In the ongoing debate regarding the new Physician Services Agreement (PSA), much has been made of the fixed annual budget in each year of the deal. The amounts are huge ($11.5 to $12.5 billion). This can make it difficult to grasp what it means for individual doctors. What is clear is that this represents almost a quarter of the health-care budget and more than 12 per cent of the total provincial budget.
Doctors are paid in many ways, with the two most common being paid a fixed salary or being paid for each service they provide (fee-for-service or FFS). Other physicians are paid through some hybrid of these two models, or other newer models of payment. Payment models are often based on type of patient seen (simple vs. complex), acuity (sick vs. less sick), level of expertise required, and time of day.
Many voting against the PSA argue that a fixed budget prevents physicians from providing necessary care to patients. No one is suggesting this. Patients who need care will be seen, necessary tests and surgeries will be done, family and specialist clinics will still see patients and physicians will continue to get paid to provide these services.
It is also important to recognize that the sustainability of the health-care system is an issue across Canada. With 42 cents of every provincial dollar being spent on health care in Ontario, this is a real concern that needs to be addressed.
No one on either side of the debate is arguing that changes aren't necessary or that the costs of the system are unsustainable.
So How Will the Budget be Achieved?
The ministry and the OMA have agreed to "co-manage" spending in the PSA. They have also agreed that if they can't reach agreement, a neutral, third-party facilitator will be present to make a binding recommendation. But what will they cut?
There are some "gimmes" right off the top. One example of this would be ensuring that tests and procedures are ordered in keeping with best evidence. In our practice back X-rays are a classic example of a test that is rarely needed.
There are many reasons these tests and procedures are done: out-of-date incentives in the fee codes, defensive practice, meeting patient expectations, or simply being out of date on the guidelines. By setting parameters on tests and procedures, there stands to be significant savings, both from a health system and physician payment perspective.
Times and technology have changed, meaning that tests and procedures that used to take hours can now be done in minutes. There is no question that this technology costs money and that physicians providing these services are highly skilled; however, the fees paid for these services have not been adjusted to reflect the current realities. Similarly, guidelines and parameters regarding how many physicians are required to participate in providing a given service, based on how sick a patient is and where the physician is practicing, have not been updated in more than a decade.
These are just three examples. However, no one on either side of the debate is arguing that changes aren't necessary or that the costs of the system are unsustainable.
Why Should Physicians Take This On?
Physicians are deeply committed to their patients and the majority are strongly in favour of Canada's publicly funded health-care system. The Royal College of Physicians and Surgeons of Canada, the certifying body of all specialists except family physicians, has identified that resource stewardship is a core competency of physicians. The College of Family Physicians of Canada has similar language articulating the need for family physicians to demonstrate "wise stewardship of scarce resources."
We, as physicians, need to take this responsibility seriously and to be accountable to ensure that current and future patients, continue to receive appropriate, evidence-based care. We need to ensure that our health-care system remains sustainable as our population grows and ages.
If the tentative PSA is ratified, the Choosing Wisely Canada campaign has given us a starting point for these discussions. Using the best evidence available, they have created guidelines and resources to "help clinicians and patients engage in conversations about unnecessary tests and treatments and make smart and effective choices to ensure high-quality care." This is what is truly required as we move forward, a clear partnership between government, physicians and patients build a better system.
If the tentative PSA is not ratified, it is likely that government will undertake this work on their own, without the insight and experience of physicians who see patients each and every day. Rather than the nuanced approach of a bilateral facilitated committee, they will likely follow the pattern of the last four years and arbitrarily make a combination of across the board cuts and cuts to fee codes that they see as driving cost, regardless of how necessary those services might be.
We continue to be hopeful that, despite its imperfections, Ontario's doctors will vote to ratify this PSA. This will demonstrate our commitment to being full partners with government in achieving the best care for our patients -- both now and in the future.
Neither of our views reflect the organizations for which we work.
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