Ontario Association of General Surgeons
& OMA Section on General Surgery
P.O. Box 192, Stn. Main,
Peterborough ON K9J 6Y8
Phone: 705-745-5621 / Fax: 705-745-0478
E-mail: info@oags.org / Website: www.oags.org
Attn. General Surgeons of Ontario
From: OAGS & OMA Section on General Surgery
Re: Response to OMA/MOHLTC Contract Negotiations
Date: May 29, 2012
Dear Colleagues,
We are writing to provide you an update on the current status of contract negotiations between the OMA and Ministry, and
on several specific issues impacting General Surgeons. The OMA has communicated much of the specific information to
members, including the fee code changes imposed by the government by means of regulation. Attached are several
documents providing more information on the changes proposed by the government side during negotiations. Only the
2012/2013 changes have thus far been enacted by regulation; however, we have included all of the proposals by the
government side for the presumed 4-year cycle of the next agreement.
The position of the government has not budged during 3 months of negotiations, to the degree that the government intends
to freeze total payment for physician services at the current approximate $11 billion per year. Given estimated health care
utilization growth and impact, the government believes it needs to reduce current year fees to achieve $450 million in savings.
By the end of year 4, the government intends to reduce fees to achieve about $1.1 billion in savings. In effect, the growth in
utilization, both for new physicians entering the system and for our aging and growing population, is to be shouldered and
paid for by physicians rather than government. This is a major departure in philosophy and reasoning from the past. This
approach is not a “wage freeze”, as publicly expressed by government, but clearly represents a wage reduction.
We have expressed a number of concerns, both around process issues and around some specific changes which affect General
Surgery. In terms of the latter, there are 4 major fee changes we are concerned about:
1) After-Hours Premiums – These are to be reduced by an absolute 10%. We feel this is an issue of equity and fairness
and are very disappointed that government wishes to reduce a reasonable (or even undervalued) premium for work
performed outside regular hours. Most workers in society get at least a 50% premium for any overtime work, yet we
are only entitled to such a premium if a surgical case “begins” after-hours, regardless of its lengthy duration. Such
cases are often more difficult and more complex; they involve significantly more effort to book and organize than
regular day cases. There are often significant delays and down time waiting for such surgeries to begin. Furthermore,
in many smaller communities, General Surgeons provide on-call services in excess of HOCC guidelines and in excess of
specialty body recommendations and policy positions. Such reductions in after-hours premiums may decrease
availability of General Surgery coverage in smaller communities. The workload and fatigue associated with afterhours work decrease the availability and productivity of physicians the day post call, further decreasing our ability to
OAGS BOARD OF DIRECTORS
Dr. Jeff Kolbasnik (President), Dr. Chris Vinden (Vice President), Dr. Peter Willard (Secretary),
Dr. Dennis Desai (Treasurer), Dr. Angus Maciver (OMA Section Chair & OAGS Immediate Past President),
Dr. Frank Baillie, Dr. Philip Barron, Dr. Suru Chande, Dr. Ian Chin, Dr. Ciaran Kealy,
Dr. Jack Long, Dr. Alan Lozon, Dr. Harshad Telang, Dr. Alice Wei
SECTION EXECUTIVE
Dr. Angus Maciver (Chair), Dr. Jeff Kolbasnik (Vice Chair), Dr. Philip Barron (Immediate Past Chair),
Dr. Chris Vinden (Tariff Chair), Dr. Peter Willard (Secretary),
Dr. Ciaran Kealy (Board Member-At-Large), Dr. Harshad Telang (Board Member-At-Large)
Page 2 of 3
May 29, 2012
generate income and care for our patients. Most surgeons would find reductions in these premiums for surgical work
insulting and offensive, beyond simply bad policy. We also note that after-hours premiums for non-surgical work (e.g.
K codes for emergency department consults) have not been decreased.
2) Laparoscopy Premiums – The laparoscopy premium for advanced surgery performed laparoscopically is decreasing
from 25% to 10%. The government has mistakenly lumped this issue with other initiatives where it argues
technological advancements have made surgery easier and faster. With advanced laparoscopic procedures, though,
the surgery typically takes longer and is more difficult and more complex than the equivalent open approach. In fact,
when these premiums were introduced, we presented a bilateral committee of OMA and government with evidence
that, even after the learning curve, these surgeries continue to take longer to perform, by an average of 25%.
Furthermore, it was introduced as a quality initiative, and funding for it was taken out of the pool that would have
been available to General Surgery for any other fee increases. The benefits of such laparoscopic surgery accrue
specifically to patients (through better cosmesis, less pain, quicker recovery, fewer adhesive complications, etc.) and
to government (through reduced hospital stays and lower total cost), yet not to surgeons who require longer blocks
of OR time to complete such surgeries. The increasing proportion of advanced laparoscopic surgical procedures is a
tribute not only to this initiative but also to other educational and mentoring programs. The length of time required
for laparoscopic surgery no longer appears to be significantly longer than that for open surgery, but this outcome is
the result of the fact that more routine surgeries are now performed laparoscopically, while the open approach is
reserved for more complex and difficult procedures. In a matched or randomized assessment, though, laparoscopic
procedures continue to take more time and are more difficult to perform. It is unfortunate that this bilateral quality
initiative recently agreed to by government would be targeted.
3) Endoscopy / Colonoscopy Fees – Fees associated with these services are being reduced by 10%. We acknowledge
that income earned during an endoscopy block typically exceeds that earned during a similar OR block or office day.
However, it is also the case that colonoscopy fees have not received any targeted increases in many years, and that
the technology involved has not progressed to a degree to make endoscopy services particularly quicker or easier. It
has also been the case that we have relied on endoscopy work to subsidize many other aspects of General Surgery
practice which are undervalued. There have been bilateral initiatives between government and other OMA Sections
to redirect money from certain fee codes to others that are felt to be undervalued; we believe the same approach
should be considered for endoscopy services. Furthermore, increasing volumes of endoscopy services are performed
in outpatient clinics where the costs are paid out of the physicians’ professional earnings. Such mechanisms
effectively undervalue endoscopy services, and this issue needs to be addressed since colonoscopy fee decreases will
disproportionately affect such practices. While outpatient colonoscopy clinics staffed by gastroenterologists may
remain viable (given the significantly higher consult fee available to gastroenterologists), such clinics staffed by
General Surgeons are at increased jeopardy.
4) Varicose Vein Surgery – The government has imposed a number of changes which will restrict access to such surgery
to a significant degree, effectively blocking or delisting varicose vein surgery. We do not believe the implications of
such changes have been adequately contemplated. We note as well that varicose vein surgery performed and billed
in good faith during April may be subject to complete cost recovery by the Ministry, potentially leaving patients
responsible for paying surgical, anesthetic and hospital fees.
Additionally, we have expressed a number of concerns regarding process. While we have only been privy to the OMA’s
description on the nature of preceding negotiations, we conclude that the government has not been negotiating in good faith.
The OMA has, in fact, offered not only a freeze on fees, but also temporary reductions in fees, in recognition of the
government’s efforts to manage a significant budget deficit. Such offers exceed any proposals or settlements by any other
public sector group. It seems clear that an agreement which would be acceptable to physicians could not have been
negotiated with this government.
We are also concerned by the retroactive implementation of the fee code changes. While agreements are frequently
concluded after the expiration of the previous one, any retroactive changes, either increases or decreases, are agreed to by
both sides. In this case, the government has unilaterally changed not only the fee codes, but has unilaterally implemented a
clawback on fees already paid. We believe this approach is unfair.
Page 3 of 3
May 29, 2012
We note as well that surgeons are doubly affected by restrictions in health care funding. Hospital budget deficits are
disproportionately tackled by restrictions in OR access and outpatient endoscopy and clinic services, which are often provided
by surgeons. It is clear that government funding for hospitals in the past few years has been, and in the near future will be,
insufficient to deal with patient demand, and surgical services are likely to suffer most significantly. Such challenges will
disproportionately affect the care of surgical patients.
Finally, we are quite concerned about the effect of recent government actions on the relationships between physicians and
government. We have achieved significant improvements in health care and have achieved significant savings and efficiencies
as a result of a positive working relationship based on trust, respect, and mutual responsibility. The government’s
unwillingness to negotiate in good faith and its imposition of unilateral regulatory changes affecting physicians will
significantly damage this relationship, and will thus damage our ability to co-manage the health care system to the benefit of
patients. Negotiations are now at a stand-still, with no meeting even scheduled since the imposition of government
regulations. Mutual initiatives have become very difficult to pursue.
The OAGS and the OMA Section on General Surgery have been supportive of recent OMA efforts to deal with these issues.
We do not feel job action resulting in significant service disruption is currently appropriate; we support the public relation
initiatives and advocacy that is being advanced by the OMA. We encourage members to discuss concerns with patients and
individuals in positions of authority, and to express these concerns to government. We encourage local press initiatives that
members wish to undertake, with a focus on the impact of government action on patient care rather than the impact on
physician earnings. A number of resources for such activities are available on both the OMA and OAGS websites. We also
encourage physicians to continue to bill appropriately and discourage initiatives to bill “creatively” regardless of the
government’s current actions. We, nonetheless, encourage members to become familiar with all aspects of the fee schedule,
as it is likely many members underbill in certain situations.
Most importantly, we must ensure that our frustrations with government do not damage the primacy of delivering high
quality care to our patients, who must remain our top priority.
We appreciate the comments already sent to us by members and would appreciate further suggestions and input. We will
endeavour to keep you informed of significant developments which impact our group.
Sincerely,
Jeff Kolbasnik, MD, FRCPSC
OAGS President
Angus Maciver, MD, FRCPSC
OMA Section on General Surgery, Chair
JK/AM/lq
Encl.
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and the opinions of the Ontario Medical Association. The Ontario Medical Association administers the distribution of Section, District and Branch Society
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