Thousands denied eye care amid optometrist dispute
Children, seniors shut out for weeks in long-standing battle with province over OHIP fees
Even when she squints, Dunia Katoub, 10, can’t see what her teacher writes on the board at school very well. She needs an eye exam, but can’t get one, despite her parents’ best efforts.
She’s one of thousands of children, teenagers and seniors who have been denied eyecare amid the ongoing fight between Ontario’s optometrists and the provincial government.
When she’ll be able to get checked depends largely on when the Ministry of Health reaches an agreement with the Ontario Association of Optometrists, which stopped providing services on Sept. 1 over long-standing funding disputes.
The start of school made it clear Dunia’s eyesight had deteriorated and she needs a new prescription, said her father, Mohamad Katoub. He began calling optometry offices around Kingston, where his family lives, to schedule an appointment, only to be rejected over and over.
Finally, he snagged one through an online booking system at a clinic that seemingly had open slots. When they arrived Saturday, they were informed the optometrist wouldn’t see Dunia. The receptionist explained optometrists all over the province are not examining OHIP-covered patients, because of a job action protesting inadequate government funding.
“Dunia was feeling that she was abandoned from a service that she deserves,” Katoub said. “She was expecting that this problem would be solved this week … She needs to see, and to have the same vision like her colleagues.”
Katoub offered to pay out of pocket but was denied; it’s illegal in Ontario for optometrists to accept personal payment, private or workplace health insurance for OHIP-covered age groups.
Dunia’s teacher has moved her to a chair closer to the front of the class, but there are materials she can only read with help from friends at school, her father added. On Monday, Katoub called his walk-in clinic and asked to see a doctor for a referral to an ophthalmologist. The clinic refused his request, and suggested he take his daughter to an emergency department.
While adults pay for eye exams out of pocket or through insurance, exams for kids and seniors are covered by the Ontario Health Insurance Plan. The money OHIP pays the optometrists per exam has barely budged over many years and now covers about half the costs. The Health Ministry says its proposals are reasonable, including a lump-sum payment.
Katoub is a dentist, humanitarian activist and research fellow at the Syria Impact Study at the University of California, Berkeley School of Public Health. Having researched and experienced issues like this one becoming politicized “to the highest level” in Syria, he was “shocked” to find his family feeling the impact of a political health-care clash in Ontario.
“I didn’t expect the government would ignore the demands of a group who are providing valuable services for people, or that the health-care workers who are providing the services would just cut the service because they are not receiving what they want,” Katoub said. “This is the health of our children.”
Sheldon Salaba, president of the Ontario Association of Optometrists (OAO), said he empathizes with families dealing with lack of access to eyecare. But it took the withdrawal of services to convince the government to react and hopefully fix “a broken system,” he said.
“For those people who are experiencing delays, I apologize to them. We don’t want to do this to them.”
The OAO estimates a 95 per cent average participation rate in the job action by optometrists. Roughly 250,000 appointments have been cancelled since Sept. 1, with around 15,000 examinations being cut daily, and the province is seeing delays in referrals for cataract surgery in the range of 2,000 a week, Salaba said.
After the Health Ministry declined a proposal to work with the OAO on a study reviewing the operating costs of optometry offices in the province last December, the association said it commissioned an independent study by a national accounting firm (BDO). The firm determined the average operating cost to provide an eye exam in Ontario was $75.51 in 2019, not including the doctor’s compensation.
Overhead cost can vary by region, said Hamilton-based optometrist Tyler Brown, but typically ranges between $75 and $80. In downtown Toronto, it can reach $95, whereas in more rural areas it’s closer to $70, he said. That number reflects mostly staffing and rent expenses. Another big factor is the price of purchasing and maintaining expensive instruments used for eye exams, like OCT machines that scan the back of the eye and layers of the retina for disorders and can cost hundreds of thousands of dollars.
Under the current cost structures, the province reimburses 55 per cent per OHIP-covered eyecare exam, forcing optometrists to pay the remainder.
That brings the total reimbursement to around $44, if the operating cost is $80. In 1989, the province paid about $39 per exam, so the change to funding over three decades is around $5.
All of the OAO’s requests for the ministry to address the underfunding, enter a formal negotiation process, and “at minimum” cover the operating costs of delivering services were ignored, Salaba said. So on March 30, 96 per cent of Ontario optometrists voted to stop performing OHIP-covered eyecare services starting in September, unless the government agreed to binding negotiations.
In August, there was a virtual meeting and two days of mediation. Then, on Aug. 17, Health Minister Christine Elliott issued a statement. She announced a proposed lump-sum payment of $39 million to Ontario’s roughly 2,500 practising optometrists, which the ministry says would cover a retroactive period over the past decade.
Salaba said optometrists performed 34 million services in the last decade, so the one-time retroactive payment averages just over $1 per optometry service.
“That wasn’t a negotiated proposal. It’s not something we’re asking for and I think it’s a big waste of taxpayer money,” he said. Salaba added the public release of the offer discussed in the mediation session was badfaith bargaining.
“They’re playing games right now.”
On Aug. 23, Elliott tweeted an open letter to Ontario’s optometrists. It outlined proposals to the OAO in addition to the $39 million, including a commitment to a joint working group supported by a mediator and an increase of 8.48 per cent at the fee code level.
Like other health providers, optometrists must enrol for the Medical Claims Electronic Data Transfer Service, which allows them to submit claims electronically for reimbursement of OHIP-insured services. The claims are submitted using fee schedule codes, which represent the service provided. They submit those claims typically once a month, Tyler Brown said. The government then reviews the claims and provides reimbursement upon approval.
The proposed increase of 8.48 per cent at the fee code level means the ministry is willing to reimburse optometrists an additional 8.48 per cent for each service they deliver. This does not include the optometrist’s payment for the service, or reach a funding level that covers the operating costs for these services. It would only move the average reimbursement for an eye exam from around $44 to $48, requiring the average optometrist to still pay more than $30 to examine an OHIP-insured patient, Salaba says. It leaves the province far behind others in government funding for seniors’ eye exam services specifically, he added.
In Manitoba, the province with the second lowest funding, the government reimburses $77.18 of the total cost. To equal Manitoba, Ontario would have to raise compensation by 65 to 70 per cent, Salaba said.
The province hasn’t contacted the OAO since the start of the job action, he added.
A ministry spokesperson said Wednesday the OAO recently declined a third-party mediator’s conditions that would allow the parties to resume mediation.
The spokesperson added the “fair and reasonable” proposal put forward “is designed to take immediate action to address years of neglect and represents a starting point for further discussions.” As the ministry waits for the OAO “to return to the table,” optometrists will receive $39 million as part of their October OHIP payments, regardless of whether a deal is in place, the spokesperson said.
The College of Optometrists of Ontario policy for services during job action states they should help patients “make alternate arrangements, which can include referring patients to another care provider.”
Salaba said there’s currently no trust between the OAO and the government that would encourage the association to enter the proposed arrangement. The optometrists won’t end the job action until the government commits to ensuring the operating costs of eye exams are entirely covered, and that the province will not “be funded the worst in the entire country,” he added.
Catching visual disorders and issues at a young age, ideally under 12, is critical, Brown said. If early intervention doesn’t happen, a problem can persist for life. As well, 80 per cent of learning is visual, meaning kids’ education and development is affected, he added.
For seniors, optometrists aim to catch degenerative changes and conditions that if not caught early on through routine examination, can harm the quality of the lives of the elderly even leading to blindness, Brown said.