OMA Section on Rheumatology Report

As we transition to shorter and cooler days there is much to update you on regarding the OMA’s activities.

1. CPSO’s draft policy titled “Continuity of Care”

The College of Physicians and Surgeons of Ontario (CPSO) is proposing new policies on: Availability and coverage; Managing Tests; Transitions in Care and Walk-In Clinics that will impact all physicians in Ontario. So, while the government continues to clawback physician salaries and maintain targeted cuts to the fee schedule, the CPSO is recommending increasingly onerous standards for those services.

The ORA Executive and Board strongly encourage you to review the CPSO draft policy titled “Continuity of Care” as it proposes some key changes to the way physicians’ practice.  These changes will increase the administrative burden, particularly for rheumatologists in solo practice.

The draft policy can be found at http://policyconsult.cpso.on.ca/?page_id=10258. Please submit your feedback to the CPSO online, via email, regular mail, and/or through online survey. The deadline for feedback is December 9, 2018.

To facilitate your participation, the ORA has drafted a letter (see link at the end of this section) which you are free to use as is or modify and sign your name to.  You can view other physicians’ and patients’ feedback to the CPSO at http://policyconsult.cpso.on.ca/?page_id=10260

This information may assist you in modifying the draft letter attached before you send it to the CPSO and OMA, which we strongly recommend you do. Now is your chance to be heard!

OMA staff have also prepared a succinct consultation guide that highlights key policies and provides a summary for members to ensure complete accuracy of the proposed draft policy.

https://www.oma.org/wp-content/uploads/CPSOdraftContinuityofCare.pdf

PLEASE TAKE A FEW MINUTES TO READ THE KEY ELEMENTS OF THE CPSO DRAFT POLICY:

–         Physicians must have an office telephone that allows voice mail messages to be left during operating hours AND outside of operating hours reviewed and responded to in a “timely fashion.” The voicemail outgoing message must be accurate and up to date regarding practice hours, closures and coverage information.

CONCERNS: What is timely? Would voice mail messages have to be archived? Is this even feasible?

As stated in feedback by a physician on the CPSO website: “I have issue with the ability of patient to access their doctor via telephone 24/7. Any testing be it screening or focused has a context behind it that could affect the importance of a result. Also, the normal ranges vary from person to person and the trend is more important than individual results. By asking doctors to answer calls 24/7, you will be increasing enabling patients to act on “noise” from lab results and the actual “signals” ie true positive and true negative results in a significant clinical context, will to be drowned out. By enacting this policy, you will cause untold harm to patient as physicians will end up reacting to the noise that testing inevitably generates, while actual important (ie clinically significant) testing will be harder to respond to. In addition, you will be causing higher rates of physician burn out and stress which will make the outcomes for patients even worse.”

–         Physicians must co-ordinate care for their patients during temporary absences from practice – both planned (e.g. vacation) and unplanned (e.g. illness) and inform patients of the coverage arrangement. Physicians must arrange for another provider to provide care during these absences. Physicians must also inform patients of coverage arrangements during temporary absences.

CONCERNS: How is this feasible for an unplanned absence, which is by definition sudden and unforeseen? How can an unaffiliated health care provider of the same specialty gain access to the absent physician’s office and EMR? With shortages of specialists and long wait lists, finding another physician to cover even a planned absence is usually not feasible. What happens when multiple specialists are away simultaneously attending a specialty CME conference?

–         Physicians in a “sustained patient-physician relationship” must have a plan in place to coordinate patient care outside of regular operating hours.

CONCERN: If the plan does not allow for “going to ER, going to a walk-in clinic, seeing the primary care physician, or calling Telehealth” as the menu of choices provided, it is a recipe for specialty physician burnout.

–         Physicians must be able to receive and respond to critical test results 24 hours a day, 7 days a week, or make coverage arrangements with another health-care provider to do so.

CONCERNS: This is especially challenging to do for physicians in a solo practice. It is a recipe for burnout, and physician retirement ahead of schedule. This policy will drive physicians to other jurisdictions, worsening the Ontario physician supply in future. As physicians, we advocate a balanced lifestyle, as a precondition for good health and wellness in our patients. How ironic and counterintuitive that the CPSO policies promotes the opposite view for its health care practitioners.  See above re the impracticalities of obtaining coverage.

–         Physicians must copy the patient’s primary care provider on all tests ordered.

CONCERNS: This is already done in general, but laboratories often fail to carry through, claiming that they cannot identify the physician to be copied on the test results, despite clearly printed instructions on the lab requisition.

–         Physicians must track test results for “high-risk patients” (e.g. calling patients to verify they did the test and/or contacting the diagnostic testing facility).

CONCERNS: High-risk patients may not be known in advance; only in retrospect when their behaviour identifies them as such. High-risk patients may be the most difficult to contact (fail to answer their phone, have no voicemail, change phone numbers or have no phone, no fixed address, etc.). It is unrealistic to expect physicians to phone high-risk patients and/or diagnostic facilities to verify that patients have done their tests. CPSO fails to mention the patient. Should a physician be solely responsible for ensuring that an ordered test is completed by the patient? Even high-risk patients must at least bear some of the responsibility to comply with a requested investigation. Physicians should not be expected to police our patients.

–          Physicians who receive critical or clinically significant test results in error have an obligation to report the result to the patient or others involved in their care. If the test result is received incidentally (ie., physician is copied on a report), physicians must make “reasonable efforts” to notify the patient or ordering health-care provider if the physician has reason to believe that the ordering provider will not get the test result.

CONCERNS: What is a reasonable effort? Some system must be in place to protect the patient and the doctor equally. The ordering physician is ultimately responsible for any test ordered, and the lab is responsible for properly relaying the results to the appropriate health care providers. The lab should be accountable. The labs should carefully verify they have the correct physician address, phone number, cell phone, home phone number and fax.  Physicians in Ontario are already overburdened by administrative tasks on their own patients and struggling with adequate resources due to the ongoing unilateral cuts to our incomes for the last 4+ years. We cannot cope with additional unpaid work. It seems unreasonable that physicians have an obligation to notify a patient they have never met for fear of discipline from the College.  I don’t want to become the default critical/clinically significant result handler, simply because I’ve been cc’d on a test requisition, or worse received a test in error.

–         Consultant physicians must acknowledge referrals no later than 14 days from the date of receipt and indicate whether the referral is accepted and provide the actual or estimated appointment date and time. They must also indicate whether this information was communicated with the patient.

CONCERNS: Fixed timeframe may not be feasible if volume of referrals is high or the consultant is away from their practice for more than 14 days.

Overall:

As stated by a member of the public in feedback on the CPSO proposals: “I think that these policies are overreaching and draconian. As a reasonable person, we as patients must accept some degree of responsibility for our care. Asking our doctors to be available 24/7 is ludicrous. What if they need a vacation? A small-town doctor may not be able to find a replacement, should he then never be able to take time off? This will only serve to force doctors out of small towns. And as for having my doctor hold my hand to make sure I get a test done…. He has better things to do. If he tells me to get a test done after we talk about why I came to visit him, I sure am getting that test done. If I don’t, that’s on me and only me.”

While the OMA is hoping all members will participate in the CPSO consultation efforts, they are also eager for members to connect with the OMA directly to help them formulate their response to the CPSO. The contact info for feedback to the OMA is COC@OMA.org

You can email your comments to the CPSO atcontinuity@cpso.on.ca

A draft letter you can personalize and send to CPSO and OMA is available on the Members section of the ORA website. Please visit this link: ORA Members

  1. Negotiations

Negotiations continue with the Conservative Government. In late August, the Ford government changed its negotiation team. The new team consists of Mr. Robert Reynolds (Chair), Mr. Craig Rix, Dr. Joshua Tepper & Mrs. Lynn Guerreiro. On August 23, the OMA Negotiations Committee met with the government’s new team. The substance of the talks is confidential; however, the OMA Board believed that additional exploration was warranted. Though doctors have been without a contract for over five years, the OMA’s goal has always been to have a fair agreement for members and a productive relationship with government. The OMA repurposed the previously scheduled arbitration dates of Sept 17, 20 & 21 for additional mediation with the government. Unfortunately, mediation failed. The Ford government advised that its position before the arbitration board is the same as the previous government. Go-time for arbitration is October 22.  The Binding Arbitration Framework allows for the OMA to continue its Charter Challenge launched in October 2015 regarding the government’s course of misconduct towards physicians since 2014.

  1. Relativity

Income relativity continues to be a contentious issue amongst physicians. This year, to increase transparency and fairness in the process of determining relativity among specialties, the OMA (in addition to the annual Spring & Fall Council Meetings) has scheduled a supplemental Relativity Council Meeting October 21, 2018 which I (Dr Kovacs) will attend. In the current CANDI (Comparison of Average Net Daily Income) model, the relativity position is determined at the level of each OHIP specialty. The Ministry has developed their own relativity model called RAANI (Relativity Adjusted Annual Net Income) because they contend that the OMA’s relativity tool CANDI significantly overestimates physician overhead. The government claim physician overhead is closer to 20% than 30% of gross billings. The OMA Relativity Advisory Committee is working to develop a new Relativity Metric that hopefully will be perceived as fair, and adopted with fewer objections. A hybrid mechanism is anticipated for determining the relativity methodology and allocations for years 1 and 2 of the next PSA (covering 2017-19), with a new process to determine the relativity model thereafter. Questions may be forwarded to: Relativity@oma.org.The Relativity Advisory Committee (RAC) Report is available to all members and posted on the OMA Special Council, Relativity website: RAC Report Sep 27, 2018

  1. Resignations from the OMA Board of Directors

Two members of the OMA Board of Directors recently resigned. On August 27, 2018, Dr. Silvana Bolano, resigned as Medical Specialties Assembly Director. The reason was not stipulated. On September 28, 2018, Dr. David Jacobs, a radiologist who is vice-president of the Ontario Association of Radiologists, and Coalition of Ontario Doctors co-founder, emailed his resignation letter to all members. His objective is to establish an association of specialists with representation and negotiations distinct from the OMA. A brief OMA News Release by President Dr. Nadia Alam, September 28, 2018 https://www.oma.org/sections/news-events/news-room/all-news-releases/statement-from-oma-president-nadia-alam-on-oma/ and President’s Update  October 1, 2018 https://mailchi.mp/oma/oct01-update-89117?e=1e10f8a664 challenge the incorrect assertions made by Dr. Jacobs, namely that negotiations with the Ford government failed, when in fact the OMA continues to work to reach a negotiated settlement. As well, there is no indication that the government supports the profession splitting or endorses negotiations with a breakaway physician group.

  1. Disclosure of Physician Billings

In 2014, the Toronto Star filed a Freedom of Information (FOI) request for the names and billing data of the top 100 OHIP billers from 2008-2012. The OMA deems physician billing as private information and opposed this. The Ontario Court of Appeals ruled that physician billings and names do not constitute personal information. The OMA is waiting to hear whether they will be granted permission to appeal this case to the Supreme Court. The OMA contends that physician billing is personal and should be kept private. Privacy is a fundamental right protected by the Canadian Charter of Rights and Freedoms. Moreover, publishing gross income (versus net income), out of context, paints an incomplete picture of the physician income structure in Ontario and may be misleading to the public. The OMA has also learned that the Toronto Star has filed an FOI request for all physician billings and names – this request is on hold pending the outcome of the current top 100 billers’ case.

  1. President’s Tour

The 2018 OMA President’s Tour is officially underway. Dr. Alam is travelling across Ontario visiting physicians in numerous branch societies. The Tour schedule, including locations, dates and registration links, is available here https://www.oma.org/sections/news-events/news/membership-updates/

We will continue representing Ontario’s rheumatologists at Medical Assembly teleconferences and Assembly meetings, as well as all regular and special OMA Council Meetings. Upcoming meetings are Relativity Special Council Meeting, October 21, and Fall Council November 23-24.

You may also keep up on OMA issues by reading the Ontario Medical Review (OMR), the OMA monthly magazine available in print and on the OMA website: www.oma.org

Provided is a link to OHIP Billing Resources and OMA Quick Reference Guides at www.oma.org/sections/billings-and-agreement

Online educational modules on billing, patient care, practice management and retirement planning are available through the OMA Education Network at:

https://learn.oma.org

As well, an online Privacy and Security Training Module is now available from OntarioMD:

https://www.ontariomd.ca/products-and-services/privacy-and-training-resources

Julie Kovacs and Philip Baer, OMA Committee Co-Chairs