What the Ontario government has done to physicians is so extraordinarily unfair that it is hard even for physicians to understand what has happened to them.

Throughout the long and arduous contract negotiation process the government insisted that it needed to set a maximum for the total amount it was prepared to pay physicians for their services, creating a “hard cap” on payments. This meant that, if physicians performed more services due to an increase in population and an increase in demand for services as people get older and sicker, the amount the government would pay for each service would decline.

The OMA resolutely refused to accept that physicians should be responsible for funding any increase in service to patients, and proposed many alternatives, including offering a three year pay freeze. The government declined this offer, and refused to go to binding arbitration. Instead, they imposed the settlement that they wanted.

So far, it seems that they have got away with this tactic, although the OMA is pursuing its legal options. If the “hard cap” survives a legal challenge the government may try to do the same to other employees.

Imagine if they decided to treat the teachers the same way. They would set a total amount that they were prepared to pay all the teachers in the province. If more children entered school, that would be the teachers’ problem. If there were more children who had special needs, that would be the teachers’ problem. If more teachers entered the system, then each teacher would be paid proportionately less.

There is no way any union would accept this imposition, but the OMA is not a union and physicians cannot go on strike, so we are an easy target.  The “hard cap” has been imposed and is in effect. So far we have been subjected to a 3.15% fee cut in February and a 1.3% fee cut in October. Further pay cuts seem inevitable. It is also important to remember that physicians have to pay for office expenses and hire staff out of these fees. If half of the fees you earn go to overhead, then a 5% cut in fees is a 10% cut in actual disposable income.

The actions of the Ontario government would be illegal if they were undertaken by any other employer. Only a government, which can write its own laws to make anything it wants to do legal, would dare do such a thing.

Where can we go from here? The OMA is pursuing legal options and conducting a public relations campaign. Both are worthwhile, but neither of which looks likely to succeed. There may be some protests and job actions, but the College of Physicians and Surgeons of Ontario severely limits physicians’ ability to act 1in any way which significantly impacts patient care. In theory, unions with the right to strike could realize that they may be next and come out on strike in support of the physicians.

In reality, it seems that the thumbscrews will be tightened even further throughout at least the term of Wynne’s government and maybe even longer. Physicians will complain, but never gather enough political momentum to overturn the current policy and get the binding arbitration they are morally, if not legally, entitled to.

In the long run, the government does have a point when they say that the current system is unsustainable. Only in Canada do we have a system which combines publicly-funded healthcare with a fee-for-service payment system for physicians. Other countries with public health care use salaried physicians to deliver care, so they have control of costs. Physicians who work on a fee-for-service basis outside Canada have to justify their fees either to the individual patient or to the patient’s insurance company.

We are approaching a huge and painful transition point. Eventually physicians will be on salary and paid by the hour, not by the volume of work done. This will transform health care. Physicians work out what is the best use of their time and what can be delegated, what procedures are really necessary and not just something they can get paid to do, and they will be able to spend more time with patients who really need them. Physicians will lose some freedom and flexibility, but they will gain paid vacation and study leave, health and dental benefits, and a secure pension.

If the government wants control over total payments to physicians, it needs to start hiring physicians who are paid a salary and who get benefits, rather than imposing an arbitrary cap on fee for service payments.