Every single Ontario physician who saw the recently-released New Graduate Entry Program (NGEP) for new family doctors had the same thought. “Is the government serious?” (If the link doesn’t work, keep trying. It works eventually.)
Unfortunately, they are very serious, and this is exhibit A of what happens when unilateral action is imposed without physician consultation. You get a short-sighted plan.
Let me first address what likely led to this proposal. The government was being widely criticized for limiting new family physicians from joining FHOs in non-underserviced areas. The 416 and 905 are vote-rich areas, and are largely not considered underserviced. The messaging that doctors could not start practices in these areas was likely having some political traction, and the ministry needed to do something to rebut this. They can spin this as being at least an option for new grads, as terrible as the conditions are.
The second issue that likely led to the NGEP was the ministry’s frustration with new grads not committing to starting up practice and sticking with that practice. From my experience here in London, we have had a number of physicians start up practice and leave the area within their first 3 years. That revolving door is frustrating for patients, and is not conducive to a quality patient-physician relationship. Rewarding physicians for providing continuity was likely part of the ministry’s plan.
But this plan was clearly drawn up by bureaucrats.
The limits set on billings outside of the FHO/FHN group is the most detrimental to patient care. The cap on year 1 outside billings at $0 is likely intended to discourage new grads from moonlighting in walk-in clinics and other clinical areas not related to their patient care (concierge clinics, marijuana clinics, etc.). But what they have failed to realize is that by setting a $0 cap, they are completely limiting new grads from benefitting financially from providing any non-FHO high value services, like house calls, or focused practice work in palliative care, obstetrics, psychotherapy, inpatient care, or ER work. Frankly I have no problem with physicians doing other part-time work, as long as they are meeting the FTE commitments that they have with their FHO (more on that later). I understand if the ministry wants to set some sort of reasonable cap on non-FHO work to ensure physicians are doing the necessary FHO work, but a $0 cap is absurd.
The proposed compensation schedule is a complete non-starter. The income proposed for year 1 will barely cover overhead for physicians in major urban centres. If the ministry is truly interested in having a serious dialogue about this plan, then they must adjust the proposed annual compensation levels for all three years. The issue of internal relativity and whether novice physicians should be subject to lower compensation is an issue to be debated amongst physicians, but this level of discrepancy between family physicians is completely unacceptable under any circumstances.
As for the “Practice Improvement Plans” suggested in the NGEP…I began to write my thoughts on this, but this quickly devolved into an essay unto itself on the relative merits on pay-for-performance programs in Ontario. I will post this essay later this week. In short, of course we need some metrics that look at measures like access and quality of care. And tying some element of physician funding to those measures is not unreasonable. But what the ministry has proposed in the NGEP is draconian. Patient experience surveys? To how many patients? By what means are they being surveyed? What are they asking patients? What will the cut-offs be for deeming success? Are they not aware of the literature showing that giving financial incentives to reward “increased patient satisfaction” also leads to increase hospitalizations, increased opioid and antibiotic prescribing, and to increased utilization of lab and radiology services? I’ll go into detail in my next piece about potential solutions that would actually work for accountability measures, but what the ministry has proposed is baffling, and will create a litany of unintended consequences.
Let me give a bit of praise where deserved. I do actually like the idea of establishing a 40-hour work week as 1.0 FTE, and having the physician declare their FTE commitment as part of their contract. We all know that there are a minority of physicians in FHOs who are being paid as full-time physicians, but spending only part-time hours in their clinic. This needs to be addressed, and I don’t think the ministry is entirely unreasonable for having some expectation that FHO capitation payments will be paid roughly according to how much time is spent in the clinic. And I am definitely in favour of the ministry enforcing that FHO physicians deliver the after-hours care that they are contracted to provide. The FTE commitments and after-hours enforcement should be implemented both for new grads and for established FHO physicians. Throw in a maximum number of holiday weeks a year for FHO physicians, beyond which those vacation weeks will be paid at a markedly reduced base compensation rate.
The number of patients proposed to be rostered per year is not unreasonable. Although I will concede that if two part-time physicians want to join forces to split 1.0 FTE and a targeted roster number, I think that should definitely be accommodated. Also, I like the general idea of the mentorship program, although far more details are needed before it can be endorsed.
But on its whole, this program cannot be endorsed to graduating family physicians. It has far too many flaws, has too many gaps in potential interpretations, and given how trustworthy the ministry has been to date, this is not a contract that new family physicians should be signing. The worst thing for the ministry is that this will do nothing to keep graduating family physicians in Ontario.