Dissecting the Ontario physician contract

Autopsy of the done deal reveals both benign and malignant elements

By Julie J Mercier

"I'm still confident that doctors will see this as an improvement; an agreement that starts to address the serious problems we have here in Ontario for patient care." — Dr John Rapin, OMA President

Last month saw the end of the often acrimonious negotiations between the Ontario Medical Association (OMA) and the Ministry of Health and Long-Term Care. A new and improved $2.4 billion contract was approved by a healthy 74% of the 15,068 doctors who voted. Had it been rejected once more, the deal would certainly have been a public relations nightmare. Prior to the vote many pundits were portending a complete collapse of the Ontario healthcare system if the government's offer died on the table.

The breakdown of relations between Ontario's MDs and its politicians, which has been simmering for decades and bandaged by several preceding governments, came to an ugly head during Premier Dalton McGuinty's current tenure. The new deal is a giant leap forward for some doctors, but for many others it remains an egregious slap in the face.

TEAM PLAYERS
At one end of the spectrum are those conspicuous 'yes' voters. Giving the deal the thumbs up were the Ontario College of Family Physicians, NOW Alliance, northern doctors and the majority of members from all specialties minus dermatology, orthopedic medicine and diagnostic medicine. Whether these physicians were open to the new incentives offered in the government's proposed primary care reform philosophy, including nice perks for rostering patients and joining Family Health Teams (FHTs), or just wanted it to be over was unfortunately not reflected on the ballot. One thing's certain; FHTs, which are similar in design to Quebec's well-established CLSCs, remain a hotly debated issue.

The key to earning these extra incentives is enrolling, also called rostering or registering, patients so the government can monitor what kind of care the patient is receiving, and reward the doctor accordingly. Doctors must also sign a two page contract with the patient. If a doctor has a rostered Comprehensive Care Management (CCM) practice of 1,500 patients, for example, he or she will see a boost of $25,560 in the first year, and up to $38,700 in the fourth year of the deal — which works out to a raise of 28.5% over four years.

END OF SOLO PRACTICE?
In the original deal it was necessary for a physician to be on call 24/7 to qualify for these benefits. Now the only requirement is that he or she work one three-hour block per week during either an evening or weekend. Things get even sweeter when one joins one of the three types of FHTs. For example, Family Health Group (FHG) physicians will see a raise of 30.5% over the course of the deal, while those in the larger Family Health Networks (FHNs) will see a boost of 35.5% over four years.

Other benefits of rostering include being remunerated up to $10,000 a year for administering preventive medicine, such as flu shots, mammograms, and other bonuses such as taking on patients older than 69, bonus codes for diabetes management, smoking cessation and many others. As Dr Val Rachlis, president of the Ontario College of Family Physicians and a big fan of the deal, noted in a March 21 letter to the College's nearly 7,000 members, rostering will allow doctors to "understand the true demographics of our practices so we can tailor how we manage our office time to meet the needs of our patients, while re-balancing our lifestyle...."

Another major booster of the deal is the NOW [Negotiating Ontario's Well Being] Alliance, a group representing over 100 rural communities. "We believe that not only is this deal good for comprehensive general practice, it is particularly good for rural practice," said NOW Co-Chair Richard Adams in a public statement.

Satisfaction with the deal also runs high among northern doctors. They've gained a bonus for their work in the province's remoter regions. One such doctor is Thunder Bay's Dr Ken Arnold, a family physician at Port Arthur Health Centre. "There have been a lot of improvements, but there's a lot of noisy rhetoric from those opposed," he told a local newspaper, referring to high-earning specialists in southern Ontario. "For northern physicians, [the deal] is very acceptable."

SHORT ON SOLUTIONS
In the 'no' camp sits a vocal group of detractors, made up of the Specialists Coalition of Ontario (SCO), the Coalition of Family Physicians (COFP) and independent activist Dr Ken Milne. Each group had its own reasons, but disdain for government interference inherent in FHTs and the perceived failure of the contract to seriously address the issue of doctor shortages provided a common cause.

Dr David Mark of the COFP publicly stated that the deal "doesn't make Ontario competitive enough to save family practice." SCO co-chair Dr Bill Hughes echoed his concern, concluding the deal essentially leaves specialists "treading water." He added, "...a few [would] do well and so they should, but government attempts to micromanage healthcare never work and they won't work this time."

The Ontario government estimates 1.2 million people in the province are living without a doctor. Dr Ken Milne, the self-proclaimed 'rural rebel,' warned in a missive entitled "Agreed Statement of Faults," that these so-called 'orphan patients' could increase to over 3 million by 2008 under the new deal. Dr Milne, like his colleagues at the COFP, thinks the Liberal offer of a 2.5% pay hike over four years for GPs and FPs (2% for specialists), retroactive to April 2004, will still leave Ontario MDs making less than those in other provinces make now. And what's more, he says after decades of sub-inflationary increases the government's offering will serve to repel rather than attract doctors to the province. This, Dr Milne reasons, would put further strain on ER and out-of-hours doctors and exacerbate the current waiting list fiasco.

Some of the finer points of the FHT scheme remain a sore point for physicians opposed to the deal. One, Brantford GP Dr Ilmar Kents, is particularly incensed by the campaign to get patients rostered. "Rostering fits the government agenda to a T and does absolutely nothing for patient care," he says in an interview. "To be honest, some doctors have actually cut office hours and walk-in clinic hours because they get paid whether they work or not. Fee-for-service is part of the same free enterprise method Western civilization was founded upon."

STOP THE EXODUS
Dr Charles Shaver, from Queensway Carleton Hospital in Ottawa, has a novel idea to treat the shortage problem: retain docs who are thinking of retiring. As such, he was disgusted that no incentives for older doctors were included in the plan. Perks aimed specifically at retirement-age physicians, like free disability coverage and pension, are essential, he says. Doctors, like nurses, are exposed to diseases like SARS, AIDS and potentially the Avian flu, he says, but they don't have the same benefits. "Nurses are covered," he points out, "but doctors are not."

In light of these deficiencies, 56-year-old Dr Kents, for one, is seriously considering voting with his feet. "Alberta has answered my request for information about moving there with open arms and treated me with dignity," he says. "Ontario only treats us with disdain."

Check out Dr Shaver's guest editorial "We have a right to expect proper disability coverage".