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Guyatt also suggests that “intellectual conflicts of interest are completely ubiquitous” and have generally been ignored.

Thus the board's justification for putting him on contract to provide advice on projects: "The former CEO has specialized knowledge and experience with partnerships solutions." Still, the Partnerships brass were not oblivious to the conflicts that might arise if Blain were retained as a consultant on a project that was also being vetted by the board.

"In order to mitigate the risks of any conflict of interest arising from this arrangement," the review reported, "the board chair was required to recuse himself from any meetings where his projects or his contract were being discussed." Instead, another member of the board was designated to serve as temporary chair. The designated lead director also oversaw the authorization of Blain's consulting contract. "While this conflict of interest issue appears to have been generally well managed," the finance report went on to say, "there could be the perception by some stakeholders that the contractor role still conflicts with the board chair's role of providing independent oversight." Any such perceptions were history by the time the report was completed in July 2014. Blain had already departed as board chair earlier in the year, replaced by Dana Hayden, a former deputy minister turned private consultant.

The internal auditors didn't let Partnerships entirely off the hook for tolerating the unorthodox arrangement in the first place. "The government should consider reinforcing the conflict of interest guidelines for board members of crown corporations and government agencies and ensure that those guidelines are appropriately followed." In other words, "not guilty, but don't let us catch you doing it again." The audit findings, including recommendations to rectify other questionable procedures at Partnerships BC, were forwarded to a steering committee of government and industry representatives, chaired by deputy finance minister Peter Milburn. The committee reported back to Finance Minister Mike de Jong on Oct. 23 with further recommendations for tightening up procedures at Partnerships.

De Jong released both reports and accepted both sets of recommendations in the course of announcing the change of direction for Partnerships BC on Dec. 16 of last year. That was the same day the Liberals chose to announce they were greenlighting construction of a hydroelectric dam at Site C on the Peace River. Just one of those amazing coincidences, but it goes some way to explaining why there was relatively little reporting of the findings regarding Partnerships BC.

There matters stood until this week, when the New Democrats, drawing on a wealth of material gathered by their research department, challenged the Liberals over Partnerships' dealings with Larry (Two Hats) Blain. The highlights package: The contract with Blain's delightfully named consulting firm, Aardvark Insights, was worth $219,000. During that same four-year span he also collected $188,836 in fees and expenses as chair of the board. All this atop the $264,000 he was paid to serve as a director of three other government-owned corporations, and the almost $4 million he was paid for his eight-year service as CEO.

"There's plenty of Blain to go around," quipped one press gallery wag as the New Democrats built their case against the Liberals during question period Wednesday. Another joke making the rounds rebranded P3s as B3s, for "Blain, Blain and Blain" Responding for the government, de Jong paid tribute to Blain's well documented contributions to the agency and cited the audit findings that "the conflict issue appears to have been generally well managed." But he also said this: "Whilst one can suggest that by recusing and taking (other) steps ... the procurement process is properly followed, the standard that we set and expect of agencies, the leadership within those agencies, goes beyond that. There must not only not be a conflict; there must be no appearance of a conflict." Which is as close as the finance minister came to admitting his sense of relief that when the audit branch blew the whistle on this arrangement, Blain had already left the building at Partnerships BC.

The Facts: In 2012, the Health Employers' Association of British Columbia introduced an Influenza Control Program Policy requiring health care workers to get a flu shot or wear a mask while caring for patients during flu season, which the union grieved. The employer, representing six Health Authorities in B.C., implemented the policy in response to low vaccine coverage rates of health care workers and an inability to achieve target rates of vaccination through campaigns promoting voluntary vaccination commencing in 2000. Acting on the advice of Dr. Perry Kendall, B.C.'s Provincial Health Officer, and relying on evidence suggesting that health care worker vaccination and masking reduce transmission of influenza to patients, the employer moved towards a mandatory policy. Asserting that members had the right to make personal health care decisions, the B.C. Health Sciences Association filed a policy grievance, contending that the policy violated the collective agreement, the Human Rights Code of British Columbia, privacy legislation, and the Canadian Charter of Rights and Freedoms. Extensive expert medical evidence during the hearing indicated that immunization was beneficial for the health care workers themselves, but was divided as to whether immunization of health care workers reduced transmission to patients. The evidence was similarly divided as to the utility of masking.

Comment:

Having determined that the policy was reasonable under the KVP test, Diebolt turned to the Irving test applicable to policies that affect privacy interests, which he characterized as requiring an arbitrator to balance the employer's interest in the policy as a patient safety measure against the harm to the privacy interest of the health care workers with respect to their vaccination status. Determining that the medical privacy right at stake in the annual disclosure of one's immunization status did not rise to the level of the right considered in Irving, which involved "highly intrusive" seizures of bodily samples, Diebolt further held that the employer's interest in patient safety related to a "real and serious patient safety issue" and that "the policy [was] a helpful program to reduce patient risk." Diebolt also considered that the employer had chosen the least intrusive means to advance its interest in light of the unsuccessful voluntary programs and in providing the alternative of masking. To quote the arbitrator: "[W]eighing the employer's interest in the policy as a patient safety measure against the harm to the privacy interest of the health care workers and applying a proportionality test respecting intrusion, based on the considerations set out above I am unable to conclude that the policy is unreasonable."

Diebolt also upheld the masking component of the policy as reasonable, finding on the evidence that masking had a "patient safety purpose and effect" by inhibiting the transmission of the influenza virus, and an "accommodative purpose" for health care workers who conscientiously objected to immunization. Observing that mandatory programs have been accepted in New Brunswick and the United States, Diebolt also considered that regard should be paid to the precautionary principle in health care settings that "it can be prudent to do a thing even though there may be scientific uncertainty." Moreover, he held that the absence of a reference to accommodation did not make the policy unreasonable, noting that this duty was a free-standing legal obligation that was not required explicitly to be incorporated into the policy and that any such issue should be addressed in an individual grievance if made necessary by the policy's application. He also rejected the union's submission that the policy could potentially harm health care workers' mental and physical health, considering the evidence to fall short of "establishing a significant risk of harm, such that the policy should be considered unreasonable."

Turning first to the KVP test, specifically whether the policy was consistent with the collective agreement and was a reasonable exercise of the employer's management rights, Diebolt noted that the only possible inconsistency with the collective agreement would be with the non-discrimination clause, given his ruling regarding the scope of Article 6.01, and that he would address this issue in his reasons with respect to the Human Rights Code. Diebolt then turned to the reasonableness of the policy and found, after an extensive review of the conflicting medical evidence that: (1) the influenza virus is a serious, even fatal disease; (2) immunization reduces the probability of contracting the disease; and (3) immunization of health care workers reduces the transmission of influenza to patients. Accordingly, Diebolt reasoned that the facts militated "strongly in favour of a conclusion that an immunization program that increases the rate of health care immunization is a reasonable policy."

Diebolt instead regarded the policy as a unilaterally imposed set of rules, making it necessary to establish that they were a legitimate exercise of the employer's residual management rights under the collective agreement and met the test of reasonableness set out in Lumber & Sawmill Workers' Union, Local 2537 v. KVP Co., [1965] O.L.A.A. No. 2 (QL) (Robinson). In addition, given that the policy contained elements that touched on privacy rights, Diebolt held that the policy must also meet the test articulated in CEP, Local 30 v. Irving Pulp & Paper, Ltd., 2013 SCC 34 (CanLII) (reviewed in Lancaster's Disability & Accommodation, August 9, 2013, eAlert No. 182), in which the Supreme Court of Canada held that an employer cannot unilaterally subject employees to a policy of random alcohol testing without evidence of a general problem with alcohol abuse in the workplace, based on an approach of balancing the employer's interest in the safety of its operations against employees' privacy.

In a 115-page decision, Arbitrator Robert Diebolt denied the grievance and upheld the policy as lawful and a reasonable exercise of the employer's management rights.

The Decision:

As noted by the arbitrator, no Canadian decision has addressed a seasonal immunization policy similar to the policy in this case. However, a number of decisions have addressed, and generally upheld, outbreak policies mandating vaccination or exclusion on unpaid leave. B.C. Health Sciences Association President Val Avery expressed his disappointment in the arbitrator's ruling, stating: "Our members believed they had a right to make personal health care decisions, but this policy says that's not the case." Avery said the Association is studying the ruling and could appeal. On the other hand, Dr. Perry Kendall, B.C.'s chief medical officer of health, applauded the decision, calling it a "win for patients and residents of long-term care facilities."

In 2012, Public Health Ontario changed its guidelines to call for mandatory flu shots because not enough health care workers were getting them voluntarily. Other municipal public health units – led by Toronto Public Health – also called for mandatory shots. Ontario's chief medical officer of health, Dr. Arlene King, stated in November 2013 that, while the government wants to see a dramatic increase in the number of health care workers who get a flu shot, it is stopping short of making vaccinations compulsory, but has instead implemented a three-year strategy to "strongly encourage health care workers to be immunized every year." She acknowledged, however, that the number of health care workers getting inoculated remains at 51 percent for those employed in hospitals and 75 percent for those in long-term care homes. For further discussion of the validity of employer rules, see section 14.1 in Mitchnick & Etherington's Leading Cases on Labour Arbitration Online.

The data, which were released Sept. 30 by the Centers for Medicare & Medicaid Services (CMS), a branch of the US Department of Health and Human Services that manages care for more than 100 million Americans, describe 4.4 million payments totalling $3.5 billion. The payments were from commercial sources for “consulting fees, research grants, travel reimbursements, and other gifts” made to 546 000 US physicians and 1360 teaching hospitals during the last five months of 2013.

Early analyses of the data reveal that some drug-makers spend lavishly on doctors, especially doctors from a small subset identified as “thought-leaders” who communicate with their peers most energetically in return for compensation in cash or luxury travel and other in-kind payments.

But with the pharmaceutical industry alone spending about $30 billion per year promoting products, and with 90% of that money directed to physicians and other prescribers, the scale of inappropriate relationships aimed at distorting evidence-based clinical judgments for commercial gain is potentially significant, says Neil Kirschner, senior associate for Health Policy and Regulatory Affairs, American College of Physicians.

Not all financial relationships between clinicians should be viewed as improper, the CMS cautions. In a statement emphasizing “the importance of discouraging inappropriate relationships without harming beneficial ones” the agency underlined that many payments support research and other medically important activities.

“This is an opportunity for the public to learn about the relationships among health care providers, and pharmaceutical and device companies,” CMS Administrator Marilyn Tavenner said in a statement accompanying the release of the data on CMS’s “Open Payments” website. The release was mandated under the “Sunshine” section of the US government’s 2010 Patient Protection and Affordable Care Act.

New data from the US describe 4.4 million payments to physicians totalling $3.5 billion.

Kirschner and Wen both mix their praise for the CMS with criticism of the quality and scope of the data released so far. The information is for a partial year only, and about one-third of the records were withheld due to concerns about accuracy voiced by the American Medical Association and other groups. CMS’s decision to exempt payments within continuing medical education programs also attracted heat.

The primary beneficiaries of the CMS disclosure will be patients, Kirschner believes. “The public availability of this data will increase patients’ trust in doctors,” he says. “The evidence suggests even little things like meals can have an effect on prescribing and that there will likely be a reduction now in things you would want reduced, like free trips for doctors paid for by industry.”

These observations, Kirschner notes, are rooted in evidence after the State of Massachusetts began publishing state-wide data in 2004 similar to what CMS has released (Arch Intern Med 2010;170:1820–6).

Dr. Leana Wen, founder of Who’s My Doctor?, an advocacy group calling for full physician disclosure of all commercial relationships, agrees with Kirschner’s view that the CMS data dump will yield salutary results for patients.

These latest data are a “very good start,” but Wen would like to see far more financial data made available, including information about how physicians are paid. “It can make a huge difference to the care they receive if payment is by volume of procedures delivered.” The group is also calling for physician disclosure about their political affiliations and “philosophy of practice” concerning issues such as contraception, abortion, early breast cancer screenings and vaccination.

“Plenty of studies have shown that marketing relationships between physicians and health care companies can introduce conflicts of interest that influence prescribing, research, education, use, and ultimately patient outcomes,” says Kirschner. “And there is substantial evidence that this is often in ways that favor the company’s interests.”

Despite the shortfalls, Canadian lawmakers should follow the US lead, says Dr. Andrew Boozary, cofounder of Open Pharma, a Toronto-based group that advocates for greater medical transparency. “A province like Ontario could take up this charge. There’s no doubt that patients benefit from financial disclosure.”

Boozary notes that conflict-of-interest disclosures are now the norm in medical research and publishing. “Patients clearly deserve the same.”

Emily Nicholas, spokesperson for Patients Canada, another group that advocates for medical transparency, agrees. “It seems contradictory for a health system or government to promote patient engagement, patient-partnership, self-management and shared decision making and yet withhold certain information that they believe patients don’t need, can’t handle, or will over-react to.”

After leaving that hospital in July, 2005, Mr. Georgiou took a top position with the province's procurement agency, Infrastructure Ontario. But outside of his day job, the former executive began working for a private family construction business, Toronto Engineering Company (TECO). By March, 2006 - and until December, 2007 - TECO was working for St. Joseph's hospital. During this period, Mr. Georgiou became involved in a scheme to defraud York University with bogus construction invoices.

Mr. Georgiou used two family businesses, including TECO, to invoice the university for $64,800 worth of renovation work he acknowledges his company never performed. (Mr. Georgiou was not charged criminally and reached a settlement with the university.) When The Globe presented evidence to St. Joseph's last September that the hospital had also done business with TECO, the health centre hired Deloitte to investigate. The firm completed its probe this past spring. Deloitte found that over the course of nearly two years, St. Joseph's Health Centre processed 18 TECO invoices worth about $223,000 for repairs, painting and project management. The report shows Ms. Bahl approved all but five. (The hospital's thenproject manager of redevelopment, Doug Wilson, signed off on the rest.)

Deloitte found no evidence that Mr. Georgiou declared his TECO ties to the hospital, although internal hospital e-mails suggest Ms. Bahl was aware of his connection, the review states. Through their lawyers, Mr. Georgiou and Ms. Bahl criticized the fairness of the reviews. The report was not a full-blown audit and drew no conclusions. Deloitte did not interview Mr. Georgiou, Ms. Bahl or any other former hospital employees or vendors.

In a letter to The Globe, Mr. Georgiou's lawyer, Gavin Tighe, said TECO's dealings with St. Joseph's began after Mr. Georgiou left, so there was no conflict, but that, regardless, his client disclosed those ties. "TECO competitively bid on work at St. Joseph's Health Centre," Mr. Tighe wrote, adding that "TECO did not at any time contract or pay BJ Quality Flooring or Darwin Fisher Flooring to perform work." Deloitte also determined that there "may also have been an attempt to conceal" the involvement of Ms. Bahl's husband in the renovation projects.

Travis Walker, a lawyer representing Ms. Bahl, wrote to The Globe that Ms. Bahl "denies any impropriety" and that "any potential conflict of interest was disclosed to senior management" and "no concerns were ever raised." It is not clear exactly what policies Mr. Georgiou and Ms. Bahl may have violated, because St. Joseph's has refused to comment on the rules it had in 2007. A hospital spokesperson said "gaps in the procurement process at the time are historical and have since been mitigated" and that Deloitte unearthed "no substantive findings that indicate any further exploration is required." St. Joseph's would not answer questions on the report. When Mr. Georgiou left St. Joseph's Health Centre, he was one of the most powerful and connected members of the hospital, having served as vice-president for five years and interim CEO for 10 months.

About a month before he began working for Infrastructure Ontario in January, 2006, Mr. Georgiou's family members registered TECO in Ontario. Mr. Georgiou's wife, Helen Saoulli, and her parents were listed as directors. Mr. Georgiou acted as a project manager for TECO, according to a statement he made during the York investigation. Over the next two years, TECO invoiced St. Joseph's for work that included installing a new security gate for the emergency department, wall patching and painting, and disposal of chemical waste, documents obtained through a Freedom of Information request show. BJ Quality Flooring, the company owned by Ms. Bahl's husband, Bojidar Danef, was listed as a subcontractor on seven of the quotes, the Deloitte review found.

The auditing firm noted there may have been an attempt to conceal Mr. Danef's involvement because, at some point in the process, BJ Quality Flooring was changed to "Darwin and Fisher" [sic] - except that the contact name, telephone number and price stayed the same. Doug McDonald, owner of Darwin Fisher, a commercial flooring company in Mississauga, says his company has never done business with TECO and he has no idea why TECO invoices would include it. Mr. McDonald noted that during that period, Darwin was doing extensive work for St. Joseph's, and that on some occasions, he hired Mr. Danef as a subcontractor. Last November, Mr. Georgiou's employment as vice-president of St. Michael's Hospital was terminated after The Globe revealed his involvement in the York fraud, and later the fact that he had private business ties to the president of a construction company that won a $300-million contract with the hospital that Mr. Georgiou had overseen and helped award. After those stories were published, Markham Stouffville Hospital - where Ms. Bahl was then a senior executive overseeing a redevelopment project - launched an internal probe when a whistleblower came forward with concerns. The findings brought a wave of departures, including those of Ms. Bahl and Mr. Wilson, who had left St. Joseph's and was working with Ms. Bahl in Markham. Mr. Wilson could not be reached for comment.

The Markham Stouffville review, which Deloitte also conducted, found that Ms. Bahl hired five of the hospital's contractors to renovate her 6,480-square-foot home, received favourable pricing from some and awarded renovation contracts at Markham Stouffville to her husband's flooring company and her late uncle's window-covering business. It appears Ms. Bahl also mixed her professional connections with her personal life when she was at St. Joseph's hospital. Deloitte found evidence that one of the hospital's furniture vendors "assisted Ms. Bahl in procuring office furniture for her home at a 50-per-cent discount from the list price," the report said. In another instance, Deloitte noted Ms. Bahl may have tried to circumvent hospital procurement policy by counselling an art supplier to invoice through a company that was already doing work for the hospital, rather than submit a payment request directly.

"This is the only way I can cover the cost," Ms. Bahl wrote to the art supplier in an e-mail obtained by Deloitte.

He will succeed Dr. Charles Webb, who takes over as president when Dr. Bill Cavers finishes his one-year term next week. Day's lawsuit is expected to last seven months and is tentatively scheduled in the B.C. Supreme Court at the end of the year. So Day could be leading Doctors of B.C. at the same time he's in court against the government.

Health Minister Terry Lake said that could present challenges. "I obviously want to have a positive relationship with the Doctors of B.C. I've obviously had that with the past presidents. It may pose, I guess potentially, some difficulties if we have an active legal case going forward whether I'm able to meet with the president-elect. "I don't know at this moment in time if this will provide any obstacles, but we'll seek advice on that." "But this is a democratic process, it's an organization of membership, of self advocacy, and we have a working relationship with the Doctors of B.C. and we have to obviously abide by their democratic process." Opposition health critic Judy Darcy said she's flabbergasted by the election.

"Brian Day has led the charge to try to bring more private forprofit health care to B.C. I know those are not values shared with the majority of B.C. doctors that I've spoken with, but it is very disturbing at a time when there's an active court case with government about bringing in more private health care in B.C. that this is the person leading the Doctors of B.C." "That's pretty serious if the minister can't meet with him because there's a legal case, but also Doctors of B.C. is involved in many, many joint committees across the province ... so I think it's very worrisome ... and I'm very concerned about what it means for health care in B.C." Darcy said patients end up in the private system out of frustration and she thinks government should do more to improve access to publicly funded care.

But Day said he expects his trial will be over by the time he's president because lawyers for both sides have been trying to scale it back by reducing the number of witnesses testifying. Day's lawsuit contends patients have a constitutional right to pay for private care if their health is suffering by waiting too long for care in the public health system. Under current laws, private clinics are not supposed to collect money from patients if the treatment is an insured service in the public system.

As to Darcy's concerns, Day said: "Everyone like that is against using the private system until you, or a family member or friend, needs it. When it becomes a personal matter, they may want and need to access care in the private sector." Referring to a front-page story in The Vancouver Sun Tuesday about the projected explosion in cancer cases due to population aging and growth, he said: "That's the sort of thing we need to be spending public health dollars on, not skiers at Whistler who harm their limbs and want quick surgical repairs."

Cavers said, in an interview, he couldn't comment on whether Day's simultaneous lawsuit and presidency could present conflicts or potentially awkward interactions between the government and Doctors of B.C. "I can tell you that when you are president, you are representing the interests of all doctors. It's not about your personal agenda. And if anyone has a reason to recuse themselves from board discussions, then they do that. Because sometimes interests do collide."

Cavers, a Victoria family doctor, said the organization is constantly interacting with the Ministry of Health on a multitude of issues involving the health system. But most often, he said, the meetings are between government staff and Doctors of B.C. staff. Cavers recalled having a halfdozen direct encounters with the health minister in the past year. Ruddiman declined to comment.

Dr. Lloyd Oppel, an emergency medicine physician at the University of B.C. Hospital who was third in the balloting, said he has no idea if Day's presidency will "present lots of hiccups," nor if the trial will be a distraction from Doctors of B.C. work. "Brian (Day) appeals to doctors who like his gutsy style, the fact he's not afraid to fight the good fight. They see him as a beacon of hope for change. So I knew when he entered the race that he'd have a big effect," Oppel said. Sun health issues reporter pfayerman@vancouversun.com Follow me on Twitter: @MedicineMatters Read more about Brian Day on my blog: vancouversun.com/medicinematters © 2015 Postmedia Network Inc. All rights reserved. Illustration: • Steve Bosch, PNG Files / Dr. Brian Day will become president of Doctors of B.C. in 2016-17.

It may pose, I guess, potentially, some difficulties if we have an active legal case going forward whether I'm able to meet with the president-elect of the Doctors of B.C. I'll have to obviously seek [legal] opinion about that." Darcy questioned why the province's doctors would choose a champion of private medicine to represent their concerns to government. "Brian Day has led the charge to try and bring more private, for-profit health care to British Columbia," she said. "I know those are not values shared with the majority of B.C. doctors that I've spoken with."

Darcy said many doctors end up referring people to the private system, not because they believe in it but out of frustration. "We need to hear those voices loud and clear saying we need to be investing in innovation and improving wait lists in the public system. And that's the answer rather than moving to a private system." The current president, Victoria family physician Dr. Bill Cavers, will step down on June 6, to be replaced by Dr. Charles Webb until Day begins his term.

Cavers said the president's job is to represent the interests of all doctors. "It's not about your personal agenda. And if anyone has a reason to recuse themselves from board discussions, then they do that. Because sometimes interests do collide."

While the association does not support two-tier health care, Carvers said there is room for private care clinics to help relieve pressure on the public system, by providing elective day procedures, for example. "We believe the patient should get timely access to care and if they can't, then the government and/or health authority should provide some public funds so they can get access to care as a backstop, as a safety valve," Cavers said.

A total of 2,176 votes were cast Tuesday. Day was elected with 946 votes, while Dr. Alan Ruddiman received 945 votes. Dr. Lloyd Oppel was a third with 285 votes. ceharnett@timescolonist.com

Dr. Brian Day is the 2015-16 president- elect of Doctors of B.C. He will assume the position in June 2016.

The plan is still for SCI to start performing surgeries by February, 2012, the company says.

Indeed, this nasty internal fight is remarkably similar to what the Republican Party establishment is undergoing in the U.S., with angry OMA dissidents unleashing Donald Trump-style brutishness and Tea Party-style radicalism to scare patients, silence critics and ultimately take over the OMA leadership. Suddenly, the OMA deserves our sympathy because this time it is actually taking on the good fight for Ontario patients.

The conflict centres on a tentative four-year deal reached on July 11 between the OMA and the provincial government on everything from increases in funding for physician services to giving doctors a stronger voice in managing and reforming the health-care system. The tentative agreement came after two years of bitter fighting between the OMA and Ontario Health Minister Eric Hoskins and his senior bureaucrats.

Under the deal, the overall budget for physician services, in other words their pay, would increase by 2.5 per cent a year, rising to $12.8 billion in 2019-20 from the current level of $11.9 billion. But a recently formed group calling itself the Coalition of Ontario Doctors and alleging it speaks for thousands of OMA members wants the tentative deal scrapped, arguing that if approved it would result in fewer doctors, fewer health clinics, less patient care - and even lead to the death of patients.

Like Trump in the U.S. with his anti-Muslim, anti-immigrant rhetoric, such claims by these dissident doctors are meant to scare Ontario patients. At the same time, the coalition, suggesting the deal's approval method was rigged, hired high-priced lawyers and went to court to force the OMA to hold a general meeting, now set for Sunday in Toronto, where doctors will vote in person on the deal rather than cast ballots online.

In addition, some angry doctors have taken to social media to bully, silence and question the motives of physicians who back the agreement. Combined, these tactics are irresponsible, reprehensible and unworthy of doctors who claim their first priority is care of their patients. Leading the charge against the OMA is the Ontario Association of Radiologists, which has about 1,000 members and is bankrolling the court challenges and ad campaigns against the OMA and the tentative deal.

As a group, radiologists are among the highest-paid doctors in Ontario, earning an average of more than $600,000 a year, with some topping $1 million. In recent years they have benefitted from new technologies that allow them to perform medical procedures quicker, thus allowing them to see more patients and send more bills to the government. Despite all their gloom-and-doom rhetoric about pending deaths brought about by the deal, what the dissidents are really upset about is - what else? - their own wallets.

Think of it as a rich man's self-pity. They won't say it openly, but these rich radiologists, along with some ophthalmologists and cardiologists, are most furious because their fees will be cut more than those other physician services. What the deal tries to do is level the pay structure so doctors with similar training receive the same net incomes.

For its part, the OMA concedes that many doctors who support the agreement aren't completely happy with it. But they believe the main benefit is that the deal establishes a period of peace and a better relationship between doctors and the government, one that has been very destructive over the past few years.

Regardless of the outcome of Sunday's vote, the OMA will never be the same, much as the Republican Party will never be the same after Donald Trump's candidacy and the emergence of the Tea Party. Within the OMA, many conservative doctors who hate the Liberal government at Queen's Park, dislike government interference in their profession and want to run the health-care system as they did 30 or 40 years ago are on the move.

The physicians' deal is the first target in their sights. Next up is the leadership of the OMA, its bargaining team and its specialty sections. Yes, it's time to feel some sympathy for the OMA. Bob Hepburn's column appears Thursday. bhepburn@thestar.ca

The Ontario Medical Association deserves public sympathy as it takes on dissident doctors, Bob Hepburn writes.

Legal precedent: Whatever way the case is decided at trial, it is likely to be appealed and eventually reviewed by the Supreme Court of Canada. A decision from this level will mean all provincial and territorial governments will have to revisit equivalent laws. The foundational pillars of Canadian medicare - equitable access and preventing twotier care - could well be vanquished in the process. Wait times: Day will likely argue that Canada performs poorly on wait times compared to other countries, and that other countries allow two-tier care; thus, if Canada is allowed two-tier care, our wait times would improve. But this approach is too simplistic. Comparisons to the British health system, fail to recall that, despite having two-tiers, it has in the past suffered horrendously long-wait times. Recent efforts to tackle wait times have come from within the public system, with initiatives like wait time guarantees and tying payment for public officials to wait times targets.

By looking to Britain, we are comparing apples to oranges. British doctors are generally full-time salaried employees while most Canadian physicians bill medicare on a fee-forservice basis. Consequently, the repercussions of permitting extra billing in Canada could eviscerate our publiclyfunded system, whereas this is not the case in Britain. Imagine if most doctors in Canada could bill, as those at the Cambie clinic have done, whatever they want in addition to what they are paid by governments?

Conflict-of-interest incentives: Evidence suggests there is a danger in providing a perverse incentive for physicians who are permitted to work in both public and private health systems at the same time. Wait times may grow for patients left in the public system as specialists drive traffic to their more lucrative private practice. Sound improbable? Academic studies have noted this trend in specific clinics that permit simultaneous private-public practice. And recent U.K. news reports have profiled a case where a surgeon bumped a public patient in need of a transplant for his private-pay patient.

Competition: Proponents of privatized health services often claim it would add a healthy dose of competition, jolting the "monopoly" of public health care from its apathy. But free markets don't work well in health care. Why? Because public providers and private providers won't truly compete if the laws Day challenges are struck down. Instead, those with means and/or private insurance will buy their way to the front of queues. Public coverage for the poor will likely suffer, as is clearly evident in the U.S., with doctors refusing to provide care to low-income patients in preference for those covered by higher-paying private insurance.

Of course, this is all based on an outcome that is not yet known. It may be that the charter challenge in B.C. will be unsuccessful, but clearly the stakes for ordinary Canadians are high. Sadly Dr. Day is not bringing a challenge for all Canadians. Isn't it past time our governments and doctors work to ensure all Canadians - and not just those who can afford to pay - receive timely care? Colleen Flood is Professor and University Research Chair in Health Law Policy at the University of Ottawa. Kathleen O'Grady is a Research Associate at the Simone de Beauvoir Institute, Concordia University and Managing Editor of EvidenceNetwork. ca

This clearly puts the doctors involved in a conflict of interest. In a health system experiencing a significant shortage of practitioners, medical resources are drained from public hospital-based "free" care and into private purses. It also ties health care quality and accessibility to a patient's wealth - precisely what the Canada Health Act tries to prevent. For example, Montreal Children's Hospital - one of Montreal's two pediatric university hospitals - has decided to stop offering many medically necessary services. Instead, it will direct some patients to a new outpatient clinic. There, parents may be billed for such services as dermatology, endocrinology, general pediatrics and other important specialized care.

This steady disintegration of the principles of health care could soon be irreversible. Premier Philippe Couillard's new Bill 20 will legalize direct patient billing for medically necessary services provided outside of hospitals. The provincial government is confident that Ottawa won't intervene to enforce the Canada Health Act in Quebec (the federal government hasn't intervened in the past decade). Bill 20 makes legal practices that were grey-zone breaches in the universal public health system. This is creates a parallel, legal private health-care system subsidized by public health insurance. This could be the final blow to health care in Quebec. An unhealthy coalition - the Couillard government, private clinic owners, medical federations, private insurers and even some hospital administrators - is irresistibly pushing to decrease the care offered in public institutions and to increase the market share of direct payment and privately insured services. The only chance to save health care in Quebec is direct intervention by the federal government. Prime Minister Justin Trudeau and federal Health Minister Jane Philpott must enforce the Canadian Health Act in Quebec, even cutting federal health transfers until the province conforms.

Doing anything less will mean access to care according to a Quebec patient's wealth, rather than their needs. Astrid Brousselle is a professor in the Community Health Department, and researcher at the Centre de recherche de l'Hopital Charles-LeMoyne, Universite de Sherbrooke and Canada Research Chair in Evaluation and Health System Improvement. Damien Contandriopoulos is a professor in Nursing and a researcher at the Public Health Research Institute at University of Montreal (IRSPUM). CIHR Research Chair in Applied Public Health.

He said he wants an investigation into the events leading up to the decision to terminate the employees and the actions taken by the government afterward. Mr. Lake also rejected the New Democrats' concerns that newly appointed Ombudsperson Jay Chalke could be in a perceived conflict of interest because of his previous employment as the head of a Ministry of Justice branch from 2011 to 2015.

"It's about the office," said Mr. Lake. "It's not about the individual. His job is to be the Ombudsperson, and this kind of review certainly falls within the purview of his office." Members of B.C.'s legislature unanimously approved Mr. Chalke as the new ombudsperson two months ago, and he officially started his new post this month.

Opposition NDP Leader John Horgan said the review is a step forward but he still favours an independent public inquiry. Mr. Chalke has the option to appoint another official from within his office to conduct the review, he said. "I do believe this falls again short of what we've been calling for and what the individuals involved have been calling for, and that's true independence and the ability to have a public and open process here," Mr. Horgan said. The workers were part of a drug-research grant program and were fired in September, 2012, amid allegations of inappropriate and possible criminal conduct.

Then-health minister Margaret MacDiarmid said there were allegations that employees inappropriately accessed sensitive medical records, but charges were never laid and media reports later showed the RCMP never investigated the claims. A government-appointed review concluded last year the firings did not follow existing procedures and reached premature conclusions. Labour lawyer Marcia McNeil's report last December found the investigation was flawed from its start.

The government has consistently rejected calls from the NDP and the fired workers and their families to order an independent public inquiry to unravel the scandal and determine who was responsible for the firings.

Dr. Brendon Carr (president and CEO of Island Health) when asked at the Island Health Board meeting here in June stated that there will be a premium in cost for the surgeries at the private clinic. We know private, for profit, health care is more expensive. He said they have the information and would provide it, but when I wrote and asked what the difference in cost for the taxpayers between surgeries in public or private, for profit, operating rooms, Mr. Peters declined to answer the question.

Our provincial government is seeking to change the BC Health Act to permit patient stays of up to three nights in private, for profit, surgery clinics so their plan into the future is to embrace private, for profit, surgery clinics. In the provincial government's own report it states the reason why our public hospital operating rooms sit idle quite often is due to lack of funding. The government and Island Health think it is okay to contract out these surgeries because the surgeries are still being publicly funded but our taxpayer dollars will be spending more for the profit margin.

I pointed out to Dr. Carr that we have a shortage of doctors in Canada and he agreed. He said it would be the same doctors doing the surgeries in the private, for profit, surgery clinics. I asked how they can usurp our doctors into the private system without straining our public system more. He just said they will be watching it. That doesn't bode well for our public operating rooms. I fear that our provincial government is seriously undermining our position in defending the Dr. Brian Day court case on behalf of all British Columbians. At the very least it looks like a huge conflict of interest when they are seeking to contract an enormous number of surgeries to private clinics.

Our provincial and federal governments seem determined to starve the public health care system in favour of private, for profit, health care. They have let the surgery wait lists increase substantially. Our federal government refused to renegotiate the Canada Health Accord and brought in a new funding formula. They are telling us they are "increasing"  funding of the transfer payments to the provinces by three per cent, tied to the cost of living. Currently they are paying six per cent annually so this actually is a massive cut to the provinces for public health care in the amount of $36 billion over the next 10 years. With the federal government's cuts to health care funding, the share of federal CHT cash payments in provincial-territorial health spending will decrease substantially from 20.4 per cent in 2010-11 to less than 12 per cent over the next 25 years. This, according to the Parliamentary Budget Office, will bring the level of federal cash support for health care to historical lows. National Medicare was implemented across Canada by provinces and territories on the understanding that the federal government would contribute roughly 50 percent of the spending on Medicare.

Canadians are vehemently opposed to private health care whether it is using our public tax dollars or not. Canadians should not have to suffer and wait a long time for surgery. Funds would be far better invested in the public health care system which is being starved by our governments. It is very difficult for Canadians to see our medicare in serious jeopardy. The Canadian Medical Assoc., Canadian Doctors for Medicare, Canadian Health Coalition, Council of Canadians, B.C. Health Coalition, HEU, CUPE, Citizens for Quality Health Care and many others are united to protect, strengthen and expand our public health care. Please check out their websites and get more information. Please vote in the next two elections and vote for health care for the benefit of all Canadians. Lois Jarvis Citizens for Quality Health Care Campbell River

Recently, Centric has been buying up market share across Canada, acquiring surgical centres, diagnostic clinics, medical equipment companies, and Lifemark, the largest rehabilitation company in the country. It’s a vertically integrated company that looks to rival our public health-care system with its array of services and products.

could expose Canadian governments to sanctions under the investment provisions of NAFTA

claim damages should the province of Ontario regulate the services provided by Centric in a manner that diminishes the profitability of its investments

there is a lack of transparency and accountability

Just ask Dr. Wayne Hildahl of the Pan Am clinic in Winnipeg, a clinic that was previously for-profit but now operates publicly through the Winnipeg Health Authority. Hildahl has publicly said that when the clinic was for-profit, he had the advantage over government officials negotiating contracts to provide medical services because he knew his costs and they didn’t. And under its investor-based ownership, the Pan Am clinic cut corners, with outdated medical equipment — including dull scalpel blades! — to increase profit margins. His clinic now charges the government $700 for a cataract procedure instead of the $1,000 it charged when Pan Am was a for-profit facility.

Centric is also pushing for physicians to invest in the company

Researchers in Arizona found that those doctors with a financial interest in their facilities treated more patients whose conditions were least severe and would bring in the most money.

These conflict-of-interest problems led the U.S. Congress to deny medicare reimbursements to doctors for procedures done in hospitals in which they are shareholders.

The bill will usher in a new era of commercialisation but still does not make clear the public duties of the economic regulator, Monitor.

And while the proposed duties of clinical commissioning groups remain weak, they will be given the freedom to compete for or select their registered populations, as well as “flexibilities” in defining which services to provide. Allowing clinical commissioning groups to also enter into joint ventures with private companies will create inequalities in entitlement to care and introduce commercial conflicts of interest.

New commercial actors will be driven to compete and maximise income, overshadowing the need to cooperate and collaborate in ways that place the patient and population at the heart of the health system. The absence of clear responsibilities for geographically defined populations will make it difficult, if not impossible, to link clinical NHS commissioning with social care services or with plans and interventions to act on the social determinants of health.

the bill hands over greater control over public budgets to the dictates of the market

The VON was trapped, and ultimately crushed, by that contradiction. It was not the first - the Canadian Red Cross Society's legendary blood transfusion service flamed out in an even more spectacular fashion with the taintedblood scandal in which 20,000 recipients contracted hepatitis C or HIV - and it will not be the last. Canadian Blood Services has taken over the former Red Cross role.

The health-care advocacy group Friends of Medicare said the neardemise of the VON is proof that "experiments in private care must be ceased." But the VON's story is much more complicated than the "public, good; private, bad" and "notfor-profit, good; for-profit, bad" narrative. For a long time, governments funded not-for-profit groups in the health and social services sectors - hospitals, home care, group homes, the Red Cross and so on - in a pretty loosey-goosey fashion. These groups did good, and they were funded relatively well.

But as budgets soared, new accountability measures were put into place. In the home-care sector, for example, competitive bidding was introduced. Stodgy old organizations such as the VON were not ready, and did not adapt. Their market share fell from more than 90 per cent to about 20 per cent. On the surface, this is a good thing. Canadians spend $219-billion a year on health care, including about $10-billion on home care, and, as consumers and taxpayers, they deserve to get value for money.

While we like to preach the gospel of value-for-money, we don't measure it well - the ultimate irony being that expensive bureaucracies have been built to ensure home-care agencies are lean and mean. The VON had many disadvantages in a competitive market.. place - first and foremost that it never provided just home care to its clients. It delivered hot meals, made friendly visits (especially to veterans), ran adult daycare programs, provided respite care to families, visited new mothers and babies, did flu shots at home and did countless other little things that never had a place in the accounting ledger. Some were covered by government payments, but many were not. The VON supplemented its funds from government contracts with charitable donations. It had more volunteers (9,000) than staff (6,000). The VON also paid its workers a decent, living wage. The work force - mostly nurses and therapists - is unionized, salaried and they have benefits, including a pension plan.

In the brave new home-care industry, piecework is the norm, meaning nurses get paid per visit, and few have benefits, pensions or stable employment. It is also in the interest of workers (and employers) to get visits done quickly, and cram as many as possible into a day. While this is a cost-effective business model, anyone with a loved one in home care knows that there is little continuity of care. The relationships that are so important to intimate acts such as health-care delivery to frail seniors living at home are virtually non-existent. When you have a strict business model, when all that matters is the much-vaunted bottom line, none of that gets counted.

The real tragedy in the VON's unravelling is not that another home-care business is biting the dust (after all, there are hundreds more out there), but that the "old-fashioned" way of delivering care - taking the time required to talk and listen to patients and treating them as people, not "units of service" for example, not just changing their dressings, but feeding them and filling the fridge - is falling by the wayside. With the VON's collapse, we have a home-care system that may be more efficient - at least in theory - but one that has less heart.

the consumer is naked in the screening market place. There's no one really protecting people from being exposed to screening that is neither recommended, didn't have scientific support, that had evidence of harm in terms of exposure to radiation and good evidence that kind of screening causes huge amounts of follow up in the average person

They're marketed as providing peace of mind, when they are statistically more likely to do the opposite, which is to give you a bunch of things you now have to worry about that you never knew you had to worry about before.

they may say prostate cancer screening improves survival time, as opposed to improving survival, meaning the time you survive after they've diagnosed you with the disease. If you're tied to the railway track, and the train's coming down the track and it's going to hit you at a particular time, you can see it maybe without binoculars at five miles, say a five year survival rate. Or, if you use the screening test, binoculars, you can see it at seven miles. Your survival time has improved. The date at which the train hits you does not change, but the statistics look like the survival time has improved by two years.

what have the independent experts said about the value of the screening. The United States Preventive Services Task Force is one of them. The Canadian Task Force on Preventive Health Care, that's the Canadian equivalent. Most of the stuff you see about prevention is biased. For every one site like this funded by the taxpayer with largely no conflicts of interest, there's a hundred sites that will tell you other things.

the business model depends on overdiagnosis and over treatment

There's a huge gap in the pharmaceutical world between what the marketers or advertisers say and what the evidence says. In screening it's the same niche

It's a bigger tent. There's the patient advocates, the radiologists, the urologists, the specialists and the others who are pushing various types of screening. And the drug industry is there too.

You don't need to prove the benefits of a screening test before you launch it on the public.

many doctors feel they have lawyers looking over their shoulders as they consider whether or not to recommend a screen

I think that's a largely US thing, but I think it motivates physicians here as well.