specific ties to anyone or anything in the OMA apart from my wife and friends (though if they want to cut me a cheque I'll say whatever they want), and God knows I don't work for the Ministry of Health. I thought it was important to publish an opinion that isn't bound by OMA or government messaging. If you disagree, I respect that 100%, and feel no obligation to "correct" your opinion.

  3. Why does everyone keep talking about a 4 year deal?
    It will be 5-6, given there is always a deliberate delay to get a new one done after it expires. Deliberately. This has happened for decades. So the deal then becomes 2.5 % per year (roughly) followed by ZERO % for 1-2 years. More pay cuts/savings for the government. That really changes the math..but why is this never mentioned?
    A 5-6 year deal covered by a vague pamphlet.
    And the endless talk about not being able to strike drives me nuts. Its called job-action, and it works...was anyone angry at their kids teachers last year? It was annoying, but the public felt it was a union/government thing...and it worked really well. GPs can legally take a holiday when they like. The ER will cover them , like it does from 5 pm and all weekend anyways.

    Frank, some of us actually do believe in principles, as you mention above. Honest question: do you now make your living from clinical practice?

  4. As I see it, a strike works by causing enough of an inconvenience that the public gets fed up and demands that the government fix the problem. I don't see that with the divisions in the profession and the CPSO dictates, the doctors can reach the "critical mass" of public inconvenience.

    But let's say that they can. Let's say that the doctors muster enough of a legal job action that the public does push the parties back to the table. We forget that the after-effect of a strike is near-universal contempt for the union. I can't count the number of people whose dislike of teachers, postal workers, etc. is visceral.

    You might say, who cares? Let the public hate doctors. I see the logic there. As the OMA ad campaign highlights, doctors' standing with the public didn't win them a hill of beans. The problem is that when the public hates politicians caving into, it votes in the Mike Harrises and Rob Fords of the world. Winning their battle in the garbage strike earned Toronto's trash collectors privatization of the service. The existing workers had job security, but that bargaining unit signed its own extinction.

    I don't make a living off practice these days (for reasons having nothing to do with money), but I did until the end of 2015. I had the displeasure of seeing my pay slashed repeatedly and then clawed back just like everyone else. My wife, who's now the breadwinner, is in full-time practice, so the outcome of the dispute affects my family as it does anyone else. If you don't feel I have enough "skin in the game", fair enough.

  5. I vote No. The OMA says they got the best deal they could and this is likely true. I don't blame OMA. I don't want to change OMA structure I want to tell govt I don't accept being held solely accountable for utilization. I don't want to go to a doctor that has a finically incentive to deny care. I vote no because as health care deteriorates due to govt policy I don't want govt to be able to say well the doctors agreed to this. I don't accept the massive cuts. If govt wants to keep cutting till there are no docs left so be it.

    1. Look, I won't convince you and that's fine. I respect your rationale, your principles, and your choice. Agree to disagree.