As the number of people across Ontario without a family doctor reaches a record high, Premier Doug Ford’s government is facing a fresh push to make family practice more attractive to physicians by improving compensation.
The contract that covers how doctors are paid in this province, known as the physician services agreement, expires at the end of March. The government is in negotiations with the Ontario Medical Association (OMA), the doctors’ bargaining agent, on a new deal.
Family doctors’ pay in particular is in the spotlight in those talks, in a way that it hasn’t been for a long time.
That’s in part because there’s a growing chorus of physicians arguing that compensation is one of the key root causes why at least 2.2 million Ontarians don’t have a family doctor, a number forecast to nearly double in just a few years.
“The reality is the current contract that we have is modelled on the economics of 2001 and not on 2024,” said Dr. Sohail Gandhi, a family doctor in the town of Stayner, near Collingwood, and a former president of the OMA.
“The workload has gone up, the need for extra staff has gone up and the gross billings that we get haven’t been able to keep up,” said Gandhi in an interview with CBC News.
Over the past 10 years, inflation as measured by Statistics Canada has totalled about 25 per cent. During the same period, the average family physician’s yearly billings to OHIP have risen just 5.1 per cent, according to figures provided by the OMA.
A typical Ontario family doctor’s practice runs like a small business, with costs for staff, rent and other overhead paid out of their revenue from OHIP billings. But unlike the typical small business, Ontario family doctors can’t just arbitrarily boost their prices to bring in more money.
OHIP revenue ‘stagnant’ as costs rise
The erosion of net income is a significant factor in some family doctors choosing to retire, shifting into another area of medicine, or opting not to open a family practice in the first place, says Dr. Ramsey Hijazi, a family physician in Ottawa and the founder of the Ontario Union of Family Physicians.
“Our revenue is completely stagnant and all our costs continue to go up,” said Hijazi in an interview. “Most businesses would go bankrupt.”
Dr. Mekalai Kumanan, who practices in Cambridge and is the president of the Ontario College of Family Physicians (OCFP), says many of her colleagues are questioning the financial sustainability of their practices.
“What we’re hearing from family doctors across this province is that they’re actually struggling to keep up with the rising costs of running a clinic,” Kumanan said in an interview.
“With a really large number of patients who don’t have access to family physicians, we certainly need to be thinking about retention and how we can keep family physicians in practice,” she said.
All the family physicians interviewed for this story say the financial pressures of running a clinic contribute to a growing reluctance among medical school graduates to choose family practice when they launch their careers.
Fewer grads choosing family medicine
Barely 30 per cent of last year’s grads ranked family medicine as their first choice for their specialty training, according to data from the Canadian Resident Matching Service (CaRMS). The figure was 38 per cent in 2015, and has been on the decline for years.
That dwindling supply of family medicine residents in turn becomes an even smaller number of doctors choosing to enter family practice after finishing their residency.
With some prominent family doctors now publicly discouraging grads against launching a practice, it’s hard to see how the trend reverses.
Last month, the Ford government announced a deal with the OMA for a retroactive 2.8 per cent increase in compensation in 2023-24, the final year of the current physician services agreement.
Medical students need to match to a residency spot to fully qualify and get licensed as a doctor. But despite a shortage of family physicians, about 30 per cent of family residency spots went unfilled as part of a concerning decline seen over the last five years.
“I’m sorry, 2.8 per cent is a bagel and coffee,” said Dr. Alykhan Abdulla, a family doctor in Manotick, a suburb in Ottawa’s south end. “It’s going to give me that much more incentive to tell everybody to not consider family medicine.”
Ontario has two general models for paying family doctors through OHIP:
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Roughly 40 per cent of family doctors are compensated on the fee-for-service model, in which the physician bills OHIP for each time they see a patient;
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Nearly 60 per cent are on the capitation system (also known as the patient enrolment model) , in which OHIP pays the physician an annual lump sum for each patient on their roster, depending on the patient’s age and sex.
How much do family doctors get paid?
Family doctors don’t have complete freedom to choose between those models. The Ministry of Health has long had restrictions on how many physicians can join the capitation system, and the OMA wants those lifted.
Here are some examples of what OHIP actually pays in these two systems:
- $256.34 for a male patient aged 60-64 to be on the doctor’s roster for a year.
- $37.95 for the most commonly billed patient visit, called an “intermediate assessment.”
“I got a haircut yesterday and it cost me $40,” quipped Gandhi during his interview.
“There’s this stigma that family doctors are absolutely rich and they make so much money,” said Hijazi. “People are shocked when they hear that you make $38 off a visit.”
Some doctors suggest comparing that figure with what a typical Canadian insurance company pays for 30 minutes of massage therapy ($73), an acupuncture appointment ($100), or an hour with a psychologist ($240).
Meanwhile, private clinics are popping up in Ontario where nurse practitioners charge patients $80 for a consultation, double what OHIP pays a doctor.
The Ministry of Health reimburses pharmacies up to $75 for an over-the-phone review of the medications a patient is taking.
Ford promises ‘great deal’ for doctors
“It’s insulting, it’s so demoralizing for physicians to know that we are stuck in this model where our services are not valued,” Hijazi said. “Contrary to (politicians) calling us health-care heroes … they don’t actually value our work and that’s become very clear.”
CBC News asked Ford during an unrelated news conference on Friday whether his government is willing to pay family doctors more.
“We’re going to support the family doctors and by the way, I want to thank them all, they do an incredible, incredible job,” Ford said in response. “You’re all absolute champions and we’ll be able to come up with a great deal.”
Ford also described the amount of paperwork that family doctors have to do as their “number one issue” and said the government is working with the OMA to reduce that burden.
CBC News asked Ontario Premier Doug Ford whether his government is willing to pay family doctors more.
The average family physician in the province spends 19 hours a week on administrative tasks, according to an OCFP survey of its members last year.
Ontario doctors say while the paperwork burden does need to be reduced, the province could also bring in a related change to make family practice more appealing: actually pay family physicians for medically necessary administrative tasks.
Family doctor numbers jumped after B.C. pay reform
British Columbia recently revamped its payment system and is now compensating family doctors for time spent reviewing lab results, consulting with other medical professionals and doing clinical administrative work.
Since the B.C. payment changes took effect, some 700 more family physicians have opened practices — a 20 per cent jump in just a year.
Abdulla expresses frustration at the amount of time he spends on tasks that don’t involve directly caring for patients.
“Sending referrals, getting declined from referrals, fixing those referrals, dealing with all kinds of data inputs,” Abdulla said in an interview. “Filling out a disability tax credit, filling out an insurance form, writing out a sick note for people, making sure that people get a handicap sticker — all of those things take up time.”
The paperwork burden is one of the reasons why some 5,500 trained family physicians in Ontario are not actually running a family practice, said Gandhi.
He says these family doctors are instead choosing to work solely in hospital emergency rooms, at walk-in clinics, or as associates to other medical specialists.
Province adding spots in medical schools
“We need to try and encourage these people to get back into a comprehensive care family practice as much as possible because that could be done more quickly than training new physicians,” he said.
The government has promised to boost the number of doctors coming out of Ontario’s medical schools by adding 260 undergraduate and 450 post-graduate spots by 2028.
Experts say there are other ways the province could quickly connect more Ontarians to family doctors. One is to allow more physicians to practice in family health teams, alongside nurses, social workers and other health professionals supporting them to take on more patients.
About 3.4 million patients are enrolled in the 184 such teams scattered around the province, according to figures from the Association of Family Health Teams of Ontario.
Inside the Village Family Health Team in Toronto, where family physicians work alongside nurses and other health professionals.
For the past decade, Ontario has made it all but impossible for physicians to form new family health teams. All but three of the existing teams were created between 2005 and 2012.
The Ford government announced plans last month to create new primary care teams to serve about 300,000 patients. Some will be full-fledged physician-led family health teams while others will involve teams of nurse practitioners.
The federal government’s new $3.1 billion healthcare funding deal with Ontario also requires the province to create new primary care teams to help more people connect to family doctors.
Expanding team-based care is one of the OMA’s top priorities in the current negotiations, along with reducing the administrative burden and boosting compensation, says the organization’s chief executive Kimberly Moran.
“What we need to do is make sure that physicians’ real income keeps pace with inflation, just at a fundamental level,” Moran said in an interview.
She says investing in family physicians will in the long-run be better for the province’s finances and better for people’s health.
“When you have a family doctor for every citizen, you’ll see that cancers are detected earlier, you’ll see the rates of hospitalization are much lower, you’ll see that chronic illnesses are managed much more effectively,” said Moran.
