After Ontario doctors reject province's fee deal, what's next?

Now that Ontariodoctors have voted against a tentative agreement with the provincial governmenton physicianfees, the two sides are heading into uncharted territory.

It's a bitlike the Brexit vote for the U.K. to leave the European Union. Doctors voted no for a wide variety of reasonsand may end up surprised by what happens next.

The government isn't obligated to negotiate fees with doctors.They aren't members of a union, they don't have an enshrined right to strike or to collective bargaining.

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The province can simply go ahead and unilaterally set thefees paid by the Ontario Health Insurance Plan (OHIP).

Is that the next step for Health Minister Eric Hoskins? He certainly isn't ruling it out.

Asked by CBC News in Windsor Tuesday afternoonif he'll impose a deal, Hoskins replied: "I have always and still believe that an agreement is by far the best path forward. But it needs to be one that is fair to both sides and fair to Ontarians, and it needs to reflect the fiscal realitythat we find ourselves in."

Meanwhile, the Ontario Medical Association is in crisis. Its leadership endorsed the tentative deal that was rejected by its members in a vote that saw 63.1 per cent against, and 36.9 per cent in favour.The OMAsays it wants to get back tonegotiations immediatelyin the wake ofthe "no" vote,but doctors know that Hoskins's next move could be to impose a fee agreement.

"We believe thatwe pressed the government as far as they would go," OMA president Dr. VirginiaWalley told CBC Radio's Metro Morning on Tuesday.

Given that, how can doctors expect the province to cut them a sweeter deal now? "That's to be seen,"Walley said."I can't speculate on that."

The proposed agreement rejected by the doctors would haveboosted the $11.5-billionOHIPfee-for-service budgetby 2.5 per cent annually over its four-year term. Some doctors arguethat this effectively amounts to a pay freeze, since the amount of services they have to perform is increasing as Ontario's population grows and ages.

What's important to note about the tentative deal is it would not have affected all physicians equally. A key provision is to "work together to jointly identify savings," particularly to "update" fees for services that can now be performed more quicklybecause oftechnological change.Thebest-paid specialists, including radiologistsand ophthalmologists, figured this meanstheir fees would be targeted. It's no coincidence those groups led the charge against the deal, along with some anesthesiologists.

They may end up targeted anyway.Successive Liberal governments have been quick to imposefee deals on doctors when bargaining runs aground.

In May 2012, after failing to reach an agreement in negotiations,the McGuintygovernment slashed OHIP feesfor a host of services. The two sides eventuallywent back to thetable and in November of that year reached a tentative agreement.OMA members voted 81 per centin favour of that deal, even though it rolled back only six of the fee cuts.

Not long after that agreement expired, another round of negotiations failed to produce a deal and in January 2015Hoskins imposed an across-the-board fee cut of 2.65per cent, followed by another round of cuts that took effect in October.

Even the doctors who led the "no" campaign are uncertain whetherHoskinswill impose a deal.

"I hope not," said Dr.NadiaAlam, a member of the group Concerned Ontario Doctors, in an interview on CBC Radio's Metro Morning."Thegovernmentspent the last week or two talking about how it wants to return to a trusting, collaborativerelationshipwith the doctors. I certainly hope they're going to honour that statement."