I've been fairly upfront about my opposition to the tPSA as it currently stands. I believe it's a step in the wrong direction. That said, I've had a chance to read and listen to those who support the deal, and there are some very valid arguments to discuss from the "Yes" side. I thought I'd take a minute to lay out the points that got me closest to considering a "Yes" vote, as well as a bit more that I've posted previously about why I'm still not convinced.
The Best Argument I've Heard For The tPSA
There are good reasons to vote "Yes" to this agreement. The most convincing arguments I've heard have tended to follow this general train of thought:
1) The tPSA provides the most funding we can reasonably expect to get for physician services over the next 2 years and almost certainly provides the most funding overall for the next 4 years.
2) The tPSA provides us the best chance at binding arbitration for the next deal in 4 years' time, while providing meaningful third-party oversight for the remaining negotiations in the interim.
3) The tPSA provides incentives for the OMA (not individual physicians) to push for policies that hold down physician costs.
4) The tPSA provides some protections for physicians or physicians-in-training on what I would consider relevant but comparatively small side-issues.
I accept and agree with all these arguments. Combined, they make a reasonable case for voting "Yes" to the tPSA, particularly in the short-term. If I was nearing retirement, I'll be honest in saying I'd have a hard time voting this deal down. I think the OMA has made some major missteps in negotiating with the Ontario government and promoting its position to the public, but I'm doubtful that these would be ameliorated in any significant way by rejecting the tPSA or changing the OMA/negotiating team. For the next 4 years, as bad as this deal is, we're not going to get much better by rejecting it.
Why I Will Still Vote "No"
Put simply, I will vote to reject the tPSA because our healthcare financing problems - as well as my financial stake in the healthcare system - last longer than 4 years. And at the end of those 4 years, we could be in a very, very bad situation. We've never had a total cap on physician services before. Consenting to it now, even under some duress, makes it that much harder to eliminate later. Eventually it may be recognized as bad policy, but that could be a long way down the road, decades from now.
I've described before why a collective hard cap is such a bad idea, but let's put some numbers to the theory. To keep up with demand for physician services, we'd need to increase a collective cap on billings by 3-3.5% each year. To keep up with inflation as it currently stands, we'd need an additional 1.5-2% per year increase on the cap, plus an equal increase in fees for each billing code. In sum, we'd need a 5% increase in the cap, plus 1.5-2% increase in actual income just to break even in real terms.
It's incredibly easy for the Ontario government to spin this to the public as a 5% increase in salary, even if it's simply a cost-of-living adjustment plus funds for enough new physicians to keep up with population growth and aging. It's much harder for the OMA to explain why it's not a 5% raise. Binding arbitration would help, as any arbiter should understand these points well enough. However, the government's trump card - that they can't afford such a high increase for budgetary reasons - is hard to refute. There will always be a need to save money on healthcare, that's the nature of healthcare economics. Even a reasonable, informed arbiter may not believe a 5% increase in the cap is justified.
The problem is that we'd need a 5% raise in the cap each and every year, with each and every deal. If inflation or healthcare usage increases, that number has to go up. Anytime we fall below that, billing compensation drops and incomes drop even further as overhead costs are largely static and can't be easily reduced.
Rejecting the tPSA means short term losses for physicians, likely sizable ones. I'm comfortable with that. Ontario physicians on the whole make a bit more than we should when looking at national and international comparisons. The Ontario government does have a short-term budget problem that needs to be addressed and physician compensation is part of that. Ontario physicians can afford a hit to their incomes, even a reasonably substantial one, so long as we get back on a sustainable path. Accepting the tPSA means sparing ourselves short term pain but at the risk of larger long term losses, possibly permanently holding down physician salaries long past the point of reason or good economics.
Conclusion
When we talk about a sustainable healthcare system, we need incentives for all parties to push for sustainable funding mechanisms and to behave in taxpayers' and patients' best interests. The tPSA provides incentives for the Ontario government and individual physicians to do the opposite, giving only the OMA a loose incentive to push for reasonable policies. Bleeding physicians slowly is not sustainable, does not encourage physicians to behave responsibly with government funds, and in the long run will likely hamper access to important services for Ontario patients.
The cap will likely overwhelm future discussions between the OMA and Ontario government, distracting from more important matters. The "Yes" side has presented the tPSA as a pathway to more evidence-based policies in future negotiations. I don't believe that we're likely to get well-crafted policies by accepting such a poorly-constructed one as the backbone of this agreement.
One big flaw in my argument I must acknowledge - we could reject the tPSA and still end up with a global physician budget. If we don't win the right to binding arbitration and fail to rally the public to our cause, or if we win binding arbitration but fail to convince the arbiter, we could still be stuck with a global cap on physician billings. However, if we accept the tPSA, I believe we all but guarantee such a cap will exist for the foreseeable future. I cannot consent to that.
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