ONTARIO CONFEDERATION OF UNIVERSITY FACULTY ASSOCIATIONS
SUDBURY AND DISTRICT MEDICAL SOCIETY
CONTENTS
Monday 2 December 1991
Election of Vice-Chair
Subcommittee report
Ontario Medical Association Dues Act, 1991, Bill 135
Ontario Confederation of University Faculty Associations
Sudbury and District Medical Society
STANDING COMMITTEE ON SOCIAL DEVELOPMENT
Chair: Caplan, Elinor (Oriole L)
Vice-Chair: Sola, John (Mississauga East L)
Fawcett, Joan M. (Northumberland L)
Haeck, Christel (St. Catharines-Brock NDP)
Hope, Randy R. (Chatham-Kent NDP)
Malkowski, Gary (York East NDP)
Martin, Tony (Sault Ste Marie NDP)
Owens, Stephen (Scarborough Centre NDP)
Sullivan, Barbara (Halton Centre L)
Wessenger, Paul (Simcoe Centre NDP)
Wilson, Jim (Simcoe West PC)
Witmer, Elizabeth (Waterloo North PC)
Substitutions:
Harrington, Margaret H. (Niagara Falls NDP) for Mr Martin
Mammoliti, George (Yorkview NDP) for Ms Haeck
Also taking part: Brown, Michael A. (Algoma-Manitoulin L)
Clerk: Mellor, Lynn
Staff: Drummond, Alison, Research Officer, Legislative Research Service
The committee met at 1537 in room 151.
ELECTION OF VICE-CHAIR
The Chair: The first item of business for today is the election of Vice-Chair of the committee. Honourable members, may I have the names for the election of Vice-Chair?
Mrs Sullivan: I move that Mr John Sola be appointed Vice-Chair of the committee.
The Chair: Are there any further nominations? There being no further nominations, I declare the nominations closed and Mr Sola elected Vice-Chair. Congratulations, Mr Sola.
SUBCOMMITTEE REPORT
The Chair: The second item today is the report of the business subcommittee concerning Bill 135. The clerk has distributed it and everybody should have it. I would like to report to the committee that I have had a request from one other group that is not listed here on the subcommittee's report.
There are two ways of handling this. We can, one, have an amendment to the subcommittee's report permitting the Chairman to substitute in, time permitting, or, two, unanimous consent from the committee to allow for a further presentation, which could take place at 5 pm. Mr Sola, which of the two options do you prefer?
Mr Sola: The second.
The Chair: Is there unanimous consent for one further deputation before the committee at 5 pm today? All agreed? Agreed. In that case, will we as well receive the report of the subcommittee as amended? All in favour? Any opposed? Carried.
Mr Wessenger: I assume there is no reason we cannot have Mr LeBlanc at the table.
The Chair: No, I am sure everybody would be very happy to have Mr LeBlanc come to the table. Do you want to introduce him so that everybody knows who he is?
Mr Wessenger: Yes. This is Dr Eugene LeBlanc. Eugene, you might introduce yourself.
The Chair: What is your title today, Eugene?
Dr LeBlanc: I guess I am still technically the executive director of corporate policy, but for the last six or seven months I have been worrying about the Ontario Medical Association agreement.
ONTARIO MEDICAL ASSOCIATION DUES ACT, 1991 / LOI DE 1991 SUR LES COTISATIONS DE L'ONTARIO MEDICAL ASSOCIATION
Resuming consideration of Bill 135, An Act to provide for the Payment of Physicians' Dues and Other Amounts to the Ontario Medical Association / Loi prévoyant le paiement des cotisations des médecins et d'autres montants à l'Ontario Medical Association.
ONTARIO CONFEDERATION OF UNIVERSITY FACULTY ASSOCIATIONS
The Chair: The first presenter is the Ontario Confederation of University Faculty Associations, sometimes referred to as OCUFA. I would ask you to introduce yourselves to the committee, all four with your titles. You have half an hour for your presentation and we would ask you to leave a few minutes at the end so that committee members may ask questions.
Ms Perrin: My name is Marion Perrin. I am the executive director of OCUFA and I will introduce the people at the table with me. Professor Dan Geagan is from McMaster University. Professor Mike Dawes is from the University of Western Ontario Faculty Association. Representing the University of Toronto Faculty Association is Allison Hudgins.
OCUFA is pleased to have the opportunity to appear before the standing committee on social development to address our concerns with respect to Bill 135. We would like to state at the outset that we applaud the government's attempts to contain burgeoning health care costs and that we support the concept of collective bargaining for the province's physicians.
Bill 135 is, as you are aware, the Rand legislation the government undertook to introduce pursuant to article 4 of the framework agreement between itself and the Ontario Medical Association. We do not oppose the introduction of the Rand formula with respect to the province's physicians, but we do have concerns with respect to its application.
There are legally constituted faculty bargaining units at the five universities with medical schools in the province which represent physicians, as defined in the agreement between the government and the OMA and as reflected in Bill 135. In some quarters, this agreement/legislation has been called an illegal raid of faculty bargaining units.
It is no doubt obvious that local faculty associations are concerned about the erosion of their bargaining power, particularly with respect to policy and academic issues. In two cases at least, there could be a significant loss of membership. The bargaining units affected are McMaster University Faculty Association, the Association of the Professors of the University of Ottawa, Queen's University Faculty Association, the University of Toronto Faculty Association and the University of Western Ontario Faculty Association.
The agreement provides for representation of all practising physicians in Ontario by the OMA. The definition of who the OMA represents in the agreement and in Bill 135 is very broad indeed. In the agreement, a practising physician is defined as including those who provide "health care, health services or health research to or for the benefit of individuals or the community." Subsection 1(1) of Bill 135 makes it clear the OMA is to receive dues from all licensed physicians "engaged in the practice of medicine in Ontario or who conduct health research in Ontario."
Pursuant to the agreement, to obtain bargaining rights or representation rights for physicians in the university sector, the OMA serves notice to bargain. After notice to bargain has been given by the OMA, the employing agency or a member of the unit being claimed may challenge the OMA to demonstrate that it actually represents those physicians. Where the OMA demonstrates it has more than 50% membership in the unit, it may bargain on compensation, matters affecting compensation or other matters agreed to by the parties. If no agreement is reached, they have the right to go to mediation and arbitration.
These provisions have been called democratic. We wish to make two points with respect to that comment.
1. It is not surprising that a large number of physicians are presently OMA members, thereby making proof of membership for representation quite easy. The OMA is the primary professional and/or educational body of physicians in Ontario.
2. The provisions under the agreement whereby the OMA proves its membership for bargaining purposes are generous in comparison to the Ontario Labour Relations Act. Under that act, proving membership and gaining representation rights is a long and sometimes painful process for unions. Notice to bargain cannot be given prior to the union proving sufficient membership desire for that particular union to represent it for the purpose of collective bargaining. Perhaps the government will extend quicker and easier organizing and certification procedures to all workers in the near future.
The situation on each of the five campuses varies dramatically. These are complex situations which can only be handled on a local basis. Four of the five bargaining units represent clinicians to some extent. There is a range of physicians' duties as professors on each campus, from those who do only research, those who do research and teach, those who have cross-appointments with hospitals and universities, to those who teach as clinicians on an occasional or part-time basis. In medicine, like law and business, a very large number of professionals teach on a part-time basis, for a variety of reasons, including prestige.
Faculty association bargaining units have traditionally represented faculty on a wide range of issues, including promotion and tenure. Generally, clinicians receive the same treatment under promotion policies, although tenure may not be applicable. Faculty also bargain for salaries and benefits, leaves of absence, including sabbatical and other educational leaves, and a wide range of academic concerns. Life in academe goes far beyond simply negotiating for salaries. Faculty associations have developed considerable expertise in these matters, particularly academic matters at the local level, and have access to expert advice from both their provincial and federal bodies.
Physician professors work alongside other university faculty within university and hospital research settings, as well as in health care settings. This illustrates one of the reasons OCUFA has proposed that the local faculty associations and the OMA work jointly in representing university physician professors.
The Association of Professors of the University of Ottawa has formally negotiated a series of collective agreements with the university administration since certification in September 1975. The recognition clause of their agreement excludes clinicians. They clearly represent physician health researchers. However, in their view, efforts by the OMA to represent the health researcher members of APUO in any matter, and assuming of course that the administration acceded to such a request, would be a breach of their collective agreement and could potentially lead to bad-faith bargaining charges before the Ontario Labour Relations Board. In addition, any impingement on negotiating, other than compensation matters for clinicians, which would affect all faculty, would be considered a breach of their collective agreement as well.
The University of Toronto Faculty Association has negotiated a series of agreements with the university administration since the signing of its memorandum of agreement in June 1977. Their memorandum covers all faculty members and librarians. Similar to the other faculty associations, policy and academic issues as well as salary and benefits are subject to negotiations with the faculty association.
The University of Western Ontario Faculty Association has been informally negotiating on behalf of faculty with the university administration since 1971. The bargaining relationship was formalized in April 1985. Their most recent agreement is for the period 1990-93. They, like the other faculty associations, also represent faculty in a grievance process.
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In September 1976 the bargaining relationship at Queen's between the administration and Queen's University Faculty Association was formalized. Prior to this time, bargaining on salaries had taken place since the 1960s. QUFA is most concerned that academic and policy issues continue to be determined in the traditional manner; that is, between the faculty association and administration.
The McMaster University Faculty Association has been in existence since 1951 and has been engaged in bargaining with the administration of the university since 1973, prior to a formalization of the relationship in 1984. The faculty association has representation on all committees in the university. Since counsel for the OMA also represented McMaster in its pension dispute with the university administration, it may be assumed he is well aware of its status. In addition, there have been negotiations between the McMaster faculty association and the clinical group at McMaster along the lines we suggest take place at each university affected by the OMA agreement and Bill 135.
OCUFA suggests the negotiation of jurisdictional issues and membership fees and issues be local in nature, due to the wide variation of circumstances at each of the universities. We are not seeking to replace the OMA in its role of negotiating fees for clinicians; that is, fee for service or a new alternative payment plan. We do, however, seek the right to retain the traditional role faculty associations have had and continue to have in representing all faculty with respect to academic and policy issues.
We agree with the Honourable Ed Philip, who said that people "have to pay for a service (they) are getting. Surely that makes sense. Why should someone get a free ride when others are paying?" Physician-professors should pay for the benefits that local faculty associations negotiate for them and for all faculty.
We are not interested in the potential litigation that could result due to the agreement and Bill 135. We are interested in working with the OMA for a productive labour relations climate for the benefit of all members of the university community.
As part of my concluding paragraph, I would like to point out an attachment from McMaster University. President Ed Daniel from McMaster was unable to be with us today. He has outlined where they are in their negotiations with the McMaster clinical group at this time. It is quite a productive process and that is what we foresee on each of the campuses.
We request members of this committee to put forward the following amendment to Bill 135:
"1(3) This act does not apply to individuals represented by faculty bargaining units in Ontario universities, except where the individual faculty bargaining units and the Ontario Medical Association have reached agreement on jurisdictional and membership issues."
In addition, late last week we proposed to the OMA that there be included in an agreement between us a dispute resolution clause at the local level to ensure that there are no untied ends in this matter. I would now like to ask Dan Geagan from McMaster to say some words.
Mr Geagan: Ed Daniel, our president, is not able to be here today -- he is employed full-time in the medical centre as part of the medical faculty -- nor is Frank Baillie, the president of the clinical faculty association. So I come as the McMaster member of the OCUFA board of directors.
These remarks are additional to the letter that is included and are not in any of the packets. McMaster has both a faculty association and a clinical faculty association. We maintain close liaison. The clinical faculty association began negotiations over this conflict, as we perceive it, before it was aware that OCUFA had any reason to be involved. Since that time OCUFA, the clinical faculty association and the McMaster University Faculty Association have been talking to one another and working towards an agreement, which the proposed amendment would support.
The president of the McMaster University Faculty Association estimates that 120 or more physicians in the medical centre have funding which is not related to fees as clinicians. Mostly, their salaries come from the university or research grants.
Academic working conditions at McMaster are negotiated by the faculty association. We are currently discussing a grievance procedure and a revised promotion and tender document. There are categories in that which would apply primarily to members of the medical faculty.
There have always been serious inequities in the medical school. Because of the way it is set up, people who are employed by the university often work side by side with people who are employed in the medical centre. Research there is not always strictly divided. This agreement, as I see it, threatens to extend those inequities into the range of the faculty because in both the teaching area and the research area, physicians work side by side with engineers, physicists, biologists and psychologists. In fact, we have people working together who would be covered by separate agreements, and particularly agreements which would cover their working conditions.
With respect to the relationships within university faculties, it is only fair to have all the people doing the same work and have conditions regarding their status in the university defined with a single agreement.
Mr Dawes: My name is Michael Dawes. I am here representing the faculty association of the University of Western Ontario. Our association was formed in 1955 and has grown since then, both in numbers and in the scope of its duties and responsibilities, and is currently recognized officially by the board of governors as a negotiating agent for the faculty on economic working conditions, including salaries, pensions and other benefits. The list has been extended since the statement you have in our brief to include much more general concerns as well.
I would like to stress that our association is not a union. We are not certified. Membership is voluntary. Our membership is currently approximately 850. It is difficult for us to get exact numbers of those members who will be affected by Bill 135 in its current form. Our best estimate, by going through a list of our members and making the decision one way or another, is 124.
Our association is deeply resentful of the way this agreement has been foisted upon us without consultation. To us, it removes a long-established right of negotiation on behalf of many of our members. I wish to speak to some of the statements that have been made by representatives of the Ontario Medical Association.
The first is that physicians are "fundamentally different from the typical university academic." This has certainly not been true in history. I would like to remind you that probably the first university in the modern western world was founded in Italy and was a medical school. The association between medical schools and universities has continued since that time.
At Western we have many professional schools: medicine, business, law, engineering, dentistry, nursing and so on. They form an integral part of the university. There is no clear dividing line between faculty. All of these professional groups are valuable for their teaching partly because of their practice.
Second, we have a statement that "the overwhelming majority of their income" -- that is, people in this group -- "is generated through the fee-for-service system." We are unable to verify this statement. We do not have access to individual incomes of our faculty members and we certainly do not have access to their OHIP billing records.
We contend that it is all over the place, that there is a real spectrum. Some of our members will have a large proportion of their income derived from OHIP billing and some will have a very small proportion. We suggest that it would be very difficult to verify that. So the statement from the OMA appears to be a matter of opinion.
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Third, I would like to look at the claim that "there has been virtually no community of interest between these physicians and other faculty." It just does not seem likely. There are 124 of these individuals who have voluntarily joined our organization. It is hard to explain why they would do that.
As I said in the brief, I do not want to rebut the letter line by line, but I would like to emphasize that we consider many of the statements that have been made in discussions so far to be merely matters of opinion and not backed up by any particular evidence.
I reinforce what Marion Perrin has said: We have no quarrel with the OMA's right to negotiate remuneration for clinical services or other issues which are properly dealt with between the OMA and the government. Some division of the rights and responsibilities is clearly appropriate. We do not see it so far. There are the two areas that Marion has outlined, jurisdiction and membership, which will be difficult to unravel. There are a lot of arrangements and careful negotiations to be done if we are to arrive at a satisfactory conclusion.
We are pleased to hear that the OMA looks forward to working co-operatively with faculty associations and OCUFA in the future, but I should point out that so far our local association has received no contact from the OMA looking for such negotiations.
The Chair: Thank you very much. Further presentations?
Ms Hudgins: Could I have just a few minutes of your time?
The Chair: I have a couple of members who would like to ask questions. You have until approximately until 10 after, so we ask that you leave a few minutes.
Ms Hudgins: I appear here on behalf of the president and the executive director of the University of Toronto Faculty Association. They have asked me to express two concerns. We had hoped that in further discussions with the OMA it would have been unnecessary to come here and express these concerns, but unfortunately we are still in a situation where we have to make them known.
We have two concerns. The first is with respect to those of our licensed MDs who are doing basic health research. They do not see patients. They do not do anything along that line, but suddenly, because of the breadth of subsection 1(1) they are going to be swept into the OMA representation. Our second concern is with those clinicians who do fee-for-service work but who have concerns with respect to tenure and promotion, ultimately academic concerns which our faculty association, if there have been difficulties, has dealt with in the past.
To date, those two areas have not been addressed by the OMA. We have no objection to the OMA continuing to negotiate for fee for service or whatever alternative payment plan may in fact be agreed to with the government, but these other two areas cause us great concern.
The Chair: Thank you very much for your presentation. We have probably enough time for each caucus to have three minutes in total.
Mr J. Wilson: Thank you very much for appearing before the committee today. One of the reasons, of course, we had asked that there be some hearings on Bill 135 was expressly because OCUFA had indicated some concerns with the legislation. We in the Ontario PC caucus are sympathetic to your plight and will be introducing an amendment tomorrow during the clause-by-clause which is almost, except for a couple of legal words, exactly what you are asking for. We will be looking for all-party support on that.
I do need to know a couple of things. One is with regard to clinicians. If the university did not have an agreement with clinicians like the one you have worked with, which you have given us in the brief from McMaster, would that mean the MDs would be paying two fees? Would they be paying an OMA fee and a faculty association fee?
Ms Perrin: One of the reasons the clinicians are interested in this agreement at McMaster is just that; they do not want to have to end up paying two fees. As we see it, there would be a rebate from the OMA fee to the faculty association fee, which is probably about one quarter or less of the OMA fees. That is exactly what is being worked on between the McMaster faculty association and the clinical association at Mac.
Mr J. Wilson: But without an amendment to the act allowing you to do that, it would be clear they would have to pay the two fees.
Ms Perrin: Yes, that is right. They would have to pay the full fee to the OMA, but the fee at McMaster is voluntary. That is why there is a potential loss of membership. Where physicians will have to pay two fees is at Ottawa.
Mr J. Wilson: I understand the fee is not really the issue; it is the other rights.
Ms Perrin: No, it is a small part of the issue.
Mr J. Wilson: You mentioned there are approximately 124 clinicians affected at Western. Do you have any idea what the total number would be at the five medical schools?
Ms Perrin: We are not sure. It comes from the federal level, I understand.
Mr J. Wilson: It is probably not accurate then.
Ms Perrin: There are approximately 6,500 doctors who are associated with universities. What "associated" means is a big question. It could mean they are just associated with them but do not do anything for them. According to these federal stats, there are 2,500 physicians who work full-time in universities, but again, I do not know what it means.
The Chair: Just for clarification, is that full-time in Ontario or across Canada?
Ms Perrin: As I understand it, and I received these from Dr LeBlanc, it is in Ontario.
Mrs Sullivan: Like the Progressive Conservative caucus, our caucus is very interested in what you have to say and our support of the issues you raise. I find it passing strange that you were not consulted in relation to the decisions that were made in the OMA agreement with the Ministry of Health and did not participate in the vote. Surely that is a significant part of the collective bargaining process.
I wondered why you have not included in your recommendation for the amendment to Bill 135 additional detail about the nature of a dispute resolution process in the course of trying to come to terms with who will represent whom. It seems to me that even with the amendment you have put forward, there still would be required a fee-splitting or fees being paid to both associations. In the case of Ottawa, clearly that would not solve that problem, but as well, when there is disagreement, when the jurisdictional and membership issues cannot be solved, why would you not want to have in statutory form a dispute settlement mechanism?
Ms Perrin: I had not suggested the dispute resolution mechanism until late last weekend, speaking with the OMA on this issue. I felt it was getting late in the process and the bill was coming up and these hearings were coming up. The amendment before you was drafted before I even thought of that. By the way, when I suggested that to the OMA last week, that was the only new issue introduced in our discussions since the summertime.
Mrs Sullivan: We may want to explore that further. If I have half a second, do you believe that in its current state and from its past history of bargaining, the OMA is currently qualified or experienced enough to bargain in relation to the unique situation of physicians on university campuses?
Mr Dawes: We have seen no evidence of that.
Mr Owens: Like Mrs Sullivan, I too found it passing strange that you feel you were not consulted on this legislation. My understanding is that this whole process went through fairly extensive consultations. I am not sure how you were missed or if it was intentional, but are you saying you were not consulted in any way, shape or form on this issue?
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Ms Perrin: Absolutely no one at OCUFA and absolutely no one from any faculty association was contacted. The first time we knew about this was in early June 1991, when we saw a summary of what the framework agreement set out with respect to universities. The interesting thing about it all is that the people who negotiated on behalf of the OMA were well aware that there were faculty association bargaining units out there, but in the terribly long process it took to get this agreement, absolutely no one thought to consult with us at all.
Mr Owens: We will certainly ask the OMA the same question. My next question is with respect to the singular bargaining units. The move these days in the health care field is towards single representation rather than having, as one of your presenters indicated, people all over the map with respect to workers in health care institutions. Coming from a health care institution just down the street, I have an understanding of that process. Why is one group taking care of the labour relations aspect with respect to wages and salaries, as I understand the OMA has done in the past, and leaving folks such as yourselves to address issues around tenure and academic issues problematic for you?
Ms Perrin: In the past the OMA has dealt with the clinical fee-for-service item and that is all. Clinicians who have needed help on their academic issues have come to the faculty associations and it is because, in that area, they have a community of interest with the rest of the people who happen to teach and do research in the university sector.
It is a very complicated area. I have worked for professors for two and a half years now and I would not pretend to be able to tell you everything about it, but the process within the university structure has been so complicated that it requires the expertise that is there and the OMA does not have that expertise. The academic area is probably more important in many ways than the salary issue.
This agreement crosses boundaries. It comes into trying to negotiate now for health researchers who have been and are clearly our members. We have negotiated academic issues for all faculty, or those policies which have been negotiated affect the clinicians, for example, as I stated, the promotion aspect or the promotion and tenure policies. That is because the expertise rests with the faculty association in all those areas and not the OMA.
The Chair: Thank you for appearing before the committee today. We appreciate your very thoughtful presentation. I am sure, if any of the committee members have any additional information they require, they can contact you. Similarly, if there is additional information you think will be helpful, since the committee will likely be making its deliberations tomorrow, I suggest you be aware of that time line so that you can, following today's hearings, submit to us tomorrow in writing anything further you would like to say to the committee.
SUDBURY AND DISTRICT MEDICAL SOCIETY
The Chair: The next presenters are the Sudbury and District Medical Society, Jack Hollingsworth and John Malloy. Please come forward and introduce yourselves to the committee members. We have all received your written presentation. You have half an hour and we would ask if you would leave a few minutes at the end in case any members of the committee have a question. Would you begin your presentation now, please. Just speak into the microphone. Hansard will pick it up.
Dr Hollingsworth: My name is Dr Jack Hollingsworth and I am here representing the views of the Sudbury and District Medical Society.
Dr Kosar: John Malloy could not make it. My name is Dr Stephen Eugene Kosar and I am also with the Sudbury and District Medical Society.
Dr Hollingsworth: Ladies and gentlemen, it is indeed an honour to make this presentation to this esteemed body of politicians today. I stand before you representing the views of the physicians from northern Ontario who are members of the Sudbury and District Medical Society. I will direct my comments to Bill 135, which deals specifically with Randing of all doctors in Ontario. However, because this was presented to the members of the Ontario Medical Association as a package deal, including the remuneration negotiations and the threshold package, this indeed must come into the discussion.
I will endeavour in this brief presentation to prove beyond reasonable doubt that, first of all, the medical doctors were not given the appropriate information on which to make the decision to vote for Randing. The OMA set out to coerce the doctors to vote on this issue with totally inadequate information and of course also linked it to the emotive issue of remuneration. In addition, I will attempt to prove to you that this package deal in reality translates into rationing of health care.
As my information package will clearly show you, we already have rationing of health care in northern Ontario, dealing with patient-to-doctor ratios three to 12 times those of southern Ontario. Let me emphasize -- and I diverge from my presentation for a moment -- that those figures are three years old. They are 1988 figures derived from the manpower review and they misrepresent things.
For example, in my own subspecialty, gastroenterology, we have lost one gastroenterologist in northern Ontario. The figures are one gastroenterologist for 152,000 patients, whereas if you compare us to southwestern Ontario, it is one for 73,000, approximately. In fact, we know there are more than 18 gastroenterologists in southwestern Ontario now. Even given those figures, which are not in our favour, we still have huge discrepancies; so we already have rationing of doctors' services in northern Ontario. Let me remind you that for every dollar spent on gastroenterology in northern Ontario, there are two dollars spent in southwestern Ontario, given your own figures, which are indeed out of date and inaccurate at the moment. We can say the same about internal medicine -- about twice the rate.
Let me turn my attention now to the Ontario Medical Association itself. Although this association is in theory a democratic body, because of the time lag it takes to become a member of the executive and inner cabinet of the OMA board, this body functions similarly to a politburo. Many of the agendas and decisions are made at the level of this inner board or cabinet and distributed downwards to council in the form of reports.
It is extremely difficult for an ordinary member of the Ontario Medical Association to influence events at this level. I can affirm that. I was present at Maple Leaf Gardens myself. It is very difficult to influence matters at this level. I know the Ontario Medical Association is in the nice position of presenting after me and can comment without my chance to rebut them. I am sure Dr Wyman or whoever is presenting will comment on this, but I can assure you it is extremely difficult to influence the Ontario Medical Association.
In addition, the Ontario Medical Association is a multimillion-dollar-a-year business and funds are provided to specific members of the OMA to sit on committees. Of course, this entails attractive trips to the metropolis of Toronto on a monthly basis for some of these people. The periods differ for different committees.
Let me also point out that the Ontario Medical Association is subject to laws under the Corporations Act and is not allowed to elect its president directly from the floor, as most unions can; unions are bound by division-of-powers legislation, I understand. This means the president does not stand on a platform and become directly elected but rises through the ranks of the inner cabinet and the board.
In addition, the Ontario Medical Association seriously differs from a normal union in that it is not just there to provide for the welfare of its members, but also describes in its mandate other issues, such as looking after the public interest. Although they describe looking after the public interest, one wonders how much of the public interest of the patients in northern Ontario they have at heart, given that we already have rationing on a two-to-one basis, at least in northern Ontario. This of course will result in draconian cutbacks in health care in northern Ontario.
In addition, members who are Randed will have their fees sent to the Canadian Medical Association to support that organization and also many journals, such as the Ontario Medical Review, the Canadian Medical Association Journal and Humane Medicine. These are distributed to doctors on a regular basis, despite the fact that they may not wish to receive them. These are not small union pamphlets distributed to members to update them on issues but indeed serious medical journals which are largely funded from membership dues.
At the council level, a motion was brought up and passed that the Ontario Medical Association would look at ways of collecting dues from non-members. This simple motion has been exceeded by far in this Randing agreement reached with the government.
Let me direct your attention to the information package and the copy of the proxy votes sent out by the Ontario Medical Association. These votes have only one column you can sign, giving the Ontario Medical Association the power to decide for you what it will do. No information was sent to the members as to how to register a negative vote. The doctors from Sudbury eventually found out, two days before the meeting in Maple Leaf Gardens, how we could bring proxies down. This is against all democratic procedures and in itself constitutes a failure of the medical association to seek the opinion of its members on this matter. One clearly gets the impression that the inner cabinet had made the decision and they achieved the high level of proxy votes by their network of committee and previous committee members distributed throughout the doctors, who are indeed the eyes and ears of the association.
The bargaining unit for negotiating fees also has quite a poor record of representing the needs of doctors in different areas. Although this current agreement may be acceptable to the bulk of the membership, most of whom are from the Toronto and Golden Horseshoe area, this is not acceptable to doctors in rural or underserviced areas.
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I direct your attention to the information package and the newspaper clippings and photocopies I have enclosed for your information. Ladies and gentlemen, clearly there is a public outcry in the Sudbury district and northern Ontario concerning the proposed changes to the delivery of health care that this package agreement will entail. I draw your attention to Northern Life, November 27, page 5. Six people on the street were stopped and asked, "Are you concerned about medical specialists leaving Sudbury because of the $400,000 cap on OHIP payments?" I ask you to read some of the comments these people, who were chosen at random by this newspaper, have made.
The Sudbury Star, Thursday, November 28: "North Facing `Second Class' Health Care." A letter to the Sudbury Star, Thursday, November 28: "We Must Find Ways to Keep Skilled Professionals." The Sudbury Star, Tuesday, November 26: "Union Urges Rae to Deal with Billings Cap Issue." Clearly, there is a public outcry in the Sudbury district.
This agreement translates into rationing of health care services, and for "joint management committee," please read "rationing of health care services." This is not acceptable to the public or to the physicians in northern Ontario. This bargaining unit, in accepting this agreement without consulting the membership appropriately in northern Ontario, has not represented our needs.
I enclose a copy of the relevant pages of the memorandum of agreement between the Ontario Medical Association and the government. The full memorandum was not circulated to us. I have one copy here for records. This was not circulated to the doctors before voting on the agreement. Fortunately for Sudbury, some forward-thinking representatives got us copies of this agreement, and indeed predictably we voted against the agreement.
I now draw your attention in particular to page 4 of the interim agreement on economic arrangements, section 10, subsections (a) and (b), which is in your package. This clearly states that threshold payment adjustments do not apply to physicians working in underserviced areas, but there is an important clause there, by arrangement with the Minister of Health or where the minister determines that a particular physician in a particular geographic or specialty area may be exempted.
I now draw your attention to the next page, the Ontario Medical Association summary of the agreement, which was a press release. This indeed is quite a rosy view of this statement. This clearly states that the threshold payment adjustments do not apply to physicians working in underserviced areas. Surely Sudbury is indeed an underserviced area, given the enclosed statistics I present to you concerning the doctor-to-patient ratios. The fact that this is a media fact sheet given by the OMA to the press -- and the government must have been aware that this was a misrepresentation -- would suggest that the government might have intervened on behalf of the doctors and their patients and constituents who are misrepresented by this Ontario Medical Association press release.
Finally, with regard to the Ontario Medical Association, the negotiations were performed prior to any consultation with the grass-roots membership and indeed were presented as a fait accompli and a package deal. The Rand agreement is a sweetheart deal for the Ontario Medical Association. The package deal is a sweetheart deal for the government, a very poor deal for the doctors and an extremely poor deal for the public, particularly those in northern Ontario.
At this point I would like to move on and direct your attention to the fact that the Sudbury and District Medical Society has been a direct negotiating body with the government and is meeting with Mr McMillan from the OHIP program, has met with Mr Floyd Laughren and Miss Shelley Martel, and indeed hopes to meet with Ms Lankin and Premier Bob Rae. I therefore submit to you that the bargaining unit of the OMA has not represented us as members and we should be allowed to form our own separate union if we so wish.
In evaluating these newspaper articles, I ask you to pay attention to the opinion of the man on the street and the public outcry that is occurring, the fact that the OMA has fallen down in its mandate as protector of the public interest. I also have submitted for your information a videotape of our most recent regional council meeting which clearly illustrates some of the problems associated with this package deal, particularly for the constituents in northern Ontario. I strongly urge you to view this videotape. It is extremely important for you to understand what the issues are in northern Ontario, and it is almost a manual of how the legislation and the government and the Ontario Medical Association should have gone about bringing changes in health care, rather than the way they have been brought upon us.
I would now like to emphasize the point that this current legislation, in total, represents rationing of medical services. We are discussing Bill C-135, which is part of a package deal presented by the Ontario Medical Association to its doctors, and I therefore feel this is relevant to my arguments.
In Sudbury, we will have virtually no obstetrical services in the beginning of the new year. Our cardiac surgeons and cardiologists will also be out of commission. We now have one neurologist. We may well have no neurologists in the new year, and other subspecialists who have co-operated with the neurologists in covering neurology no longer feel they can be part of this because their own subspecialty is indeed threatened by this legislation.
There will be a domino effect from this legislation in that each subspecialty is interdependent on the other subspecialty. For example, if a patient is admitted for cataract surgery, he may have pre-existing heart and lung problems and may require thalium stress testing or pulmonary function testing or evaluation by a cardiologist, respirologist, gastroenterologist, etc.
Once these services begin to disappear, it will be impossible to proceed with routine operations such as cataract surgery, hip surgery, etc. Also, I point out to you that it has been extremely difficult to bring Sudbury medical services to the level they are now at. I have personally striven over the last four years to recruit internists and medical specialists to the north, with much difficulty.
We have recently lost a general internist and respirologist to a southern teaching hospital. He has indicated problems with the type of lifestyle associated with living in such an underserviced area, being perpetually on call for extremely ill patients, dealing with financial cutbacks by the hospitals and dealing with geographic distances involved and logistical problems in transporting patients from outlying areas to Sudbury. These were all major factors in his decision to leave, and he has been followed by other doctors. We have lost a psychiatrist and an opthalmic surgeon recently also. Many of the specialists in northern Ontario feel the same way as this doctor did, and we feel a special case must be made for northern Ontario in this situation.
Also, it is clearly obvious that the current plan to fly in doctors from outside northern Ontario to service needs will be ineffective in saving money, and patients travelling south will cost more than the estimated $25 million that was spent last year on travel grants. In addition, fly-in doctors rarely provide long-term follow-up to patients, or indeed emergency care, but tend to hive off elective work and bring their medical income back to their home towns, which will be in southern Ontario, to spend. This will of course weaken the northern Ontario economy.
I am sure you all know that the plan -- and the OMA has been party to this -- is to allow the specialists in the southern Ontario region to have a separate billing number and then to fly north; when they are not providing services here, to provide them in northern Ontario on basically a flying-doctor regime. That videotape I have left for your reference clearly illustrates we do not want that and we do not think it is appropriate.
Finally, I would like to propose an amendment to be considered by the members of this subcommittee concerning Bill C-135. The amendment reads:
"Those doctors who belong to another medical association which collects dues may be exempted from membership from the Ontario Medical Association if they so wish."
The membership in the Sudbury area feels they have not been represented by the Ontario Medical Association. Indeed, I have heard the name coined, "the odious medical association." They have been tricked by delayed distribution of information, by misinformation to the press, which is clearly documented in your handouts, and by packaging the Rand formula with a financial remuneration package for the doctors. We feel it is totally unacceptable to have further rationing of health care in northern Ontario and can, under no circumstances, support this.
We wish to point out to you that the Ontario Medical Association is by no means a union. The president is not elected. The delegation process is extremely indirect, going via medical society, branch society, delegates to council, and finally to the Board, which then elects a representative. What this creates is a central bureaucracy which is self-fulfilling and functions in the way we have seen the OMA function over the last several years.
We did not vote directly on the Rand agreement. There was no yes or no vote possible in the proxies forwarded by the Ontario Medical Association. The Ontario Medical Association sympathizers were used to coerce other members to provide proxy votes in a positive fashion to the Rand formula.
The Ontario Medical Association also has a mandate to represent the public, which no other union has taken upon itself when looking for Randing, and indeed, many of the Randing fees go to support other factors besides the bargaining unit, publications of journals and running committees.
We wish to reinforce the statement, "No taxation without representation," particularly concerning the bargaining unit. We wish to refer you to division of powers under which union rights are protected and unions are allowed to elect their president, who runs on a platform in a much more democratic fashion than the Ontario Medical Association tends to function.
Ladies and gentlemen, if you must Rand me, I ask that you Rand me to Local 598, Canadian Union of Mine, Mill and Smelter Workers, and I will take my chances with Mr Rick Briggs, in whom I have more faith than the current leadership of the Ontario Medical Association.
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Dr Kosar: I will also address a few points. I am an ophthalmologist with subspecialty fellowship training in retinal diseases. I am the only fellowship-trained retinal specialist in northern Ontario.
I think also that Bill 135 is part and parcel of the entire OMA agreement and we must address the whole agreement. We feel that the OMA did not consider the impact of this agreement on our patients in the underserviced north. I would like to illustrate the rationing of services already occurring in my practice, and I am sure this is reflected in other people's practices.
I occasionally am involved, a couple of weeks a year, with the Canadian National Institute for the Blind which provides services in its travelling-eye van to underserviced areas in northern Ontario. They have applied for exemption from the billing cap for physicians who volunteer their time and take time away from their practices to provide services to people who otherwise would not be able to see an ophthalmologist. To date, they have not received news of any exemption, and if they do not have an exemption from the billing cap, this much-needed service will not be provided by this volunteer organization.
Last week I had a 24-year-old girl show up at my office with sudden onset of loss of vision. I felt this was optic neuritis; however, I had to arrange for an urgent CAT scan. Fortunately, due to the foresight of doctors in Sudbury in the past 10 years, we do have a CAT scan and this was readily available. Once this procedure was performed on Friday afternoon, I was advised to get a neurologic consultation. There was no neurologist to be found. This, my friends, is something that illustrates the already occurring rationing of services in northern Ontario. Had this young lady been in Toronto or somewhere in southern Ontario, she would have had a second ophthalmic consultation by now, probably a neurophthalmologic consultation as well as a neurologic consultation, and probably a magnetic resonance scan.
This is not an isolated example. There are many such examples in many specialties of rationing of services that are not available in northern Ontario. This will only get worse if the current situation continues. I would like to ask this committee to reconsider Bill 135 and to consider its impact on the patients of northern Ontario. Thank you for your time.
The Chair: Thank you very much for your presentation. I have some questions from committee members and I believe we will have enough time for about four or five minutes from each caucus.
Mr Owens: My first question is to the parliamentary assistant with respect to the statement that was made about physicians given a special billing number who fly north to treat patients so that, in fact, it is an end run around the cap. Is that true?
Mr Wessenger: I will ask Dr Le Blanc to answer that question.
Dr Le Blanc: The provision for specialists coming to the north into clinics is by arrangement usually with the physicians within the community. Wherever those physicians come from -- many of them come from Sudbury and Thunder Bay, some may come from southern Ontario -- they are exempt because there is a separate billing number. Many of them do not bother to bill fees for service. They go on sessional fees, in which case, from wherever they are, that does not affect them. The sessionals will not affect fee-for-service income.
Mr Owens: My question is to the presenters. In terms of your presentation, I heard two entirely different messages. First, you do not think your union represents you, and second, the north is underserviced with respect to health care practitioners. I do not think there is anybody in this room who would argue that the north is not underserviced in terms of medical care and we are certainly working on ways to ameliorate that concern.
The question about your union, however, is a little different. Are there not avenues for people in your section or like-minded individuals across the province to participate? In my own union, if we did not like what the executive was doing, we challenged those individuals and either removed them or had them take a more progressive line. Is that not an avenue within your organization? Have you not done that?
Dr Hollingsworth: Unfortunately, the structure of the OMA is extremely complex. There are many roads to leadership of the OMA, which takes an average time of eight to 13 or 15 years. On the central board or inner cabinet there are 23 board members. The board elects the executive. The general secretary is elected by the board, not by the membership, so what I am asking for is a little bit of perestroika in the OMA. Now, I am going to the wrong people --
Mr Owens: I find this extremely odd, to sit here having doctors complain that their union does not work.
The Chair: Mr Owens, you have used your allotted time. Dr Hollingsworth, you may answer.
Dr Hollingsworth: The reason we are presenting this is to use this as a platform to make you aware that there are very basic problems in health care that the Ontario Medical Association has not faced up to. Indeed, in the northern Ontario situation, this attitude of flying people in is not going to work, because they are not going to be living there and taking calls at night. I take calls every sixth night. If I moved to Toronto or Guelph, I would probably take calls much less frequently, for much less sick patients. We do not tend to fly people out of Sudbury; we keep our patients there. There has been much less transfer of patients down south over the last 10 years.
We have built up a really good tertiary-level health care service with the help of local politicians and the local community. We were told we could not raise money for a cancer clinic, that we could never raise $3 million. We raised $9.3 million. We were told we would not be able to get a CAT scanner, and we bought it ourselves. We have been very active in improving health care service in northern Ontario, and the doctors and the politicians and the public have all got together and done this.
What we are saying to you is, let us have our own association if we wish, if our medical society takes a vote on this. We would be willing to give them a democratic chance, unlike the OMA's attitude, which was to come with 8,500 proxies in its back pocket that were basically coerced out of the membership by what we would call OMA hacks. We will give our membership a chance to vote, and we will ask them: "Do you want to be in the OMA or do you want to be in the medical society? Do you want us to bargain for you? Do you want us to bargain for your patients? Do you want us to make your case?"
I think you will agree, ladies and gentlemen, that you have heard more about northern health care today than you have heard for a long, long time from the Ontario Medical Association.
The Chair: Mrs Sullivan, you have the floor.
Mrs Sullivan: I am interested in a particular point you raised in relation to patient service in the north and the part of the agreement that, in summary, left out some important information, which was that the threshold adjustments do not apply unless there is concurrence and agreement and participation of the minister in making that decision. That is clearly one of the things that is problematic here, in that northern doctors, it appears, cannot have the cap removed to service patients in the area, whereas southern doctors can have the cap removed to service patients in the north. While that may not be specifically applicable to Bill 135, it is certainly applicable to a portion of the agreement in which there is a problem.
I have been quite interested in comparing the population per physician, north versus south. I wonder if you are seeing, as a result of that cap, services being eliminated which might include even outreach services that you provide in communities outside Sudbury, for example, or a large location, but where you are actually taking your services on the road, which a southern doctor would not do.
Dr Hollingsworth: We provide services to all the outlying areas. First of all, any patient who becomes very ill during the night or on the weekend is transferred to Sudbury. We also provide outreach clinics all around the area, Manitoulin Island, Elliot Lake, Kapuskasing. We understand the ministry has looked at this problem and is going to give us separate billing numbers, but we have not had the final word on that.
The problem is that even with flying people in, it is the emergency services that are the most critical and these are the ones that are going to suffer. If people leave, even if they leave for three months because they have reached their cap, they are no longer available to take calls. We feel this should have been exempted perhaps from the call system. What we are asking for is an exemption for the patients of northern Ontario.
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Just look at your numbers, your statistics. Even though we feel your figures are wrong and that we could perhaps adjust them for you by 50% or 60%, we will live with your figures. Please exempt the patients. Take the threshold off northern Ontario patients and let them have the same access to health care dollars as southern Ontario patients. We ask you this as representatives of the Sudbury and District Medical Society, and we are appalled that the Ontario Medical Association has not asked you this.
Mr J. Wilson: Thank you for your very informative presentation. I do have a question for the parliamentary assistant, stemming out of the terminology used by Mr Owens. On three occasions, Mr Owens, you referred to the OMA as the doctors' union. It is fairly clear -- to me, anyway -- in reading the agreement that the OMA is going to be the doctors' trade union, but I do have a question for the parliamentary assistant. Is that government policy now?
The Chair: You can ask that of the parliamentary assistant, but not of Mr Owens.
Mr J. Wilson: They are all the same. They are all in collusion, so I will ask the parliamentary assistant. Is that government policy, that the OMA is now a trade union? I would like that cleared up for the record.
Mr Wessenger: The OMA is the bargaining agent for the doctors. Whatever you want to call that, that is basically what it is. While I have the floor, I might just say that there seems to be some lack of clarification with respect to the whole question of physicians working in underserviced areas. Any physician who is working under an underserviced area program is exempt from the threshold. I think that should be clear, and I think maybe the doctors here are working under an underserviced area program.
Mr J. Wilson: That is different, and I would like the presenters to clarify that. That is part of the problem here.
Dr Kosar: Part of the package, part of the agreement, was clause 10(a)(i), which talks about "physicians working in underserviced areas by arrangement with the Ministry of Health under the Ministry of Health underserviced area program."
I myself am under the underserviced area program because I have been up in Sudbury for only one year now. However, I have a letter here from the Minister of Health, a "Dear Applicant" letter. I had applied for an exemption, and it says that I am not exempt from the cap.
Obviously there has been a mixup in communication between the Minister of Health and OHIP, or the billing agency. I know others who have been in the same situation, so there obviously has been a lack of communication. I am not sure where that fault lies, whether it is with the Minister of Health or with the OMA, communicating to the Minister of Health who these doctors are who are participating in the program, so right now I am kind of confused.
Mr J. Wilson: In the case of specialists who do reach the cap and will be no longer practising, can you give an example of the cost to the government in terms of having to transport patients and doctors and families to the south?
Dr Kosar: I can give you an example based on my own practice, and again, this is probably reflected in other specialists' practices. I see at least 20 people a week who, before I came to Sudbury, would have had to be transferred to Toronto or another teaching centre for specialized eye care.
If you just look at the cost of the travel grant from Sudbury to Toronto, I believe it is about $150 per patient. You also have to realize that these patients often travel to other centres for repeat visits. But even if you only assume one visit per patient, at 20 patients a week, that is $3,000 a week, which translates to about $150,000 a year. I figure I am saving the government at least that much money by being in Sudbury. Transporting physicians from southern Ontario to northern Ontario as itinerant physicians will not work. It is still going to cost the government money to send them up. We need physicians to live, work and play in northern Ontario.
The Chair: Thank you very much. I have a request from Mr Hope. If the committee will permit, he would like to ask one very short question. Time has expired. What is the wish of the committee? Agreed? Mr Hope.
Mr Hope: My question stems from the $400,000, when you said you would start transferring. You mean you would have a person referred outside your community instead of treating him, even though you have met your cap? You have met your cap and you are telling me you will not see another person to treat?
Dr Hollingsworth Let me clarify that. I think that is a very good point. You are obviously focusing on finances and numbers and money here, and that is not what we came here to focus on. But if you want to focus on that, this $400,000, we do not receive this as a salary. We lose over half of it in terms of overhead, okay? Do you understand that?
We have an overhead. I have two nurses, I have two secretaries, I have a dietitian. If you come to see me, you need services. You need procedures done, you need to get dietary advice, you need to see my nurse, and that costs me money. If I am going to be paid one third of what I should get, and it is costing me 50% of what I should get, I am losing 20 cents every time I see somebody like you. I can only do that for so long before my bank manager calls in his notes, and I think you have to realize that I would become insolvent. I would like to do it, but I physically cannot do it.
Could I make one other comment with respect to the comment from the parliamentary assistant about the OMA becoming the doctors' union? If you are saying to us that the OMA is going to become our union, can you maybe suggest to it that we be allowed to elect our president or our general secretary? I personally would be quite willing to run for that job.
I have gone to the OMA this morning and put my name down for the job of general secretary. I am sure I will not be given the job, given that my views are so different from those of the current leadership of the OMA. But I think maybe they do need someone like me for a year or two. I am willing to give it two years, and I am willing to be kicked out after two years and then elect someone who is better than me if the membership so feels.
I asked the OMA's currently sitting temporary general secretary how I could go about getting elected. He said, "You could talk to Dr Wyman or Dr Thoburn." Well, I said, I am so different from those guys that the last time I talked to them they did not have anything nice to say to me. He said, "Yes, but it's tough, because they would have to change all the bylaws, and we cannot change the bylaws." I said, "Well, gee, isn't it sad, because I would like to go around and poll the membership and say, `Look, I can do something for you guys. I can do a better job than these guys are doing for you, and I can ask your opinion a lot more.' But you are saying I cannot be elected." He said, "Let me think about it." So I am waiting for his response.
The Chair: I think all members of the committee realize that your comments were facetious. Some would suggest they are not. In that case, this is your opportunity to come forward to discuss Bill 135. It really is not an opportunity for a job interview. If you wish, we could forward the Hansard of your comments to the Ontario Medical Association. In all seriousness we do appreciate your coming before the committee today and sharing your concerns with us.
The committee will be dealing with this legislation tomorrow. You mentioned before that you would not have an opportunity to rebut, and that is quite correct as far as appearing before the committee again is concerned. But if there is anything you wish to communicate to the committee, you may do so; you have all morning tomorrow. We will be meeting again at 3:30 p.m., so anything that is said today that you would like an opportunity to rebut, you can submit in writing tomorrow. Thank you for appearing today.
Dr Hollingsworth: Thank you very much, Madam Chair. I have not given up my daytime job yet.
The Chair: Do not lose your sense of humour either.
I would like to call next the Ontario Medical Association, my old friends Michael Wyman and David Peachey. Please come forward and introduce yourselves to the committee. You have a half-hour for your presentation, and we would ask you to leave a few minutes at the end of your presentation for questions from committee members. Welcome.
Dr Wyman: Thank you, Madam Chairman. I am Dr Michael Wyman, a family physician in North York and still a member of the executive of the OMA. I am a member of the board and I was the chief negotiator of the agreement from which Bill 135 arises.
I have with me today Dr David Peachey, director of professional affairs at the Ontario Medical Association, and Ms Georgia Henderson, manager of professional affairs.
The purpose of this brief is to respond to the amendments that were proposed by the Ontario Confederation of University Faculty Associations, which are intended to develop an exemption on agreement for physicians affiliated with Ontario universities from the application of Bill 135, An Act to provide for the Payment of Physicians' Dues and Other Amounts to the Ontario Medical Association.
The bill as presently proposed provides that all physicians licensed to practise in Ontario, who engage in the practice of medicine or conduct health research in Ontario, are to pay the equivalent of dues to the Ontario Medical Association on the same basis as if they were members.
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In considering the proposed amendment, it is critical that the committee be fully aware of the rationale for the payment of the equivalent-of-dues payments to the Ontario Medical Association. Once the underlying rationale is clearly understood, it is the position of the Ontario Medical Association that there can be no principled reason for exempting some physicians from the payment of such amounts on the basis that they may have an appointment to an Ontario university.
As we will discuss further, in all essential respects related to the memorandum of agreement between the government and the Ontario Medical Association, which had been sent to every member of the OMA prior to the agreement, the Ontario Medical Association plays a critical role in representing the interests of physicians who hold a university appointment. As a result, the proposal to exempt these positions from the payment of OMA dues cannot be supported either in logic or in equity.
The physicians who would be subject to this amendment consist of an undetermined number, likely in the range of 3,000 to 5,000, constituting up to 20% of the membership of the OMA. It is necessary to understand that the overwhelming percentage of these physicians do not function in an academic university setting like, for example, a history professor, but rather practise medicine in the public teaching hospitals of the province, where, integrated with their essential patient care services, largely tertiary care, they perform teaching functions.
The remuneration of such physicians consists largely of billings to OHIP, compensation which is negotiated solely between the government and the OMA. There is and can be no role for OCUFA to play in this critical aspect of clinical practice. This alone justifies the requirement that these individuals pay the equivalent of dues to the OMA.
In order to place the proposed amendment in perspective, it is necessary to understand the role which clinicians play in the health care system and the manner in which they provide their services and obtain their remuneration. Contrary to the impression which OCUFA may seek to give, all physicians who are subject to the proposed amendment are licensed physicians who practise medicine in Ontario or conduct health research. While these doctors may have some university affiliation, they are not restricted in their operation or remuneration to a university setting. Thus these physicians teach and practise in the hospital setting, where their teaching responsibilities are inextricably bound up with the practise of medicine.
Such physicians, aside from holding a university appointment, also hold a hospital appointment and generally bill OHIP for the provision of services to the people of the province of Ontario. They mostly belong to group practices and partnerships, where they carry on medical practices as independent practitioners.
Practically all physicians who have appointments in these hospitals spend a large percentage of their working day performing work governed by the OHIP schedule, and it could be reasonably estimated that 80% to 90% of their income is generated through the fee-for-service schedule which is negotiated by the OMA. While such individuals have a university appointment as well, very little of their income is derived from university sources. Real university funding, or hard moneys, were always small and have been getting much smaller all the time. Even those persons who are engaged solely in research obtain much of their income directly from OHIP amounts, since in many cases academic clinical earnings are subject to an upper ceiling and the earnings over that ceiling are used to provide income to faculty, including researchers.
Further, because the overwhelming percentage of such clinicians hold hospital appointments, their concerns are not restricted to matters dealing with the university but are critically related to all health care matters involving the operation of public hospitals and the health care system itself.
It should be noted that the government has entered into discussions with university faculties of medicine, the OMA and clinical teachers' associations with respect to altering the existing fee-for-service method of payment and establishing alternative payment plans. In a number of departments in some health science centres, agreements have been concluded directly with the government. The OMA and its designate, the clinical teachers' associations, have in most cases performed the critical role representing clinicians in dealing with the government and the deans of medicine on all issues surrounding these alternative payment plans. The faculty associations which belong to OCUFA have not been involved in these issues at any time.
The underlying rationale for Bill 135 is that all physicians in the province of Ontario who benefit from the association's activities should help to defray the costs. Historically, one critical role for the OMA enshrined in statute and recognized in the agreement is the negotiation of the fee-for-service schedule. It is also recognized that the fee-for-service schedule sets the standard for most other forms of physician remuneration.
The bill gives effect to the principle that all who benefit from fee-for-service amounts negotiated by the OMA should be required to pay their fair share of the financial efforts to obtain them. In this respect, as noted above, clinicians who hold hospital and university appointments are no different from any other physicians in the province of Ontario: The overwhelming percentage of their income is derived from billing OHIP for the performance of clinical services, and the fees which they are paid directly result from the amounts negotiated between the OMA and the government.
It would be inequitable to grant exemptions from a requirement to pay an amount equivalent to OMA dues on the basis that some of these clinicians have a small component of their total compensation from universities. Indeed, that component of university salary not infrequently is funded by OHIP billings. These moneys, often referred to as soft moneys, originate from fee-for-service billings, are remitted by clinicians to the university and then returned to the physician in the form of salary.
However, it should be noted that the framework agreement between the government and the OMA is not limited to the negotiation of the fee schedule itself. The OMA and the government have agreed to co-operate in the joint management of all physician services to achieve more value for health care spending in Ontario. To this end, they have agreed to establish a joint management committee to improve the management of the system in pursuit of high-quality medical services and related health care services in the province.
The mandate of the JMC includes action seeking to enhance the quality and effectiveness of all medical services; to develop and implement effective utilization management for all physician services; to develop and implement incentives to all physicians to bring about more cost-effective and efficient delivery of health care; to discuss strategies for the implementation of the improvement of the number, mix and distribution of all physicians; to monitor the volume changes in both the fee-for-service and non-fee-for-service systems, and to make recommendations with respect thereto.
In engaging in its endeavours in the JMC, the OMA will be required to provide significant resources, including its staff and the resources of its members. It is only fair that all Ontario physicians be required to assist in defraying the cost incurred by the OMA in the representation of all physicians in the JMC. In this respect, clinicians who hold a university appointment are no less concerned than are other physicians in relation to these issues.
It should be noted also that the OMA negotiates significant benefits for all physicians, whether fee-for-service or non-fee-for-service, including the reimbursement of certain Canadian Medical Protective Association payments. These amounts, which defray liability insurance payments, also are payable to physicians who hold university appointments.
The OMA represents all physicians in the development of social and health policy in the province and represents all physicians in consultations respecting possible legislation. Through the work of the department of health policy and its committees, public policy and public health are impacted in countless areas of clinical endeavours.
In summary, the historical rationale for the Rand formula, that all who benefit from the activities of an organization should contribute to that organization, applies with significant force to these particular physicians because of the OMA's traditional role in representing all physicians in such areas as fee-for-service and benefit negotiations, because of the significant impact that its role on the JMC will have on all physicians in the province, and because of its historic role in the development of public health policy in the province.
In all other provinces where Rand legislation has been enacted for physicians, no exemption is made for physicians who hold university appointments. In Ontario, given that the OMA carries out the same functions as organizations in other provinces and has now assumed even greater responsibilities through the JMC in matters affecting both fee-for-service and non-fee-for-service physicians, and in furthering the public interest by working towards the establishment of a more effective health care system in the province, there is no rationale for such an exemption.
It is simply wrong for OCUFA to assert that the provisions of Bill 135 result in the raiding of membership. The OMA has always represented clinicians with university appointments in fee-for-service negotiations and has been involved with them recently in discussions regarding alternative payment plans. These physicians have always been an integral part of the OMA organizational structure. For example, the current president of the OMA, Dr Adam Linton, is a full-time clinician at a teaching hospital affiliated with a university. So too is the former president of the OMA and current president of the Canadian Medical Association, Dr Carol Guzman. I am not a full-time but a part-time clinician, holding the appointment of assistant professor in the department of family and community medicine.
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The OMA has had a central role in representing all these physicians because their sources of income and professional lives are entirely different from other university faculty. Historically, there has been no community of interest between these physicians and other faculty in these respects. One point should be made very clearly, and there appears to have been some misconception about this in the debates in the House, that to the best of the OMA's knowledge none of the opposition to this bill, on the basis advanced by OCUFA, has come from the clinicians themselves. We stand to be corrected, but we are not aware of any clinician with a university appointment who has come to us and said this bill is unfair because of some impact on a faculty association. Indeed, these clinicians were a large part of the 80% of the voting OMA membership that overwhelmingly approved the new agreement with the government, including the provisions respecting dues deductions last spring, having had a full and profound discussion of the contents of the agreement prior to the presentation at the annual meeting and the general meeting.
It should be noted that the physicians in question are not precluded from joining faculty associations in addition to the OMA, and the faculty associations are not precluded from having a role in certain aspects of university life affecting these physicians. This fact, however, does not in any way justify exempting these doctors from the obligation to pay dues to the OMA, which clearly has and will continue to represent them in a myriad of ways relating to their professional life. Membership in faculty associations will remain, as at present, a voluntary decision by individuals, and the OMA will not interfere with physicians who choose to belong to such associations in addition to the payment of the equivalent of dues to the Ontario Medical Association. Thus the allegation of loss of membership by OCUFA cannot be supported. Moreover, the OMA and clinical teachers' associations wish to work positively and co-operatively with faculty associations in areas of common interest and concern. It has been our desire all along to develop a co-operative working relationship, and we will continue to approach that. This has been and continues to be clearly expressed to OCUFA. Concerns regarding the legislation in these circumstances constituting a threat or a raid are simply unwarranted.
Finally, the adoption of the proposed OCUFA amendment could seriously jeopardize the ability of the parties, both the government and the OMA, to engage in good faith negotiations in the future. The agreement entered into between the government of Ontario and the Ontario Medical Association and its members provided that the government would support the statute providing for the payment of dues by all practising physicians. In this respect, it stated specifically:
"The government undertakes to introduce and support a statute, to be given first reading before June 30, 1991, and effective as of that date, providing for the payment of dues or their equivalent to the association by all practising physicians in Ontario. The principles of this statute are set out in the appendix A to this agreement."
It would simply not be a measure of good faith, which would facilitate the type of relationship which the government and the OMA clearly envision, to have one party unilaterally alter the agreement reached at the bargaining table. The future stability of the bargaining relationship requires that commitments made at the bargaining table be honoured and implemented.
In light of the foregoing, there is no reason in policy or logic to exempt physicians who hold university appointments from the effect of Bill 135. Indeed, the purpose of Bill 135 can only be served if such physicians are included within its ambit.
In response to some of the comments that were made in the representation by OCUFA and the request that there be a local negotiation of fees and roles, and to continue to develop the relationship between the local faculty associations and the OMA, we absolutely agree. We do not believe that has anything to do with the passage of Bill 135. We contend that this type of negotiation and local agreement would continue beyond the passage of the bill and would enter into an agreement in each of the areas.
I would remind you that prior to the agreement being signed, there were agreements that had been developed between the clinical teachers' associations in each of the five universities that understood fully the content of the agreement.
Mr J. Wilson: Dr Wyman, you talk about agreements with faculty associations. The amendment we are putting forward would really require you to enter into an agreement with faculty associations before the act would apply to the positions currently covered in the university environment. You may want an opportunity to explain in a minute or so exactly why you could not come to an agreement with those faculty, given that you are talking about co-operation.
I am a former governor of the University of Toronto and spent two years, a considerable amount of time as I recall, talking about benefits, salaries and working conditions for medical practitioners in the faculty of medicine. I have a brother at the University of Western Ontario who is one of those people: I do not understand. I have a great deal of sympathy for OCUFA in terms of those people, including my brother, who work 24 hours a day at the university and have nothing to do with the OMA. He certainly looks at his faculty association as his representative.
Dr Wyman: Currently, 80% of the members of the teaching faculties around the province are members of the OMA. To have Bill 135 apply to the other 20% would not have a significant impact on their ability to continue to function as they do. In fact, we are in the process of negotiating on behalf of a large number of clinical teachers' associations and we reached agreement with the clinical teachers' groups prior to the passage of the bill. There are a large number of clinicians who have university appointments who never heard of OCUFA before this time. I am a clinical teacher and I was not aware of OCUFA or of any direct involvement by the University of Toronto faculty association on my behalf.
Mr J. Wilson: I do not recall any physicians ever showing up at the board of governors' meetings, which means the interest is pretty low there.
Dr Wyman: The OMA continues to function in a large number of areas that continue to impact on the practice of medicine outside of the direct appointment. I think Dr Peachey could enhance that a little bit, as he has been doing much of the negotiations with universities.
Dr Peachey: Perhaps I could clarify one thing the member stated: The arrangement and letters of understanding the OMA has signed for the past two years have been with the clinical teachers' associations and not the faculty association per se. The clinical teachers' associations are growing and strengthening organizations in the province on the basis that the clinical teachers in the five health sciences centres were looking for local organization in terms of representing many of their interests. It was with that in mind that the corporate OMA certainly believed it did not have the basic academic standing and understanding of the complexities of academe, and it is very supportive of the CTAs in that regard.
Mr J. Wilson: On the collection of OMA dues by the government, does the OMA reimburse the government for collection of dues and the administration thereof? It seems very strange to me that the government is in the business of collecting the dues of a trade union which it is terminating. It just blows my mind. I do not think my constituents would necessarily agree with this precedent setting. There is nothing I can do about it, I know, because it is not necessarily part of Bill 135 in that the government will vote as a block against it, but I would be interested to know whether the government is getting any reimbursement for this.
Mr Wessenger: Under this bill the government will be collecting the dues and there will be no charge to the OMA. Just as with any employer who collects dues, there is no charge to the association.
Mr J. Wilson: Is the cost of operating the joint management committee shared by the government? It seems to me it has a pretty wide mandate and will be doing a lot of work over the next few years.
Mr Wessenger: I understand the Ontario Medical Association members bear their own costs of participating in the joint management committee.
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Mr Malkowski: I would like a point of clarification in terms of the membership election process. The members have a direct involvement in electing the executive directors of the OMA. Could you explain that for me, please?
Dr Wyman: There are two streams within the Ontario Medical Association: the staff and an elected representation. The chief executive officer of the OMA is a paid position and is responsible to the executive and the board of the Ontario Medical Association. The Ontario Medical Association has 24 board members elected by region, by population around the province on an annual or biannual basis. These elections are open to all members of the association and the executive of the OMA is elected from the membership of the board.
The president of the OMA is part of the executive and is elected by the board, so there is direct representation through the membership to the board and to the executive. An additional component of the democratic process involves our council, which is a representation by population around the province and is broken down into branch societies basically related to a geographic region usually centred on a hospital. This consists of approximately 200 people elected by local representation so there are two very clear avenues of approach for the general membership of the Ontario Medical Association towards the decision-making process.
Mr Brown: I am interested in your public interest mandate. We have heard from the previous presenters about the lack of positions in certain parts of the province, particularly northern Ontario. I will speak about that since I am a northern member. The distribution in northern Ontario is remarkably less than in the south, but I will not go through the figures right now. I wonder how this agreement is going to help northern physicians or attract people in the various specialties to the north. It is not good at present and I cannot see this helping.
Dr Wyman: I do not believe Bill 135 will have any impact whatever on whether physicians go north or south, since it has to do with mandatory dues. The general agreement between the government and the OMA, in its extended process, really sets up through the joint management committee the opportunity for the OMA and the government to work conjointly towards developing manpower policies and a way of resolving the issues. I think there is a very clear desire by the Ontario Medical Association, both its elected members and staff members and the membership of the organization itself, to provide adequate health services to all people in Ontario in whatever location they happen to live. There is also a current action plan being developed through the OMA and the joint management committee on these very issues.
Mr Brown: I realize this is about the Rand formula, and I have just heard a presentation from members of a large medical society in this province from northern Ontario that told me they do not think the OMA represents their views. Their view is that this formula exacerbates a shortage of physicians in northern Ontario. Just so you understand, if you figure out the allocation per capita in the regions, this formula means the north will get about $200 per capita less for each position in northern Ontario. That is what this does. I can understand that the physicians in northern Ontario are pretty unhappy about that. More than that, the patients, the people of northern Ontario, are pretty unhappy about it.
In your public interest mandate, when we have a letter from the minister saying she is not going to extend this, I do not understand when you talk about negotiating. The minister said what she is going to do. She is not going to negotiate -- no more extension of the underserviced program grants or lift of cap.
Dr Wyman: The OMA has publicly stated that we felt the decision by the minister up to this point was against the intent of the agreement, and that the decision to have no further exemptions applied was an inappropriate process. There have been ongoing discussions, both prior to that time and since that time, to try to extend the exemptions, to try to provide for continuing services to the people of the north. We do not agree that the application of lack of exemptions is an appropriate method of providing services to the people of the north or the south.
Mr Brown: In the jargon of labour relations, we would say now that the Minister of Health is acting in bad faith in terms of this agreement.
Dr Wyman: I would have to say that is not the case. The Minister of Health has acted to the letter of the agreement and has fulfilled the exact wording of the agreement. It was not our intent when we negotiated the process that there would no exemptions, and we continue to try to work to provide exemptions for services in the north and underserviced areas. I would certainly not say that it was negotiating in bad faith.
Mr Owens: Madam Chair, I must state that I am quite impressed with the amount of latitude you have allowed the committee to have with respect to questions.
The Chair: What I have done, Mr Owens, is try to divide the time equally among the three caucuses. We have until 5:20 to complete the amount of time.
Mr Owens: My question is with respect to OCUFA and other such interested parties. You indicated that discussions had been ongoing. Will those discussions take place with respect to their concerns around faculty and tenure and other such related issues that they have an interest in?
Dr Wyman: Yes sir, they would.
The Chair: We have until 5:20, which is approximately three more minutes, to complete the time allotted for the presentation, and I have two requests, one from Mrs Fawcett, one from Mr Hope. Can you each try and take one minute?
Mr Hope: One is no problem.
Mrs Fawcett: Thank you, Madam Chair, I appreciate that. Being a brand-new member to this committee, I am trying to comprehend as much as possible. I am just wondering, what is the budget for the joint management committee? Does anyone have an idea on that budget?
Dr Wyman: I am not sure it is clear yet what the budget requirements will be. The JMC has just begun to meet. There have been discussions about developing a substructure to provide the research requirements for it. It will be meeting on a monthly basis with the costs for each side being borne by each side.
Mrs Fawcett: On a 50-50 cost-sharing basis?
Dr Wyman: We would each bear our own costs, yes. As the program of the joint management committee develops, I think we are going to have to find what the budget will be as it grows in terms of its involvement in public policy. At this point it is impossible to tell what the extent of the cost will be.
Mrs Fawcett: So that will be decided when you get the plans done and as it goes on.
Dr Wyman: Yes.
Mr Hope: Before I get on, I am totally in favour of the principle of the Rand formula. I hear a lot of allegations about southwestern Ontario being so fully medicalized; I must say that we are not. Coming from a rural area of southwestern Ontario, Chatham, we are missing a lot of services which are provided in the larger centres.
Through this bill you are the representative body of the profession, whether it be a union, as some people have a hard time saying. How can the underserviced areas, which are really not identified by Northern Life or whatever, in southwestern Ontario play an active role in making sure that the concerns of their communities are brought to your attention so that you can work jointly with the government in bringing those to light? My concern is that you being the representative body, if I have concerns in my area -- and the doctors do have concerns about getting the specialists into my area -- how can I use that as an active way of getting our concerns into your organization?
Dr Wyman: Within the Ontario Medical Association we have an additional structure process to the one I identified previously, which involves sections of physicians who have like interests. We have a section of rural practice; we have sections of family practice; we have sections of specialty interests. Through those areas, any problems of maldistribution of services will come to light. The people who function in the areas we often refer to as being underserviced are not classified by the government as being part of the underserviced areas program. A large number of those that are not covered will bring their plight to our attention.
We also have a regional representation, as I have identified, that will allow those members from the southwestern Ontario region and from central Ontario and other areas help to bring that forward. There are also local medical societies, for example Kent County Medical Society, that will look after local issues and again bring that through to the central organizational structure.
We are looking forward to being able to help resolve some of these issues through the joint management process.
The Chair: Thank you very much for your presentation today. We appreciate your coming before the committee. As you have heard me mention to other presenters, the committee will be dealing with this bill tomorrow, and if there is any additional information you think would be helpful to the committee, we ask that you submit it tomorrow in writing before 3:30.
Dr Wyman: Thank you, Madam Chair.
The Chair: Thank you very much. We had a request from another group that wished to make a presentation to the committee. I do not have the names of the individuals. Is there anyone here at this time who would like to make further representation to the committee on Bill 135? Last call.
Is that it? I can only assume that those individuals who had asked to appear before the committee today were unable to come. If they happen to be watching the presentation, and for anyone else who is viewing, as I have mentioned before, the committee will be dealing with this legislation tomorrow beginning at 3:30. If there is anyone who wants to let the committee know how he feels about it, I suggest he communicate in writing to our clerk prior to the beginning of the hearing, which will be at 3:30 tomorrow afternoon.
The committee formally stands adjourned. However, there will be a meeting of the subcommittee immediately following the formal part of this meeting.
The committee adjourned at 1722.