Progressive doctors condemn opting out

By Rhonda Sussman
Toronto Clarion, May 7, 1982

As the Clarion goes to press, the Ontario Medical Association (OMA) has reached a tentative settlement with the government over doctors’ fees. The OMA organized walkouts and postponements of elective surgery throughout the province last month.
The conflict began last December, when the OMA, representing 15,000 doctors in negotiations with the government, demanding a 20 per cent increase in fees. The government offered 10 per cent.
But what many progressive doctors believe is really at stake is our socialized health care system, which is being undermined by doctors opting out of OHIP, and charging more than the established rates for their services. The Clarion recently spoke with Toronto physicians Miriam Garfinkle and Fred Freedman, members of the Medical Reform Group of Ontario.

What is the Medical Reform Group?

Freedman: The Medical Reform Group is a group of a couple of hundred so-called “progressive” medical students and physicians as well as other people who are interested in the health care system. We have three basic principles, and they are: health care is a right that must be guaranteed without financial or other deterrents; that physicians must take into consideration the social, economic and environmental roots of disease and health; and that the health care system must be changed to provide a more significant role for health care workers and the public.

What is behind the current conflict between the Ontario Medical Association and the government?

Freedman: The obvious part of the dispute is over fees. There is some evidence that doctors have fallen behind since 1973 or ’74. Doctors’ real incomes have probably dropped slightly, but that’s because there was a great leap in doctors’ incomes in 1971 when OHIP was introduced, eliminating reduced fees. This was an artificial hike, and now it’s fallen back down in relation to the average industrial wage, and is roughly four-and-a-half times that average wage.
And I think the other thing behind the dispute is the issue of opting out, although it’s not come forward. I think doctors are trying to push the government to increase the amount of privatization of health care and health care insurance, and I think the government is interested in doing that by raising the monthly premiums which increases the amount you pull out of your pocket, which is not income-related, and so is not progressive taxation. And also by having hospitals provide services they can charge extra fees for.

Garfinkle: There’s a vicious circle going on, too. The provincial government is trying ways to fund themselves because they’re losing funds federally. And so what happens is that (the provincial government) puts more stress on things like user fees and privatization. It’s a vicious circle in that federally, [Health Minister] Monique Begin is quite progressive in that she’s willing to cut out opting out and this stuff, but unless they’re willing to fund it, it doesn’t solve the problem of where the funds come from. The provinces are now trying to find ways of not increasing their budget as well, so user fees become a way for the provinces to get out of increasing their health care spending. There’s a whole economic backdrop as well, not just doctors’ fees.
The general trend is towards privatization, which I think is a real threat to people, especially in these economic times. We’re in a recession, people are becoming unemployed, their incomes are dropping, and doctors are asking for more; more of them are opting out.

Freedman: The other thing too is that doctors don’t have to abide by the contract, they can opt out. So the OMA can sit down with the government and they can argue till the cows come home and decide 11 per cent, 14 per cent, and then 20 per cent of doctors can decide anyway that’s not enough and opt out.

Garfinkle: The thing with doctors is, they’re not a union, they’re just not. Medicine is run as private business, you have your own practice. I don’t consider this a real strike; I consider it more of a withdrawal of services. Doctors are trying to have the best of both worlds, they are trying to pretend that they are unionists, that they have the right to strike, when in fact they are small business-people. It’s not clear-cut what economic position doctors are in society. They get the best of both worlds; they get private control over their working situation, and yet they get medicare. And when they don’t want medicare, they get to opt out of medicare. They get everything and they want everything....
Personally, I’d like to be on salary. I think the fee-for-service structure is absolutely ridiculous. I get underpaid because of fee-for-service because I tend to spend more time with each patient, I don’t increase my working hours to make up for it, as most doctors do, I don’t work 50 hours a week because I think that’s bad for you and your patients.

What kind of alternative to the present system would you like to see?

Garfinkle: I would like to see more a salaried-type thing, though most doctors, I think, wouldn’t want that.

Freedman: There are increasing numbers of young doctors who I think would be prepared to take a salary.

Garfinkle: There are two ways of getting a salary. One is called capitation, which is what the government is actually encouraging doctors to try. It means paying doctors a monthly fee per patient, and that means whether your patient comes to you that month or not, you’re paid according to how many patients you have on your roster. If your patient uses another facility, like an emergency department, or goes to a parallel service, or to another family doctor, you’re not paid for that month. You’re penalized actually, it’s taken off your payment.

Freedman: The idea being is you provide good health care, they come in less frequently. On the other hand, because you’re paid per head, the more patients you have, the better it is for you. You still have revolving-door medicine.

Garfinkle: What community clinics have found is that it (capitation) is not good for lower socio-economic groups who use their health care services more because they have more health care problems. It makes doctors want to set up in a middle-class area.

Because, under capitation, doctors will want more patients who visit infrequently rather than fewer patients who make more visits?

Garfinkle: Right. Which discriminates against the poor, the elderly, and women, all of whom tend to use health services more.

Freedman: The other alternative would be a straight salary, which is called global budgeting, where they say, you’ve got three doctors in this practice, a receptionist and office expenses, here's $100,000 a year to run your practice.

Is there any for doctors, other health care workers, and the general public to work together to protest the deterioration of health care?

Freedman: There’s the Ontario Health Coalition which is a loose coalition of labour unions, health care workers and some teachers. Unfortunately, the group is rather inactive right now. One thing that concerns me is the tremendous lack of involvement on the part of the public around the opting-out issue.

I want you to comment on the government’s double standard where they don’t penalize doctors for striking, but dealt very severely with hospital strikers when they went on strike last year.

Garfinkle: I think it is important to stress what I said earlier about withdrawal of services vs. striking. It’s unclear who hires the doctors, so that’s one thing that makes what you would do ambiguous. Morally, it seems incredibly unjust, what happened to the hospital workers.

Freedman: A lot of people in the labour movement are supporting the doctors’ right to strike, but not to opt out. The NDP in B.C. gave support to the B.C. Medical Association when they were negotiating with the government. But the issue is that the labour unions are used to signing contracts that are binding. And the end result of this negotiation between the OMA and the government is that although 80 per cent of doctors will abide by it, there will still be 20 per cent of doctors and in, some specialties, 90 per cent of doctors, who will say, “it’s nice that you bargained for this, but we’re charging more.”

So you think that doctors should be prohibited from opting out?

Garfinkle and Freedman: Yes.

Garfinkle: We have thought that what they get in Quebec would be a good model. Doctors cannot be partially opted out, and partially paid by medicare. When they are opted out, patients have to pay for their full services, there is no guaranteed amount from the government.

Freedman: The situation (in Ontario) now with opting out is you go to see the doctor, the doctor’s opted out, he sends you a bill for $60, OHIP will pay you, say $50, and you are out $10. In Quebec, if the doctor is opted out, the government says that’s it, we don't cover any of it.

Garfinkle: And that really discourages doctors from opting out, because patients in Quebec don’t seem to go along with that.
What worries me about Ontario is that people are starting to accept paying for health care. That’s becoming a change of consciousness in people these days, because it’s a minimal amount, say $10.

What are your criticisms of the Ontario Medical Association?

Freedman: They’re a professional organization that are out to get the maximum benefits for their members, with the least amount of government involvement. They are not interested in social issues as they apply to medicine, they are upper-middle class people. What the Medical Reform Group thinks is that there an economic and political nature to health care problems, and there are instances where doctors abuse other people who lower on the hierarchy, and we think some of those questions should be addressed.

Related topics in Connexions Subject Index:
Health Care Funding – Health Care in Ontario – Medical Reform Group – Medicare – Physicians – User Fees

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