August 3, 2016

President's Newsbrief

Current Environment and the tPSA

We, as individuals on the Board of Directors of the Ontario College of Family Physicians, reflect practising family physicians from across the province in various practice models, ages and stages of career and backgrounds. Together, we are guided by our vision that every Ontarian receive high-quality, coordinated, comprehensive, and continuing care from a primary health-care team led by family physicians and supported by an integrated and sustainable health-care system. This statement provides a framework for us to make decisions about what work the OCFP undertakes, and how we will support you as family physicians to do the work you do every day.
We have met as a Board to discuss what we know of the tentative Physician Services Agreement (tPSA) at this point in time and to try and understand what it means for family physicians and family medicine. While many family physicians may be disillusioned, angry, frustrated, resigned or confused by the way the tentative Agreement was reached, we must remember that it is the absence of an Agreement that brought about recent changes that were not informed by physicians. As a Board, we are committed to being part of informing the proposed changes that will impact family medicine and ensuring our members are heard and updated. We remain firm in supporting family physicians to continue to play critical leadership roles as we consider how to improve and sustain our health-care system for our patients today and into the future.
Tentative Physician Services Agreement Debate
Over the last few weeks, the discussion amongst our colleagues has centred on voting 'yes' or 'no' to the tPSA between the Ontario Medical Association and the Ministry of Health and Long-Term Care. The OCFP has maintained for months that the two parties should seek a negotiated agreement and we have respected the OMA's representative rights and their leadership in this regard. While we do not have a role in negotiations, we do have a voice about the importance of family medicine and what is needed to support family physicians to continue to provide high-quality care to patients and their families in communities across this province.
These past several weeks have presented an opportunity to hear more of the concerns of family physicians - about their practices, about Bill 210, about the way in which the cuts have impacted them. Many of you are weighing the pros and cons of the tPSA and have asked important questions during the OMA's town halls and tele-town halls. Many of us will have been part of discussions in our communities and in our clinical settings.

We know that changes are needed in Ontario to strengthen primary care in our communities. The status quo will not move primary care forward without meaningful family physician engagement and participation.
The Pros and Cons of the tPSA for Family Medicine
The tPSA is a high level "framework" agreement, rather than the kind of detailed contract that we may have expected. The framework provides challenges and opportunities. The OCFP has the same information as the membership - that which has been presented and made available online or through town halls. We have assessed and are sharing an outline of the potential pros and cons from a family medicine and primary care point of view, as well as other broad areas of the tPSA.
Overall tPSA framework
  • Ensures flexibility and opportunity to have ongoing discussions with the MOHLTC.
  • Lacks concrete details about downstream impacts and requires trust between parties when relationship is fractured.
Primary care transformation
  • Ensures family physicians will be engaged by re-establishing a relationship between the MOHLTC, LHINs and family physicians to discuss how we practice, and what resources are needed to serve patients.
  • Primary care transformation proposed by Patients First requires family physician engagement. There is no clarity about how family physicians will be engaged.
Family medicine graduate spots
  • Reverses restrictions around new graduates joining FHO/FHN models restoring available spots to pre-NGEP (New Graduate Entry Program).
  • The tPSA does not include the removal of the NGEP that was implemented outside of a negotiated agreement.
Bill 210 (Patients First Act)
  • On condition of making a commitment to amending contracts to improve access to primary care by Nov. 1, 2016, sections of Bill 210 will be amended or removed. These sections disproportionately impacted family physicians.
  • The removal of two sections of Bill 210 are conditional and there are no details about what needs to be included in primary care contracts for the sections to be removed or amended.
Unilateral action and ongoing cuts
  • Predictability through the funding guarantee for no further unilateral action and active monitoring as well as an ability to add funding for unforeseeable health issues (e.g. outbreaks, etc.).
  • No reversal of previous cuts imposed through unilateral action.
  • Provides an increase of 2.5% in funding for the global physician services budget. When combined with the one-time funding in two years of the contract, this is expected to be enough to meet the demands of our system from an aging and growing population.
  • Although the best projections provided to the OMA suggested that the amount of 2.5% with the addition of one time payments in each year will fund anticipated growth, there is no guarantee that that will be the case and any overages would be the responsibility of physicians to absorb.
Joint management of the Physician Services Budget (PSB)
  • Mandates co-management of the PSB providing physicians with ongoing joint decision-making. The co-management process proposes to address two important areas: 1. fee relativity which family physicians have requested for some time, and 2. physician supply and distribution which is an issue that has long needed attention in Ontario both for family physicians and specialists.
  • The tPSA requires $200 million dollars to be cut from the PSB in two increments each of $100 million (2017 and 2019) which would be permanent fee reductions. There are no details about the impact on primary care cuts specifically.
  • The "modernization of the schedule of benefits" as part of the co-management process is meant to address fee relativity, an area of great difficulty in Ontario and other jurisdictions. While a principled approach is outlined in the tPSA, the process is not clear.
OMA Charter challenge for Binding Arbitration (BA)
  • Allows the OMA to pursue the Charter challenge to attain BA at some point in the future. The duration of the contract is seen to be in keeping with the timeline for which a Charter challenge would likely be heard.
  • While there is a commitment to pursue the Charter challenge which would determine whether BA is an option, this agreement forgoes a previous commitment to ensuring binding arbitration was in place prior to a return to negotiation.
tPSA ratification/non-ratification
  • With tPSA ratification, there is opportunity to have more physician input into details such as improving access in primary care, amending Bill 210, HHR resource planning, identifying potential billing codes to remove from the schedule of benefits, and ongoing discussions about managing the PSB.

Risk of non-ratification may include:

  • More unilateral action and cuts, including mandating of access parameters by MOHLTC and reporting to LHINs.
  • No guarantee of a better agreement to be established.
  • Bill 210 proceeds through legislative process and may or may not be amended.
Moving Forward
As family physicians, we are used to dealing with uncertainty. It is part of what we do every day in our clinical work. Managing uncertainty is possible in family medicine in part because of the relationships we have - continuous and trusting over time. Managing the current uncertainty in our environment, particularly during this time of primary care transformation, will also be possible with a commitment to rebuilding relationships.
The critical issues in our health-care system that need to be addressed for the benefit of our patients are issues about which family physicians have a deep knowledge, informed by our experience of caring daily for the people of this province. Regardless of the outcome of the vote, we need to find ways to continue to be part of decisions about the system in which we work - the health-care system in which patients receive their health care.
Each of us has to make our own decision about how much risk we are willing to live with, and we also need to weigh this against the benefit of re-building the kind of relationship within which future uncertainty can be managed for the benefit of the patients that we serve. As you consider your decision about the tPSA, we encourage you to consider both the potential risks and opportunities.
Information about the details of voting at the OMA General Meeting of Members will come to you through the OMA.  Make your vote count and ensure that you either attend the General Meeting of Members, or entrust your new updated proxy vote to a colleague who can be there in person.   
Regardless of the outcome of the vote, the OCFP will continue to engage in important discussions about resourcing our work and shaping primary care, aligned with our vision. You have your College's commitment to support you in your role in practice, in your family medicine leadership roles and in your communities, and to represent your voice in regional and provincial discussions about how to manage our health-care resources more effectively to serve our patients.
Dr. Sarah-Lynn Newbery on behalf of the OCFP Board of Directors