In recent months, the Ontario Ministry of Health began sending disparaging letters to doctors in Family Health Organizations (FHOs). 

Claiming to have a longstanding ministry practice of producing reports on FHO patients (despite never publicizing this before), the letters take on the tone of primary care watchdog, monitoring and assessing what is heavily implied to be misuse of public funding by family doctors. The Ontario Medical Association (OMA) sent out an email to members a few weeks ago expressing milquetoast sentiments of support for family doctors in light of Ministry scorn.

These letters have been met with fear, anxiety, resentment and suspicion that the timing relates to contentious contract negotiations currently underway between the OMA and the government. 

Is the government laying the groundwork to publicly smear FHO doctors? Do recent news stories about family doctors leaving primary care have anything to do with these letters? Whether or not the Ontario government intends to intimidate or smear family doctors as a political tactic, the result is a further poisoning of family medicine, an already dying specialty.

As an FHO doctor, I haven’t received one of these letters (yet), but I have seen copies shared by colleagues. The letters reprimand individual FHOs for having lower-than-average patient usage of their evening after-hours clinics and higher-than-average patient usage of what’s called “outside use.” High “outside use” means patients have the audacity to indulge in luxuries like visits to the ER or Urgent Care. 

The math used to determine these metrics is itself suspect, with one letter claiming that in one region, the average proportion of FHOs that saw a minimum of five patients in their after-hours clinics was 105 per cent whereas the “top performers” in the region met that minimum 81 per cent of the time. If I just lost you, don’t worry. 

You should be lost, because those numbers don’t actually make any sense.

“Outside use,” more specifically, is when a patient of an FHO sees a family doctor at a walk-in clinic or has certain services provided by an emergency doctor or hospitalist. The result is financial penalties for FHO doctors whenever their patients receive a service from another family doctor that the patient, in theory, could have received at the FHO. The fee paid to that “outside” family doctor is clawed back 100% from our FHO income. 

Even when patients receive services in the emergency department or during inpatient admissions that we could never provide from our offices, our payments are “negated” to cover the costs. In this way, the Ministry of Health has been picking the pockets of FHO doctors to pay for hospital services, for years. 

This has been bitterly complained about since it started happening in the early ‘00s, with no adjustments made to stop “negating” us for hospital services. With the proliferation of walk-in clinics and particularly virtual clinics, having our income “negated” is easier than it’s ever been, regardless of whether we provide the mandated after-hours clinics.

The government’s response has always been to advise us to “de-roster” our patients or else threaten to de-roster them so they shape up and stop what is viewed as wasteful behaviour. Sometimes this gets reported in the media when patients are alarmed at being de-rostered and blame the FHO doctor without knowing that they are following ministry advice. 

The letters recently received by many FHOs double down on the Ministry’s advice; that we should bully our patients over “outside use.” The thing is, we’re already harassing our patients to stop going to walk-in clinics. Shaming us for incurring financial penalties won’t make us harass them any harder. Nor will it change patient behaviour substantially. But it will create more conflict between family doctors and patients. 

Whatever the Ford government’s ultimate plan is for primary care (assuming there is one), a strategy that casts FHO doctors as parasitic waste-ers of public money, while the ministry claws back our incomes to pay for the supposed waste is a poor one. If the intent is to continue to dismantle and devastate Ontario’s primary care system — maybe to let a more privatized model take root in its place — then the Ministry of Health is well on its way to achieving that reality.

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Michelle Cohen is a family physician in Brighton, Ontario and an assistant professor in the Department of Family Medicine at Queen’s University.