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Thursday, October 9, 2008

Coalition urges doctors to reject Ontario pay deal

As Ontario doctors vote this week and next on the proposed agreement between the Ontario Medical Association (OMA) and the provincial government, a vocal alliance of Ontario physicians announced it opposed the terms of the deal and asked OMA members to reject it.

“After extensive consultation with members of the OMA negotiating team and other leaders, and careful debate at our Board, we have decided to NOT SUPPORT the new deal,” wrote Dr Douglas Mark, the president of the Coalition of Family Physicians (COFP), on Monday in a letter to all Ontario physicians.

The proposed deal, which offers physicians a 12.25% increase in fees over the next four years (not adjusted for inflation), was announced in September after negotiations dragged on for more than five months after the last contract expired on March 31.

The COFP has produced a controversial analysis of the contract, which essentially says what will be seen in reality will be around half of the advertised numbers, and called the raise “sub-inflationary.” “In other words,” Dr Mark wrote, “if this deal is accepted, you will effectively be earning significantly less at the end of its 4-year term than at present.” (Canadian Medicine has reviewed the full proposed contract; our calculations project an inflation-adjusted total increase in fees by the contract’s end, in 2012, of around one-half of one percent, or 0.5825%.)

“A rejection of the proposed deal,” Dr Mark’s letter concluded, “will send a strong message to the government that we demand to be treated fairly and with respect, and we will no longer subsidize its political agenda with underpaid labour... What do you have to lose by voting no?”

The COFP’s analysis, however, has come under fire from an influential group of four physicians, three of whom -- Stephen Chris, Chris Pinto and Allan Studniberg -- are former COFP board members; the fourth is Dr Suzanne Strasberg, who was elected to the OMA board after a COFP endorsement in 2003 and who is now the OMA’s president-elect. All four currently serve as OMA board members from District 11.

In a letter to doctors dated Wednesday, October 8, the four doctors strongly counter the COFP’s argument. “We believe that the [COFP] analysis is misleading and inaccurate,” the letter said. The four doctors’ letter corrected the COFP on the 6% of fees it had alleged would not go to physicians, but failed to address the effect of the currently high Canadian inflation rate on the actual size of the contract’s proposed fee increases.

The four doctors’ strong disapproval of the COFP’s decision not to endorse this year’s proposed contract was evident in the letter: they referred favourably to “the COFP of our day,” and wrote, “… it is unfortunate that COFP has chosen to present the information in a misleading manner,” and ended by asking OMA members to read the contract for themselves.

In an interview with Canadian Medicine, Dr Mark admitted that he expects the contract to pass. But he disparaged what he referred to as the OMA’s “inaccuracies” in its messages regarding the contract and its “scare tactics” of warning that doctors ought to take this deal to avoid a protracted conflict with the Ministry of Health. “We urge you not to be guided by fear of rejecting this contract -- it already gives us nearly nothing, except the assurance that we will be worse off in four years than we are today,” his letter said.

Dr Mark’s letter contended that “the OMA’s best efforts are simply NOT good enough for the majority of Ontario’s physicians.” He accused the OMA of conceding to the government’s current desire to rein in spending as the economy founders.

In a letter announcing the proposed deal to members on September 15, the association’s president, Dr Ken Arnold, acknowledged, “This has been a difficult negotiation. Government took a very tough stance on a number of our priority issues.”

The OMA refused to comment for this story.

The COFP-OMA discord is not new. Founded in 1996, the COFP has been a vocal critic of the OMA, even endorsing “Coalition Candidates” in OMA board elections in order to push forward reforms. The conflict reached its height in 2003, when Dr John Tracey, who was then the Chair of the COFP’s Political Action Committee, won the election to become Ontario’s nominee as Canadian Medical Association president, beating out five former OMA presidents. But a surprise “nomination from the floor” during the CMA’s subsequent vote several months later -- which is usually nothing more than a rubber stamp -- resulted in a dramatic victory by defeated OMA past-president Dr Albert Schumacher.

The last set of OMA-Ministry of Health contract negotations, produced an initial rejection from by Ontario doctors in 2004 after the COFP opposed the deal. The COFP also opposed the revised proposal the following year, exhorting doctors not be afraid of what some feared would become an “all out war” with the Liberal government. “Conflict with government is not new,” Dr Mark insisted. Despite the COFP’s efforts, the 2005 proposal passed. Its expiry earlier this year, and the struggle to agree on how to replace it, prompted the current state of affairs.

The COFP has complained about the OMA’s “union monopoly” before, but this month’s war of words has reached new levels of enmity. Dr Mark’s letter earlier this week read, “We can only wonder why the OMA, our government-appointed and supported bargaining agent, has accepted this stance and urged us to accept the new deal... rationalizing that it is the best deal that we can get. It is time to re-examine the relationship of the OMA to government, its guaranteed funding by compulsory collection of our dues... bearing no relationship to performance as our bargaining agent, and the absence of a binding arbitration mechanism for dispute resolution... We need better negotiating and a better deal.”

In response to OMA president Dr Ken Arnold’s request for comments on the proposed deal, Baker & McKenzie lawyer Stewart Saxe, the OMA’s legal advisor, wrote in a letter on Tuesday that he believed the OMA “achieved a result that obtained from the Ministry ‘every nickel’ available.” “The state of the economy must also be considered,” he wrote, “although I believe this is a good deal regardless of the state of the economy.”

Voting on this year’s proposed contract ends October 15.

Photo: Shutterstock


  1. RE: Impact of an alliance on a coalition

    Take time to review the work of John Preece on this.

    Alliances must be clearly identified as to "purpose" ( learning, linking, leveraging, locking out or leaping)

    When they are using you for " leverage" are the "period" at the bottom of the exclamation mark ( ! ) ....thus great pressure is upon you to do as "they" want

    A coalition is a "linkage" relationship where strong statements are placed in a horizontal line holding equal weight with all others.(....) ...thus the pressure is balanced

    Didn't someone in this "alliance" say " what can you lose by saying "no"? (now... there's a red flag )

    Then again there is the quiet, organized world of " associations" with a free flow that makes room for alliances to " properly " form..........
    now..there's a thought :)

  2. (cont'd) and in the free flow environment fostered by associations you get alliances " leaning " on shared strengths......

    ...that is the best alliance of all

    From Dr Douglas Mark, President, The Coalition of Family Physicians of Ontario

    Good work. Thanks for your patience and the opportunity to provide you some insights.

    I enjoyed reading your economic analysis of the OMA/MOHLTC offer where you indicated interest rates were recently over 3%. Unfortunately, the actual fee increases in the deal are not as "advertised" by the OMA. Here's an excerpt from our Oct 6th bulletin again:

    First and foremost, this deal is about compensation for our work. As widely publicized in the media, the government has offered a 12.25% increase to our fees, distributed as follows:
    October, 2008:       3%
    October, 2009:       2%
    October, 2010:       3%
    September, 2011:   4.25%
    However, a closer reading of the proposed deal reveals that physicians would be receiving only one-half of these increases, with the other half earmarked for correcting intersectional relativity disparities using complex formulas requiring the co-operation of the MOHLTC and the OMA. A few specialties are promised significant additional funds while others will get nothing extra. Some specialties, including Family Practice, are said to expect average amounts. The  actual fee increases are therefore:
    April, 2008:              0%
    October, 2008:        0%           + 3% remittance advice top-up
    October, 2009:        2.5%       + ?
    October, 2010:        1.5%       + ?
    September, 2011:   2.125%   + ?
    I've confirmed that our illustration is correct.  There is no actual fee increase for 1.5 years.  It also shows that the majority of "increases" occur towards the end of the deal (back-loaded).

    Another thing you might want to keep in mind it that our OHIP fees are currently only about half of the OMA fee schedule.  Here's something on our website that illustrates the pattern in the past. Click here: COFP - general.

    Lastly, the whole reason why we are so concerned about this deal is that we believe it will further harm our physician profession putting our aging and growing population further behind the 8 ball when faced with accessing medical care in Ontario.

    There's one more thing you might want to include that one of our Board members found out official at an OMA Roadshow meeting in KW.
    OMA Economist Reveals Deal only worth 10.5% not 12.25%
    This OMA has attacked the COFP accusing us of inaccuracies. Well, perhaps they should look in a mirror.
    Last night, at another OMA road show, an OMA Economist revealed that the average fee increase is actually 10.5% not 12.25%.

    This can be explained simply. The last average fee increase occurs on September 2011 and only runs 7 months to the end of March 2012. Since the advertised final increase of 4.25% is only for 7 months, this works out to 4.25% x 7/12 = 2.5%. Add this to the only other fee increases October 2009 = 5% and October 2010 = 3%, in the previous years, and you get exactly 10.5%.

    Not such a great deal after all.

    Dr. Mark

  4. To read for yourself what is behind the dispute between the OMA and the COFP with regard to the exact percentages of the fee increase, see sections 3 and 21, reproduced below.


    3.1 For professional services rendered during the period October 1, 2008 to September 30, 2009, the monthly remittance advice payment will be increased by 3% of the value of services provided within this service period. Effective October 1, 2009, the 3% will be allocated by the Physician Services Payment Committee (PSPC) to the OHIP Schedule of Benefits, in addition to a 2% fee increase effective October 1, 2009.

    3.2 The Parties agree to the following global increase to the OHIP Schedule of Benefits, based upon the fee-for-service payments for services rendered in the year ending March 31, immediately preceding the effective date below:

    Effective October 1, 2009; 5% (five)
    Effective October 1, 2010; 3% (three)
    Effective September 1, 2011; 4.25% (four decimal two five)

    3.2.1(a) One-half of the increase each year will be allocated on an equal percentage basis to each OHIP Specialty.

    3.2.1(b) One-half of the increase each year will be allocated to OHIP Specialties by the Physician Services Payment Committee (PSPC), based upon a relativity methodology agreed to by the Parties. The PSPC is defined in Section 5.4 of the Health Insurance Act.

    3.2.2 The amount of increase allocated to each Specialty by 3.2.1 (a) and (b) will be allocated by the PSPC to fee codes billed by that Specialty or in the form of other payments agreed to by the Parties.

    3.2.3 The PSPC in making its recommendations, especially for 2009/10, will take into consideration the work done by the Medical Services Payment Committee (MSPC) prior to this Agreement, in identifying codes as deserving change. The MSPC is a committee established under the 2004 Physician Services Agreement.

    3.2.4 The MSPC shall carry out the mandate assigned to the PSPC until the PSPC is operational.

    3.3 The rate of increase provided for in 3.1 and 3.2 shall flow through to the following contractual payments, excluding administrative and other non-clinical payments, made directly or indirectly by the Ministry to physicians (excluding civil servants):
    • Funding agreements for clinical services entered into by the Ministry of Health and Long-Term Care including Alternate Payment Plans and Alternate Funding Plans
    • Primary care models, salaries, sessionals, capitation and Monthly Comprehensive Care Fee payments
    • Mental Health Sessionals, Sessional Fee Supplement, Psychiatric Stipend, Physicians compensation in Divested Provincial Psychiatric Hospitals, Physicians compensation in Assertive Community Treatment Teams, OPOP sessionals, Visiting Specialist Program and Urgent Locum Tenens Program for Specialists sessionals, and the Hospital Pediatric Stabilization Program
    • Fees for medical services listed in the OHIP Schedule of Benefits that are paid by Ministries other than the MOHLTC, on a basis that achieves comparable economic increases as the physicians paid fee-for-service receive under s.3.1 and 3.2 for such practice. Where there is no corresponding OHIP Specialty, the flow through shall be the unadjusted increases provided for in 3.1 and 3.2.

    Non-clinical payments include payments for teaching, research, the Academic Health Sciences Centre (AHSC) AFP Innovation Fund, recruitment, mentoring, honoraria, Hospital On Call Payments and HealthForceOntario (HFO) stipends.

    Where a contract does not distinguish between clinical and administrative or non-clinical payments, the Parties will agree to a flow through to be calculated upon no less than 80% of the total contract value.

    The PSC will adjust on an annual basis the maximum allowable OHIP billings for non fee service contracts to reflect general fee increases in this contract.


    21.1 This Agreement will begin on April 1, 2008, and will terminate at the end of March 31, 2012. Negotiations to establish the next Physician Services Framework
    Agreement will begin no later than January 10, 2012. The MOHLTC recognizes the OMA as the representative of the medical profession for the purposes of these negotiations. The Parties may mutually agree to utilize the services of the “Independent Facilitator” set out in Appendix “A” Physician Services Committee to assist the Parties in negotiations for a new agreement in 2012.

  5. I'd like to correct an error in Dr Mark's letter.

    The OMA economist's alleged claim that "the average fee increase is actually 10.5% not 12.25%" is not an accurate way of describing the deal.

    The third fee increase proposed in the contract, which is to take effect October 2010, will expire after 11 months. And the fourth, which takes effect September 2011, lasts just seven months. (The contract expires at the end of March 2012.)

    Taking into account the contract's proposed fee increases and the unbalanced terms of the contract's four separate periods, the breakdown in increases in absolute income is:

    *October 2008 to October 2009: 3%
    *October 2009 to October 2010: 2%
    *October 2010 to September 2011: 2.75% (3% over a term of 11 months)
    *September 2011 to April 2012: 2.5% (4.25% over a term of seven months)

    So, the 12.25% fee increase by April 2012 actually means that absolute income will only rise by 10.25% -- slightly less than what Dr Mark wrote.

  6. Apart.....
    from the genuine angst that the rest of the world experiences as "one vocation" in particular negotiates with their source of " guaranteed " payment ( ho hum).....

    May I refer to.....

    Dr. Marks reference to the " aging" and "growing" population ( which is better stated as "growing aging") it would be worthwhile giving this article a read on whether " that population is:
    (a)even being asked
    (b)answers recorded
    (c)assumptions challenged

    Here is the document

    Now, just by chance, you have tapped into MY principal field of activity ....and if you think the " aging" population has the same respect, admiration and trust of doctors that they once had.... think again!

    And if you think they blame the government instead of the doctors ..... think again!

  7. An important feature of the agreement was to create a bilateral negotiating committee, the Physican Services Committee (PSC), which uses evidence to enhance the decisions made at the bargaining table. Since then, the agreement has been revised several times. As well, other provinces, such as British Columbia, have followed Onatrio's lead in creating Physicians Services Committees as the vehicle for negotiating physican payment levels.