Doctors’ contracts are about central planning, not incomes: Ontario’s PPSA

Physicians frustrate governments. Doctors think too little about how much care costs and too much about patients who need help. The government of Ontario and the Ontario Medical Association arrived at a mediated Proposed Physicians Services Agreement (PPSA) this month. Doctors vote on it on March 22 – 27. On March 28, we find out whether doctors will accept the agreement or send it to arbitration. Labour negotiations give government its best chance to manage the $14 billion spent in Ontario on medical services (2020-21). Contracts offer a way to control doctors’ behaviour. Medical services agreements are the heart of central planning in Canada. Read: Dr. Shawn Whatley: Bossy doctors: 7 reasons why some docs are bossy A mediated PPSA Government does not care about doctors’ incomes, nor should it. When it comes to medical services, government cares about spending and access. When it comes to negotiations, politicians care about labour peace and avoiding awkward headlines. Doctors and government negotiated (fought) through much of 2021 to arrive at a mediated labour contract, which covers April 1, 2021 to March 31, 2024. The PPSA throws another $1.1 billion at doctors over the next three years. Total spending on physician services should reach $16.2 billion by 2024, an estimated 4.8% increase. Spending always takes centre stage in negotiations. Government demands predictability. Doctors demand spending based on patients’ needs, not budgets. The two sides rarely agree. After fighting about funding, labour talks turn to focus on how fees direct care. Consider virtual care Pre-COVID, government refused to pay for virtual care except on its clunky, time consuming Ontario Telemedicine Network platform. Very few doctors bothered with it. COVID forced government to pay for virtual care beyond government’s preferred platform. As expected, patients loved being able to speak with their doctor on the drive to work instead of taking a day off work to meet in the clinic. Government hates the idea. Calling your doctor anytime from anywhere is far too easy. Canada rations care with wait times, limiting investment in technology, and by using family doctors as “gatekeepers” to service. Virtual care not only removes essential brakes on spending it adds grease to the rails. But now the public has a taste for virtual care, and government knows it. So instead of blocking virtual visits, government took steps to limit access and put the brakes back on the spending train. Virtual visits must be by video to qualify for full payment. Telephone calls only receive 85% of the posted fee. No more convenient calls while commuting to work. Government insists that video adds value— never mind the camera could be out of focus or pointed at the ceiling. During the pandemic, many elderly patients could not figure out how to allow incoming calls from a ‘No Caller ID’ number, never mind managing an iPhone. Government’s trump card As inflation runs over 5%, the PPSA might be one of the worst offers doctors have ever seen. Just before the pandemic, government passed Bill 124. Public sector salaries remain capped between May 1, 2020 and April 30, 2023. Protecting a Sustainable Public Sector for Future Generations Act, 2019, has a “moderation period (which) mandates increases be limited to 1%.” Bill 124 does not mention physicians. However, physicians do fall into the public sector. Upside-down labour law Physicians run small businesses. Office overhead consumes around 40% of total billing. General inflation runs over 5% currently, but inflation on medical office overhead has outpaced general inflation for several decades. Boards of arbitration care about perceived labour fairness, not office overhead. Medical contracts turn labour negotiations upside down. In other sectors, labour contracts centre on salaries and benefits. Salaried workers want more money, and management wants to give workers less. Overhead is irrelevant. In Canada, the tables are flipped. Management (government) is salaried, and labour (doctors) are self-employed. In medical negotiations, labour cares about overhead, and labour lawyers don’t seem to know what to do with it. It seems to short circuit their usual mindset. The government’s response to any mention of overhead has always been the same: doctors can work harder, if they don’t like the contract. This is like telling workers to get a part-time job—absurd in any negotiation outside medicare. Arbitrators seems to think it makes good sense for doctors. Micromanaging medicine The PPSA offers too much for one post. In the next blog, we will look at how the PPSA attempts to direct how doctors run their private clinics. For example, government wants to control whether doctors provide online booking for appointments. Government also wants to dictate whether doctors deal with a patient’s whole list of problems in one longer visit. Longer visits mean fewer appointments: how do we know doctors aren’t slacking off? Better to drag patients back for multiple visits—much easier to measure. At some point, voters need to break the iron triangle between government, the medical profession, and labour groups. Patient care seems too important to suffer under central planning. Change starts with realizing that contracts are about control, not incomes. P.S. In the next post, we will also tackle whether doctors should vote YES, to stop the beatings, or NO and risk even worse at arbitration. Shawn Whatley is a practising physician, the author of When Politics Comes Before Patients—Why and How Canadian Medicare is Failing, and a senior fellow with the Macdonald-Laurier Institute. He is also a past president of the Ontario Medical Association.

Doctors’ contracts are about central planning, not incomes: Ontario’s PPSA

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