Why the New Graduate Entry Program is a non-offer

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.

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8 thoughts on “Why the New Graduate Entry Program is a non-offer

      1. len

        Putting home visits in the basket for FHO docs was a major flaw of the capitation regime. If you survey family docs probably greater than 50% would say they do home visits but I would bet my lunch that less than 10 percent do more than 20 home visits in a year. So it was put in the basket (ie you are getting paid for it) but for the most part not being done. Same deal with minor procedures so the incentive is to send to your local general surgeon. There is a provision for a modest bonus if you meet certain targets for housecalls to housebound patients but you have to make quite a few housecalls. The bonus for minor procedures is the same deal (tiny) the incentive is to still send them out. The FHN contract put them outside the basket as it did minor procedures which was alot smarter. This is what shocked me about the way the baskets were put together. Years ago when they wrote up ohip fee schedules there seemed to be alot more common sense. For instance the fee for an obstetrician to do a vaginal delivery was the same as a C-section. That way the financial incentive was not skewed to do an operative delivery which cost the system alot more. . For safety reasons there is already an incentive to do a C-section if needed. Another example was the widely touted savings that are supposed to be forthcoming by eliminating annual physicals. But you can still bill the code for a full assessment as long as you use any other diagnosis code beside 916. So there are probably still alot of full assessments being billed.

        It seems to me that if you talked to people in the system you could address some of these issues and improve care and save some money.

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    1. Pamela Anand

      Also in addition to this a full time FTE is more like a 0.7 or 0.8. The ministry does not count paperwork in the full time equivalent. I did income stabilization. They told me I could only count my clinic hours. So you get paid 66 percent of the FTE if you do it according to guidelines. Imagine if any other employee of the government was told you will only get paid for 2/3’s of your work.

      Of this 66% of what you are paid, you will have to give another 33% to overhead expenses. By the way you will make less than a resident physician with no benefits.

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  1. Kevin Graham

    Thanks for posting. I agreed with many of your main points.

    I do take issue with “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.”

    I would argue it already is addressed. If you are carrying a full roster and not working or taking vacation then you are paying to have your patients seen in other clinics. The financial penalty is already there.

    If you formalize the work hours in a FHO what you are doing is giving the vast majority of FHO physicians who work well beyond a normal work week the direction and incentive to reduce their availability to their new mandated hours. FTE of 40 hours. Sounds amazing, where do I sign!

    Regulation also stifles efficiency. If a set number of patients equals a set number of hours where is the incentive to optimize your practice? Many high performing MDs can handle larger rosters with less hours because they optimize their non-office hours (telephone calls, efficient EMR use, having support staff etc)

    I am also interested that you frame working outside the office in terms of financial benefit. I think most physicians do non-office work as part of their service to their community. Certainly it is paid, but it is generally not remunerated at a level that makes it more attractive than simply working more office hours. For instance family MDs often cover 24 hr OB call. Would someone really sign up for this for the financial gain? There are easier ways to make that money while the sun is still up!
    Family doctors often provide the only access to services in small towns who don’t have specialists to cover for OB, surgical assist, palliative care etc. The provision prohibiting this is an absolute disaster for smaller areas.

    Overall though I agree – the New Grad offer is so objectively terrible that was likely thrown together to provide a political talking point.

    I hope any new family medicine physician discusses their options with some colleagues before even considering this.

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    1. supermarioelia Post author

      The financial penalty is not nearly significant enough. The Access bonus was intended to be just that, a bonus. A doc can currently take a ton of time off, and still do quite well financially, even if they lose all of their access bonus. Yes, that is a minority of docs who abuse the system in that manner, but it does happen, and it needs to be stopped.

      As far as doing things outside of the office not for financial gain, you’re preaching to the choir. I do house calls in London. Travelling across the city for one house call is financially stupid, yet I do it on a regular basis.

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  2. Serge

    I agree with a number of your comments. More thought needs to be had around what defines quality care. Please remember though your specialist colleagues train for sometime 5-7 years and enter a practice observation period known as a fellowship. They are working many more hours than 40 and carry heavy clinical loads for a fraction of the compensation proposed in the ngep often delaying settling down, starting families and paying off debt.

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  3. Shehnaz Pabani

    Finally the elephant in the room is discussed!
    The OMA should be addressing these issues with its members : choosing wisely which should include not only lab tests but also FP trying to manage their own patients rather than refering to ten different consultants!;
    The issue of FHO physicians taking on large numbers of patients under capitation but failing to provide care by only working one or two days a week at their office….meanwhile providing surgical assists and other services outside the basket of care not directly benefiting their patients. These patients end up at random WI clinics frustrated that the next available appointment at their physician’s office is in three months! These patients’ care is ‘double dipping’ into the physicians services budjet!

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