On a backdrop of mistrust, accumulated over years of disagreements and a recent history of unilateral cuts (ranging from a five to 30 per cent decrease in income depending on the specialty), tensions are rising. With an upcoming referendum on this agreement, serious discussions about the future of health care in Ontario need to happen. As a new graduate in family medicine, poised to start my own practice in a few short weeks, here's my attempt to make some sense of what is going on.
The proposed agreement promises a 2.5 per cent annual funding increase in the total amount of money that goes towards paying for services rendered by a doctor in Ontario. Estimates of the actual need are between 1.9 and 3.1 per cent, and inflation in Ontario is on average about two per cent per year. Whether 2.5 per cent is enough is up for debate. To make up this difference, extra lump sum payments are available each year if needed, and if that amount is exceeded, more cuts will happen.
Think of it this way -- you were given $500 to plan the work Christmas party, and told if you keep it under that price, there will be an extra $100 to replace the broken office coffee machine.
- Scenario 1: you stay within your budget everyone enjoys delicious coffee.
- Scenario 2: more people show up than expected and you go over by50. You don't have enough for a coffee maker, but get a kettle instead.
- Scenario 3: everyone wants to come and you overshoot by150. No one gets coffee, and next year's party is cancelled to make up the cost. It's not your fault that the party was so popular, but maybe you should have ordered less food or put a cap on the number of people who could come.
Most importantly, doctors have been told that under this agreement $200 million will need to be cut over the next four years. Doctors don't have any control over the number of people who show up at their clinics and hospitals, they simply care for those they see.
Here are the options Ontario's doctors have been given:
- Treat fewer patients.
- Stop offering certain treatments.
- A pay cut for all doctors (MOH has unilaterally done this already, three times in the past few years).
- Figure out among ourselves which specialties get a pay cut and by how much. Should a cardiac surgeon replacing a heart valve be paid more or less than an orthopedic surgeon replacing a hip? Should specialists who manage a limited subset of issues, although they have three to five years of additional training, be paid more or less than family physicians who manage the whole spectrum of health issues as well as do routine and preventative care?
- And then we have the more complicated choice -- addressing the systemic problems. Work together to look for ways to cut costs. Do quality improvement. Support other health professionals to safely take on some aspects of patient care. Flu shots at the pharmacy, or have more nurse-practitioners doing chronic disease group programs for things like diabetes.
Put the focus on prevention. Make an effort to exercise and eat well, so that less people need care for preventable diseases like diabetes, heart attack and stroke.
Part of this strategy includes something that makes us all uncomfortable and would make any politician unpopular very quickly if they ever suggested it: patient, government and physician accountability. We all take responsibility for making our health care system sustainable. Seems simple in principle, but what would that really look like?
Put the focus on prevention. Make an effort to exercise and eat well, so that less people need care for preventable diseases like diabetes, heart attack and stroke. Get your HPV vaccinations to decrease the number of women with cervical cancer and men with anal cancer. Practice safe sex to stop the spread of infections like HIV. Be responsible with contraception to prevent unwanted pregnancies. Wear sunscreen. Don't drink and drive. Don't use the emergency room for a cold. Don't go to two different walk-in clinics because you were diagnosed with a viral infection by the first one but really felt you needed antibiotics. Don't smoke. Include physiotherapy (leading to less opioid prescriptions and surgeries needed) and mental health counselling under OHIP, really work on improving the social determinants of health for everyone, mandate vaccinations and cancer screening -- to name only a few of the possibilities.
Or if we as a society don't want to impose healthy lifestyles on everyone, maybe a co-pay ($5? $10?) for unnecessary visits to the emergency room, or for every doctor's visit, or for people who make over a pre-determined amount of money each year. Or maybe hold people partially financially accountable for their part in the development of preventable medical conditions (I know this is an unpopular idea, and difficult to define).
The question of whether or not doctors ratify the current proposal between the OMA and the MOH is almost irrelevant.
If they vote NO and demand more money to fund the system, patient care won't be affected immediately, but in a few years we will be right back in the same situation -- not enough money, too many sick people.
If they vote YES, a variation on one of the above scenarios will play out. But if preventative care, social determinants of health and patient accountability are not a priority, and a national, or at least provincial discussion on what we as a society feel "universal" health care means does not occur (is in vitro fertilization included? Second or third opinions?), we may delay the collapse of Ontario's publicly funded system, but ultimately the next generation will be having these same arguments in 30 years.
Here's what I propose we think about -- what can each of us do to make this system work? Let's find a way forward that is fair, focus on funding the things that keep people healthy, and keep tackling the social determinants of health. Think about what you can do to improve your lifestyle, about if you really need to be seen in the ER or if you can wait to see your family doctor, about getting your flu shot, about lighting up that cigarette. Let's all agree that we are responsible for the state of our healthcare system, and let's all start doing our part. Or don't. Making sure our kids have health care when they get old isn't that important -- is it?
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