March 04, 2003 Volume 39 Issue 09

Joint management vehicle could get an overhaul

Physician services committee under fire for secrecy

By Matt Borsellino

TORONTO – Ontario's powerful health-care joint management tool—the physician services committee (PSC)—is attracting increasing flak for its continuing policy of closed-door decision-making.

The controversial physician-government committee was set up after the Ontario Medical Association's 1997 agreement with the province. Its terms of reference were renewed by the current four-year deal reached in May 2000. That deal ends in April 2004, with negotiations leading to a new one scheduled to begin early next year.

The PSC meets at least twice a month to:

• "build and sustain a strong, positive working relationship" between the OMA and government;

• improve models of delivery and compensation;

• identify "efficiencies" and find ways of "maximizing return" on funding;

• conduct utilization reviews and propose "appropriate and effective" ways to deal with changes; and,

• develop and recommend patient education programs among other things.

Its subcommittees and working groups have studied primary care renewal, billing audits, the schedule of benefits, technical fees, medical forms, work in emergency departments and academic health science centres, physician resources, medical malpractice and clinical guidelines.

Significantly, its terms of reference also commit the PSC "to giving appropriate opportunity to affected parties to provide timely input . . . before making recommendations to the health ministry and OMA."

Over the years, though, the PSC has alienated some of those it was meant to assure. Lately, there's been growing outside distress particularly aimed at its fee "tightening" and "modernizing" function.

When the New Democratic Party governed between 1990 and 1995, it used a committee, set up by then health minister Ruth Grier and chaired by the University of Toronto's dean of nursing, to help produce savings from the provincial health plan pool (OHIP).

"The committee actually held public meetings with groups and organizations seeking input from people about what potential cuts could be made," said Shelley Martel, a Sudbury-area MPP and current NDP health critic.

"The committee recommended cuts to the government. It was quite an open process with certainly much broader representation than just the OMA. Frankly, when you're talking about OHIP money—taxpayers' money—if you're going to be making cuts or delisting services, that's the kind of open process we should have.

"We should institute a similar open process again (that includes) public hearings and stakeholder input, the kind of broadly based committee that actually talks to people about what could and should be cut before decisions are made."

The Ontario Association of Radiologists (OAR) knows what Martel is talking about. The OAR still has a $675-million lawsuit pending against a PSC-approved utilization control plan unleashed in 1998.

More recently, the OAR has been vocal in its opposition to the hospital implementation advisory committee. That panel, according to OAR President Dr. Giuseppe Tarulli, writing in a Jan. 27 memo to Ontario MPPs and acquired by the Medical Post, is "determined" to cut technical fees associated with diagnostic imaging in Ontario hospitals "by limiting access, providing fewer services and capping the number of diagnostic imaging exams available to patients on an annual basis."

Association officials would not comment further on the PSC, citing the litigation.

The Ontario Hospital Association has tried unsuccessfully on a number of occasions to open the process somewhat and make it trilateral. David MacKinnon, its president and CEO, knows the criticisms of the PSC but doesn't share all of them.

"Until 1998, much of the dialogue between physicians and the government took place in full public view," he said. "But the nature of some of those subjects doesn't lend itself to full public debate. (The PSC) is a way for doctors and government to talk in an orderly way. It's probably better than the strident public arguments that sometimes occurred before."

MacKinnon said he also believes, however, the process needs to be broadened. "Doctors need to be more active in configuring and managing the hospitals in which many of them work," he said.

"We need more (physician) leadership in health-care management and administration. The issue with the PSC is how to build on a reasonably orderly process."

The OHA has, on occasion, lobbied to be included in OMA/government negotiations, "though not in recent times," he said. Still, the public expects physicians to lead, he said.

"We're comfortable with the current arrangement, but it needs to evolve. We need to get the ideology out (of the discussion) and minimize the public posturing. The lack of public debate may be a problem, but simply repeating persistently held opinions can't compare with actually sitting at a table and using facts to work things out."

While the Coalition of Family Physicians believes the OMA needs to be "more representative" to its members, Dr. Doug Mark, its president, feels many Ontario doctors probably don't even know the PSC exists.

"The OMA and government work together seemingly in secret through this committee," he said.

"The whole concept kind of makes sense in a way, and could work to provide more direct communication with the government, but the biggest concern we have is its lack of openness and transparency. We don't know what's happening there, and we get the feeling the OMA board doesn't even know what's going on within the PSC."

There's really no oversight to keep PSC activities "in balance," he said. "We need more information to get out to the grass roots so we can help steer them in the direction we feel they need to go. We haven't seen any significant positive results from the PSC yet, but we're hopeful they hear our message that family physicians are in crisis."

OMA President Dr. Elliot Halparin said the PSC, a 10-member panel with co-chairs from each side and a mutually chosen professional facilitator, communicates often and in many ways with numerous outside parties and OMA clinical sections as needed on an issue-by-issue basis.

"We are a very open and democratic organization, but the PSC is a bilateral committee with responsibility for the physician services budget," Dr. Halparin said. "We include input from outside groups when we feel we need it.

"Prior to 1997, when the PSC was set up, we were having difficulty with our approach to managing the health-care system. We had government-mandated hard caps, 10% clawbacks, umpires, arbitrators and referees, and legislation that negated (improvements) by the stroke of a pen.

"The changes in the way the profession interacts with the government resulting from the PSC have benefited doctors, patients and government. It's untrue to suggest we're only getting a (negotiated) 2% fee increase, for example.

"We've gained tens of millions of dollars for our members in excess of the provisions of our agreement through funds for maternity benefits, hospital on-call, evening and weekend premiums, the Northern Physician Retention Initiative, utilization provisions and emergency department funding."

Dr. Halparin was asked if the province has ever asked OMA officials on the PSC to open the process to other players. "Any idea is allowed, that's how a bilateral committee works," he said.

He was also asked if the OMA plans to seek renewal of the PSC when negotiations for a new deal with the province begin early next year. "We'll do like we normally do and survey our members to see where their priorities lie," he said.

OMA is represented by Drs. Christopher McKibbon (co-chair), Garnet Maley, Stewart Kennedy and Wayne Tanner. Mark Geiger serves as legal counsel. Government members are Drs. David McCutcheon (co-chair), Rueben Devlin and Lynn Wilson and Mary Kardos-Burton. Harvey Beresford is the province's lawyer. The facilitator is Mort Mitchnick.