OMA Negotiations: Pay For Results
After a generous settlement in 2008, the Ontario government bought four years of relative harmony with the province’s doctors. However, the province’s dire fiscal situation and on-going concerns about care quality make the 2012 negotiations the most important in memory. We offer here our prescription for a successful round for physicians, patients and taxpayers.
The Premier has signalled publicly that the government is looking for an overall compensation freeze for physicians. With important caveats, we believe this is the right starting point. Ontario’s doctors are well paid. Their compensation leads the country and there is a net migration of doctors back from the United States; hence a future mass exodus south of the border is no longer a worry. Also, we cannot afford more spending on healthcare as a society unless we are prepared to continue beggaring other important societal objectives like quality education and public transit.
Pay for Quality Care
Now the caveats: The government should provide incentives that lead to improved access and quality of care. The move to create family health teams (FHTs) was the right one. Larger practice groups provide better care and inter-disciplinary groups that include nurse practitioners, dieticians, pharmacists and other clinicians provide better care more cost effectively. However, the Ministry moved very tentatively in establishing FHTs, missing an opportunity to create cultures of accountability and a focus on results. In this round, better outcomes, including productivity, need to be recognized and rewarded. Other methods of patient consultation such as phone calls, e-mail and remote patient monitoring (telehomecare) should be encouraged and compensated accordingly.
There is strong evidence that better quality care is linked to large groups of physicians practicing together. Payment schemes should be adjusted to encourage group practice and discourage solo practice. Practice groups should provide on-call coverage as an integral part of their practice.
As a system, we are also slow to innovate in providing better clinical care. We generally understand the essence of good care, but we do little to encourage providing it consistently. Group practices should be eligible for bonus payments if they meet certain criteria. These criteria should include a basket of known quality of care initiatives, including meeting target routine screening measures and best practice care interventions for chronic diseases such as diabetes. There should also be a requirement for consistent use of electronic medical records so the quality of care can be confirmed and evaluated.
We have known for years that handwritten prescriptions are unsafe. A reasonably aggressive date should be set in this round after which handwritten prescriptions will not be accepted by pharmacies. 2015 seems reasonable. This will require the completion of EMR adoption and also electronic links to pharmacies. These are worthy investments, as drug errors are major drivers of demand for emergency services and acute care admissions.
Share Productivity Gains
Technology has fundamentally changed practices for specialties such as radiology, ophthalmology and cardiology. Digital imaging and PACS systems have improved productivity dramatically for radiologists; advances in cataract surgery have done the same for ophthalmologists. What are the implications for improving care in other areas that can be derived from the convergence of different technologies? These advances have been made possible by innovation, but also because of taxpayer-funded investments. Taxpayers need to share in productivity improvements, not simply enrich already well paid providers. A balance is required, because we want to keep incentives in place to continue to innovate and improve.
Looming Physician Surpluses?
Last year, Ontario registered as many new physicians who were international medical graduates (IMGs) as it did physicians who graduated from Ontario medical schools. At the same time, record numbers of Ontario students are being trained abroad in the hopes of coming back to Ontario to practice. This is an extraordinary shift and one that needs to be watched closely. This is occurring at a time when large increases in Canadian medical school enrolments in recent years are resulting in larger graduating classes. The prospect of unemployed (or at least underemployed) physicians in the next decade is a very real one. There is also a serious physician distribution problem across the province, with oversupply in some locales and specialties, and significant shortages in others.
Today, newly qualified physicians receive an OHIP billing number automatically. A rookie doctor bills the same rates as a world renowned expert in an academic medical centre. Both of these policies need to be reconsidered. Perhaps new physicians should practice in areas of the province where there is a demonstrated need for their services and should receive conditional billing numbers. Differential pay based on demonstrated quality and experience would also allow the government to control cost increases while rewarding quality at the same time. Less emphasis on the volume incentive inherent in fee for service payment in favour of incentives focused on quality and customer service will result in better care.
Cozy or cool?
Some worry that the relationship between the Ministry and the OMA is too cozy, and point to a recent high-level appointment by the OMA as well as a highly protective attitude on the part of the Ministry when access is sought to physician billing information. While we share these concerns, there are also areas where the government can work more effectively with the OMA to effectively advance its policy agenda.
Ontario MD is a good example. Charged with speeding the implementation of electronic medical records in physician offices, Ontario MD (which is controlled by the OMA) has done a good job of creating system standards, certifying software vendors and supporting effective implementation. Their credibility with the physician community has led to better results than government-led initiatives in other provinces.
If the OMA behaves like a traditional trade union, pandering to its most militant members, it should have no more call to influence the policy agenda than any other union. However, if the OMA is prepared to seriously pursue a quality of care agenda in concert with the Ministry, this should be welcomed.
The government has an excellent opportunity in 2012 to both improve access and quality of care for Ontarians while at the same time helping to secure the sustainability of medicare and the Province’s finances. These essential policy goals can be accomplished if additional funds for physician compensation are limited to payments for quality that acknowledge the physician’s central role in healthcare delivery. If physicians manage chronic disease more effectively and increase the safety of medications, demand growth for acute care services will be substantially reduced.
It is an ambitious agenda we have outlined, but one that we believe is essential to pursue. Without it, sustainability will remain elusive.
About the Author(s)Dr. Peter Walker is past Dean of Medicine at the University of Ottawa, Dr. Michael Guerriere is Chief Medical Officer of TELUS Health Solutions. Correspondence to Michael.Guerriere@telus.com. | October 25, 2011
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