Guest Blog: Dr. Cargill and Dan’s Law

For the past nine months, I have been visiting my sister who is dying in Nova Scotia. This experience has truly sensitized me to the needs of those who need palliative care, and I now appreciate how much I will want to be able to control how and where my life ends. But this is not always possible, as Palliative Care physician Dr. Darren Cargill found out while caring for Dan, a patient who had moved to Ontario from Alberta. Dan’s story is very moving, and it underlines some of the inhumanity in our disjointed healthcare system. Dr. Cargill confronted this inhumanity on his patient’s behalf, and that is an even more inspiring story.

I asked him as a guest blogger to speak about his advocacy on behalf of Dan, advocacy that has resulted in the introduction of Bill 54 into the Ontario Legislature. Here is what he had to say:

“Bill 54, introduced by MPP Lisa Gretzky and which was debated and passed second reading on November 17th, 2016, provides much needed support for patients and their families. Canadians who move or return to Ontario and require palliative care or home care should not be subject to the typical three-month wait to be eligible for OHIP services.
The Bill carries the support of the Ontario Medical Association on behalf of its 34,000 physicians and medical students.
The issue came to light for me when a patient, Dan Duma, was denied home care services upon returning to Ontario from Alberta. Dan was dying of cancer with a life expectancy of less than three-months. Dan’s Law prevents future patients, families and caregivers from experiencing unnecessary hardship as a result of this lack of access to needed care.
As a doctor, I know that there is no medical justification for the wait period and I believe that, especially in these circumstances, we should afford Canadians and permanent residents the right to die with dignity. The benefits of home and palliative care are not only medical – they serve to support family members and caregivers.
The benefits of timely care include avoiding potential medical complications of delayed care and the associated significant human and financial costs arising from these complications.
Bill 54 has passed second reading and was sent to the Standing Committee on Justice Policy. This bill needs to be passed before the provincial election. I am asking that you write to your MPP and ask that Dan’s law be passed.”

Why would a person have to move from one Canadian province to another if they were dying? We all know the answer to this. They would move to be closer to family members. Why should they be denied the benefits of palliative care or home care? Please send an email or letter to your MPP and ask them to move Bill 54 forward. No one should ever be denied care in Canada because they moved from one province to another to be closer to family.

You can contact your MPP in Ontario using this list. If you are a physician in Ontario, please support this work. You can find a template letter under Advocacy on the OMA website. You do not have to say much, just tell them to get Dan’s Law passed before the election.

You can tell from how he wrote those few words above that Dr. Cargill is a doctor who feels that part of his work is getting all the support his patients need, even when that requires changing the law. Think about yourself or your own family. If you, or a loved one was very ill and had to move to be closer to the people who love you, so that they could be with you and look after you, is it reasonable that your health care would be compromised? Of course not! Thank you to Dr. Darren Cargill of Windsor for working so hard to change an unreasonable situation.

Photo credit

 

Disenfranchised

I am feeling disappointed with the voting process for the Canadian Medical Association President-Elect Nominee from Ontario. A few people on Twitter are saying it only took them 5 minutes, but they clearly had all the right numbers and user names and passwords together at exactly the moment that they decided to vote. I had a spare ten minutes on a Wednesday evening before a teleconference started, clearly had none of the right details and ended up having to vote last Saturday when I could go through the information more carefully.

Some of the information that was most helpful came from a Past Ontario Medical Association President who had sent an email encouraging people to vote and from a friend I called incidentally about something completely different. I did vote but it took about half an hour, not including any time on the phone with friends. I did hear from two candidates that relatively few people had voted and so I started calling the list of people I had been encouraging to vote. I coached five people through the process as they were keen and I think every vote is really going to count in this election. I did have to coach them around the pitfalls I had encountered, and did return to the former OMA President’s email for the solution to a problem different from the one I had encountered.

I will be very interested to know what the turnout is in both the OMA and CMA elections that are currently underway. I know from the personal experience of having run in both OMA and CMA elections that the turnout is usually under 20% in both, less than the turnout in most Canadian municipal elections. Turnout in Canadian municipal elections varies although this work from the University of Waterloo outlines a rate of 35% in Vancouver, which is the lowest among several Canadian cities. The turnout in the last federal election was high – 68.49%.

The University of Waterloo article does mention that online and telephone voting usually increases voter turnout. This is the Canadian Medical Association’s first completely online election for President-Elect Nominee in Ontario so it will be interesting to see whether the voter turnout is increased. After my experience, I am guessing that this will not be the case. If I am correct, and the voter turnout is very low, I will be interested to learn from CMA how close they came to the target they set for voter turnout. By the same token, I will also be interested in seeing whether, in its second year of primarily electronic balloting, the OMA is managing better turnout rates. I have found the OMA system to be more straightforward, but this is not everyone’s experience.

I am going through this long, likely boring story of voting in the CMA election to stress that we must hold all entities accountable when they claim loftily that they are democratic without ever establishing exactly how they ensure that anyone who is eligible to vote can easily do so. Turnouts under 30% don’t suggest great accessibility to one’s franchise, but I could not find any target for acceptable voter turnout by any association or elected jurisdiction. Which suggests…what? They don’t care?? They think that low turnout is mostly the electorate’s problem??

Even countries as proud of their democracy as the United States have had to implement laws to ensure that African-Americans have fair access to their franchise, but not everyone follows these laws as the American Civil Liberties Union will attest.

As a citizen, I have volunteered in elections of every kind, in the belief that by doing so, I am doing everything I can to promote the democracies that govern me. I do this in all kinds of uncomfortable circumstances grateful that I do not face censure or death as many do around the world in jurisdictions where democracy is less secure. I even consider this expression of concern regarding the CMA’s election process to be part and parcel of my duty as a member of that organization. So I will ask my CMA representatives: Do you care that the voter turnout was so low and what specifically are you doing about it? I just hope the response does not leave me feeling like P. J. O’Rourke, who famously said: “Don’t Vote. It Just Encourages the Bastards.”

Photo credit

 

Finale

In my last moments as Chair of the Ontario Medical Association Board, I thought of the five remarkable doctors, my former colleagues on the Executive Committee ,who have been my inspiration for the past six months. They embody the compassion, devotion and civility that epitomize physician leadership. I have learned so much from them.

Like my colleagues, despite having Council’s confidence to continue personally, I found the vote of nonconfidence in the Executive Committee in general to be extremely troubling.  As much as I want to assist in mending the divisions within the Ontario Medical Association, I believe that the best thing I can do is to assist as a Board member for a few more months.  The past six months have also taken a toll on those who care most about me and my clinical work so I feel it is important to attend to the interests of my family and my patients.

I am first and foremost a doctor and nothing is more satisfying to me than watching the life come back into a young person’s face as their depression lifts. I am inspired by the clinicians that I work with in my hospital and my community. The doctors and nurses, psychologists, social workers and other clinicians in my hospital keep me grounded in what is most important in medicine. They are amazing.

In ten years of medical politics, I have learned that I am not a politician. I can’t learn the lines or follow the cues. As too many people tell me, I cannot keep my facial expressions under control. If I have had any success, it is because I am persistent. It is because my efforts to be tolerant and gracious and kind have occasionally been successful. It is because, having always worked with youth, I have learned not to take my self too seriously.

The picture below is my favourite picture of me in OMA service. This was taken last November with Ontario’s medical student leaders. On the days when I have the most worries about where we are headed, I think about these doctors-in-training and I am reassured. If the work I have done for the Ontario Medical Student Bursary Fund and Physician Human Resources have had an impact for one young doctor, then my time at the OMA Board has been well spent and I leave with a light heart.

students4-002

(Photo credit: OMSBF)

Patient Accountability: Is it reasonable?

I am puzzled by Canadian federal and provincial governments’ collective reluctance to make patients partners in their own healthcare by expecting them to accept certain responsibilities for their own health and for the sustainability of the healthcare system. Why does it seem unreasonable to governments to ask citizens to meet a minimal set of expectations in relation to health care? All Canadians pay taxes, follow traffic laws and remember to get their passports renewed. Why would they not manage similar expectations in relation to their healthcare? Healthcare is thought to be a right by many Canadians – don’t we expect to have responsibilities related to rights? Why wouldn’t we be as accountable for our health care as we are for our taxes?

The issue of patient accountability is important for me as a physician. Whenever I see resistance by the government to patients accepting reasonable accountability, it feels as though the government is saying that the responsibility for the sustainability of the health care system mostly rests with frontline providers, especially physicians.

The Government of Ontario seems to like many aspects of Kaiser Permanente’s model for health care delivery so I thought I would see what Kaiser expects of patients registered in their programs, just to see how far-fetched my notions of patient accountability are. This is a link to the section of Kaiser Permanente’s website called Your Rights and Responsibilities. The section has a list, first of all, of rights. A quick read through this will show that these are the same expectations of any Ontarian of the Ontario Health Insurance Plan, although some of these include such statements as: “Receive emergency services when you, as a prudent layperson, acting reasonably, would have believed that an emergency medical condition existed.” The next portion is about patients’ responsibilities as a client of Kaiser Permanente. There are sixteen expectations in all, grouped under three broad categories: Promote your own good health; Know and understand your plan and benefits; Promote respect and safety for others. All are reasonable; all would be easily adaptable to the Ontario situation.

So what is the big deal? Unfortunately, Minister Hoskins has often said that health care is “free” – he did this last flu season, suggesting patients get their “free” flu shot at their nearest pharmacy. Leaving aside the fact that health care is not at all “free” from a financial perspective, it sounds as though governments believe that “free” should also mean “free from any inconvenience or expectation of the patient”. But we don’t say this for other government programs – try being free from the “voluntary” aspect of your income tax, or paying a parking ticket. You’ll soon learn that the government has ways of making you meet these expectations. When health care is the single largest budget item for a provincial government, why not expect the same attention to missed medical appointments, or seeing multiple doctors through walk-in clinics? It almost seems as though the government knows that this is one of those places where you can let someone else be the bad guy. You can let me be the one to say, “You missed two appointments with no notice and, as you were told at the outset, we will not continue to see you at the clinic if you miss appointments without letting us know.”

Now that Ontario’s ability to provide health care is being limited by the resources available to fund it, now that all other efficiencies in the system have been found, is it not time to turn to patients to ask them to contribute to the system? Is it not time to say, “There are some ways you could make the system more sustainable”? This is true in Ontario, but it’s also true in the rest of Canada as well.

The Ontario government is so desperate to find resources for health care that cuts to both physician and hospital services are continuing. However, it seems that legislators are not so desperate as to risk the anger of voters by asking patients to be accountable for those elements of health care that they control. I think that most citizens are committed enough to the health care system that they would welcome the chance to make it better. As baby boomers see how cutbacks are affecting health care, either through their own experience or that of family members, they are realizing that there is a role for them to play. It’s time to ask everyone to embrace accountability.

Ministers

I am getting pretty fed up with Health Ministers. Ontario’s Minister of Health and Long Term Care, Eric Hoskins, dumped a “deal” on the table for Ontario doctors at 8 a.m. last Wednesday morning. He was in a press conference by 9 a.m. letting the public know that he had offered Ontario doctors more money than he had in August 2016. Not mentioning that the doctors had rejected that August deal, the Minister also neglected to say that he had decided to pit groups of doctors against each other with his most recent offer. His latest “deal” seems to give family physicians an increase at the same time as it cuts the highest paid specialists.

The “increase” to family physicians is very questionable since the terms and conditions to which extra funding is tied are so stringent that doctors would take a loss in order to meet the Minister’s demands. The timing of the offer is also suspect. It follows hard upon the passage of Bill 41, the so-called Patients First Act, which seeks to address problems in Ontario’s health care system with additional bureaucracy and a Command-and-Control approach that is totally unnecessary given the work ethic and devotion of most doctors. The Board of the Ontario Medical Association unanimously condemned the actions of the Government of Ontario and the Minister of Health and Long Term Care.

Hard upon this, now consider the federal government’s “Take it or leave it” offer to the provinces of an “increase” of $11.5 billion for home care and mental health. That’s meant to be an investment over the next TEN YEARS, for all Canadians. That’s an investment of about $300 for every Canadian. This is not more than a week’s worth of home care or 2 sessions with a clinical psychologist. Dr. Granger Avery, the President of the Canadian Medical Association, said, “The Groundhog Day-type discussions where political leaders bat around percentages and figures at meetings in hotels have to stop.”

Really, Ministers, doctors would like to be able to have a real discussion about a health care proposal that you introduce that does not require the use of quotation marks to alert the public to the fact that health ministers and doctors speak a different language, especially where money and patient needs are concerned.

As a physician, I would like to think that there is an opportunity to discuss why these proposals will not meet the needs of my practice. As a patient, I want analysis that demonstrates to me that the investment of my money has been careful and methodical and that investments are linked to outcomes that both my doctors and the government agree on. As a citizen, it is distressing to be a bystander to this grandstanding by legislators. This is people’s healthcare. You are governing. Please consider your proposals with the seriousness they deserve. Please talk with me, not at me.

The Auditor General, The Minister of Health and The OMA

In the next week or so, there will be so much detailed analysis of the Auditor General’s Report on Physician Billing in Ontario that the small observation I am making here today here will be lost. As I reviewed the 57 pages, the details and references convinced me that the analysis had been seriously undertaken.

Some conclusions seemed quite inaccurate to me, e.g. “Our review of Ministry data noted that for the 2014/15 fiscal year, each physician in a Family Health Organization group worked an average of 3.4 days per week, and each Family Health Group physician worked an average of four days per week.” Most of my colleagues in these models work at least a five-day week.

Other conclusions really did reflect what I have heard from colleagues in all parts of the province, e.g. “A large number of the physicians who responded to our survey emphasized that patients’ demands are the driving force behind health-care costs. Many suggested that patient accountability is required to ensure that only necessary services or procedures are performed and costs are not duplicated.”

I want to focus, however, on one observation about the 14 recommendations, or specifically the Ministry’s response to them. Ten of the 14 recommendations require the Ministry to work with the Ontario Medical Association and, in each case, the Ministry confirms this. The recommendations are simple enough as statements but they are complex with respect to the knowledge and understanding of physicians’ practices that will be required to implement them.

Here is that common theme running through the Ministry’s responses:

“Adjustments to the capitation rate will require the Ministry to engage with the Ontario Medical Association (OMA) through the negotiations and consultation processes of the Ontario Medical Association Representation Rights and Joint Negotiation and Dispute Resolution Agreement (OMA Representation Rights Agreement).”

“Contract amendments, including minimum number of regular hours and consequences for not meeting contract requirements, will require the Ministry to engage with the OMA through the negotiations and consultation processes of the OMA Representation Rights Agreement.”

“Enabling these recommendations would require contract amendments and will require the Ministry to engage with the OMA through the negotiations and consultation processes of the OMA Representation Rights Agreement.”

The problem for the Minister of Health and Long-Term Care is that his preferred way of “engaging” with the Ontario Medical Association and Ontario physicians for the past two years has been through unilateral imposition of cuts and contract amendments. With Bill 41 as the last straw, doctors collectively and the OMA are informing the Minister and the public that working without a contract and being dictated to by legislation do not further a productive relationship.

So the Minister has a problem. By the Ministry’s own admission, 10 of the 14 recommendations in the Auditor General’s Report on Physician Billing will require him to work with his physician partners and the OMA. Over the years, only the Ontario Medical Association has provided realistic ideas about how to implement government recommendations. This is well illustrated in the various examples of real practice situations outlined in the Auditor General’s report. Developing payment models and incentives that improve access for patients is necessary for the health care system to work properly. These models of care promote both a healthy population and a stable, fairly remunerated physician workforce.

Ministers pay attention to the Auditor General’s Reports. I hope the Minister of Health and Long Term Care keeps this report in mind and that he reaches out to the OMA. I hope he does, but I’m not optimistic.

Bill 41 – More Questions

Last week, Dr. Del Dhanoa, a radiologist from Northern Ontario, asked some questions that I decided to answer as another blog since they continue the series I have been working on. The questions also spark further debate about whether the Minister of Health and Long Term Care has completely explained his vision of health care in Ontario, given the degree of change being undertaken in Bill 41.

This is the first question:

“What are your thoughts about Hospital CEOs and Boards? Will they eventually go by the wayside like British Columbia because the LHINs (and Minister) have much more direct control over Hospitals with Bill 41? A Hospital Board Director told me that she/he was ready to hand in his/her resignation after reading Bill 210/41. They feel like they no longer serve a purpose and, after all, their time is largely volunteer based.”

I served on the Board of my hospital when I was the President of the Medical Staff. What is most impressive about hospital boards is how deeply they draw into the fabric of the community in which they are located. My main clinical appointment is at the Royal Ottawa Mental Health Centre, a psychiatric hospital in Ottawa. The members of our hospital Board of Trustees include prominent local lawyers, very senior civil servants, patient advocates – all very busy people who volunteer their time to ensure that the citizens of Ottawa have access to the best possible mental health care. They are all volunteers and commit a significant amount of time to the work of the hospital. They have a vision for how the community can best be served that is grounded in the reality of the advantages and disadvantages of living in the national capital and its region. Bill 41 would add another lens to that vision and, unfortunately, it seems to be a lens that could override some of the most important decisions they make.

In the narrative leading up to his question, Dr. Dhanoa mentions the reaction of one of his hospital’s Board Directors. My husband had served on the board of a local Ottawa hospital and he too believes Bill 41 as an interference that that was unneeded. He spoke of the fact that every new directive or initiative from government just added time to board and committee meetings since one often had to work patient needs and priorities around them. For example, governments have had many interventions over the years to improve wait times, as if doctors and hospitals were not already working hard to do this. Really, does the Minister believe we are trying to increase wait times? Or decrease access? Doctors and hospital boards hear concerns directly from patients and can tailor a local response to their concerns.

Here is Dr. Dhanoa’s second point:

“The language in Bill 41 is pretty clear. The Minister can act to change Hospital mandates in the “public interest” and this includes activities that decrease Hospital length of stay. As you know, LOS is the basic currency describing the activities in hospitals: from the Emergency Department to the wards, to the lab and the medical imaging department. Everything in hospitals is based on LOS.

So, really, Bill 41 gives the Minister a lot of power to change the way medicine is practiced in all of Ontario’s Hospitals to meet the LOS metric. While on the outside that sounds great, I have many reservations on how that will play out in Ontario especially when physician input is ignored.”

I think that Dr. Dhanoa makes his own point very well and underlines how important it is for physicians to sit on and participate in their hospital boards because it is one important way in which we have input into how health care is delivered. Having said this, it was the decision of Premier Wynne’s predecessor to stop physicians from having a vote on hospital boards under the changes the Liberal government made to the Public Hospital Act in 2010. Doctors realized then that their input was being marginalized by the Liberal government in Ontario.

The problem with ignoring the input of doctors is that we spend all day every day working to integrate patients’ health care. Integration is the goal of Bill 41. Why ignore the concerns of those who actually understand how this might be achieved?