Doctors looking for fair treatment
Next premier faces significant challenges and no easy answers in health care
“... health care is a field of incredible silos” — editorial, Toronto Star, May 19, 2018
Certainly whoever wins the Ontario election must take a fresh approach to health-care delivery. This topic was discussed only briefly during the leaders’ debate on May 27, although 76 per cent of CARP members recently ranked health as their top priority. Ironically, though Premier Kathleen Wynne’s father was a physician, she did not mention “doctors” again, even though they are the gatekeepers to our health system. PC Leader Doug Ford did applaud them and indicated that he would seek input from them. Andrea Horwath also barely mentioned MDs except to threaten them with higher taxes.
Ontario now has 77,500 nursing home beds. In the next five years, the Liberals would open 5,000 new long term beds; the NDP and PC parties promise 15,000. In the next 10 years, the Liberals and PCs pledge to build 30,000 and the NDP 40,000 LTC beds. No one has indicated how these would be funded. Also, more immediate action is required, Fortunately, Ford promises to listen to front-line doctors and nurses. As someone who has been “in the trenches” since 1974 in Ottawa, let me offer a couple of concrete suggestions:
Several years ago, then Liberal health minister Dr. Eric Hoskins arbitrarily cancelled the E078 fee for general internists, cardiologists, nephrologists, and gastroenterologists. This had been in existence for 10 years, increased followup visit fees by 50 per cent, and allowed these specialists to spend extra time on patients with some 30 “chronic diseases” such as diabetes mellitus, congestive heart failure, and dementia.
A quarter of Canadian seniors are taking 10 or more types of medications. Thus, at each visit, there should be a drug reconciliation to see what has changed since the previous assessment. Ideally, there should be a thorough history and physical examination; drug interactions and side effects should be explained. Sodium, carbohydrate, or fat restrictions in the diet should be clarified.
It thus made no sense then or now and was short-sighted for Hoskins to unilaterally cancel the E078 fee — an excellent example of “silo-thinking.” In the past, the existence of this fee likely prevented many patients from developing complications from their underlying illnesses or from their medications. Cancellation of the E078 could well have caused a number of desperate patients to swamp emergency departments with diseases now requiring a prolonged stay in hospital. This was not on Wynne’s “sorry” list during the debate.
Across the province, chronic patients remain in what should be acute hospital beds. This results often in cancellation of elective surgery and prolongation of wait times. In cities such as Ottawa, emergency departments sometimes are lacking nurses to take over the care of patients newly arriving by ambulance, resulting in a shortage of available ambulances over the entire city.
Home visit fees should reflect the time and effort to do this work and more competitively remunerate family physicians. These visits often entail advance care planning and discussions about goals of care. If not seen at home, these patients may decompensate and end up in emergency departments.
I suggest that in the short term, the E078 fee be restored for these four subspecialties and that proper incentives be given to doctors who are willing to do house calls. Both of these suggestions admittedly do require increased upfront funding, but result in much greater savings subsequently if patients can be kept out of emergency departments and are not admitted.
One in 13 residents of Ontario lacks a family physician. It is easy for candidates to promise a sudden increase in the number of health professionals. Yet all parties should recall that if these persons are to be encouraged to come to and remain in Ontario, they must be treated with respect and fairness.
Ontario MDs have been without a contract since March 31, 2014, and have suffered from major fee cuts and income clawbacks. Some have been forced to lay off staff or close clinics. They are now patiently awaiting the results of binding arbitration later this year. Fairness dictates that the provincial government respect the eventual decision, and not nullify it by subsequent legislation.
The Ontario top marginal federal/ provincial income tax rate is already 53.53 per cent — the second highest in the U.S. and Canada. Yet Horwath expects the “rich” to pay “a little bit more.” This will likely eventually affect most persons who now consider themselves just upper middle class. There are not enough “rich” persons to fund all of her new promises — particularly when the total Ontario debt is over $310 billion. Any promise of improved physician manpower will certainly not take place if doctors are now threatened with future punitive tax increases.