In Ontario, family doctors are the gateway to the healthcare system, including providing a referral for a specialist. If you are one of the nearly 2 million Ontarians without a family doctor and need to see a specialist, say a gynaecologist, it can be incredibly challenging to get the care you need.
Nam Kiwanuka speaks to Dr. Zainab Abdurrahman, the president of the Ontario Medical Association about the crisis in public healthcare.
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Research links
Meet the first Black woman elected to represent Ontario doctors: https://www.cbc.ca/news/canada/london/meet-the-first-black-woman-elected-to-represent-ontario-doctors-1.7525349
Gynecologic Surgery Delayed for Up to 3 Years in Canada: https://www.medscape.com/viewarticle/gynecologic-surgery-delayed-3-years-canada-2025a1000iev?form=fpf
A Toronto-area doctor spent 10 days caring for a dying baby without pay. Here’s why she’s speaking up: https://www.cbc.ca/news/canada/toronto/doctors-ontario-ohip-billing-rejected-9.6958953
Ontario, medical association near new compensation deal they say will help retain, recruit family
Ontario Government and Ontario Medical Association Confirm Funding Increase That Will Protect Provincial Health Care: https://news.ontario.ca/en/release/1005805/ontario-government-and-ontario-medical-association-confirm-funding-increase-that-will-protect-provincial-health-care
Ontario, medical association near new compensation deal they say will help retain, recruit family doctors: https://www.cbc.ca/news/canada/toronto/ontario-family-doctors-new-contract-1.7602189
Province's response:
Ontario's Medical Claims Payment System (MCPS) efficiently processed more than 200 million claims annually. To be clear, over 99% of these claims are paid automatically, exactly as submitted, reflecting the system's productivity.
Only a small fraction, 0.58%, of all claims are sent for manual review, and even among these, more than 95% are resolved within 30 days. In general, two thirds of these claims are categorized as Complex Surgical Claims, where there are multiple procedures performed, and where a three-tier review process, as is used in a manual review, is fitting.
Claims are reviewed in three tiers. A Claims Assessor handles the initial review, and if deemed necessary, it is escalated to an Assessment Officer, who further evaluates the claim and supporting context. More nuanced cases go to a Medical Advisor, a physician, for final review. Outcomes include full payment, partial payment, or return to the provider, and physicians can appeal with additional information.
This reliable, structured process ensures that claims subjected to manual review comprehensively align with the payment requirements of the Schedule of Benefits.
It’s ultimately disappointing that the OMA is choosing to focus on .58% of OHIP claims, rather than highlighting the real progress we’ve made together to support physicians.
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