Canada's doctors have fired back at Ontario Premier Dalton McGuinty for imposing fee cuts and urging his fellow premiers to do the same, arguing in a terse letter that it is unacceptable for governments to dictate unilaterally what physicians will be paid.
But with a growing number of provinces taking a look at the Ontario model as they try to rein in their own health-care costs, the doctors may find themselves fighting a battle with fronts across the country.
And Ontario is making it clear that it intends to stand firm. The province's Health Minister says limited fiscal resources leave her no option but to reduce the amount that is paid for some medical services.
In a letter to Mr. McGuinty dated Wednesday, the Canadian Medical Association and medical associations in 12 provinces and territories said Ontario's decision to roll back medical fees without consulting doctors is not what Canadians would want.
"The manner in which your government has imposed conditions on physicians without a true opportunity to build consensus is not acceptable and your efforts to convince the premiers from the other provinces to adopt a broken model that excludes true collaboration are wrong-headed," the medical associations write.
"Imposing your views on physicians and the public is a leadership style that comes with great risk," the letter says. "Patients expect that governments will work with physicians and that, together, they will put patients' interests first."
Mr. McGuinty wrote to other premiers late last week to encourage them to follow his lead in rolling back doctors' fees on some services. Technological advances, he argued, have made it possible to perform certain types of procedures more quickly, allowing doctors to treat many more patients an hour at the same fee per service.
His correspondence was, in part, an attempt to block a potential exodus of Ontario doctors to more lucrative jurisdictions if fees across the country are not aligned.
But the Ontario Premier is not alone in his concern about the rising costs of health-care human resources. Doctors' pay is a frequent topic of debate at premiers' meetings, and Alberta, British Columbia, Manitoba and Nova Scotia have all signalled they, too, are looking at changes to certain fees.
That has medical associations across the country worried that Ontario will set the trend, said John Haggie, the president of the CMA.
The doctors are concerned that Ontario has been unwilling to negotiate, Dr. Haggie said. "If you are looking at building a system on a go-forward basis," he said, "then having the trust and working with the health-care providers is going to yield a far better result than simply taking a slash-and-burn approach to a fee schedule.
But Deb Matthews, the Ontario Health Minister, points out that the doctors, in their letter, say the province should "continue negotiations, without any preconditions." And that is simply not possible, she said, because the provincial government cannot ignore its fiscal target.
"We can't spend any more money on physicians if we want to drive the transformation that the health-care system needs, that the patients of this province need," she said.
Money that is paid to doctors is not going to other health-care services, Ms. Matthews said.
"I have to take it from hospitals, or I have to take it from home care, or I take it from our drug plan. I can only spend the same dollar once," she said. "Ontario's doctors are very well compensated. And when I look at what are the greatest needs in our health-care system, the first thing that pops out is not that doctors are underpaid."