Family physicians across Ontario were dealt an absolute gut-punch by the Ontario government this past week, as the government’s arbitration position for primary care was released. In short: way more work for FHO physicians, less money, and an unimaginable amount of logistical disruption. If adopted, it would undoubtedly result in every FHO physician reverting back to a fee-for-service (FFS) model. This would make Ontario one of the only jurisdictions in the world moving towards FFS in primary care, while every other region moves towards capitation models and the resulting efficiencies that can be found in those models.
Let me start by acknowledging that there is a glimmer (if you squint) of rationale to most of the points in the government proposal. The auditor general was clear that major changes to the FHO model are needed. Doug Ford’s special health care advisor, Reuben Devlin, has not been shy about sharing his opinions that FHOs have not demonstrated the improvements in access that the government expected given their investment. But rather than put forward progressive solutions to the acknowledged problems in the FHO model, and do so in a collaborative manner, the arbitration position is a complete mishmash of ideas, each with significant, inevitable consequences that will destroy primary care right across the province.
I’m going to go section by section, explain the likely rationale from the government’s perspective, explain the problematic consequences of each proposal, and where appropriate, I will outline a potential alternative solution. (Government’s position in bold, with my response below each position).
Adjust the base capitation rate paid to FHO physicians for enrolled patients to reflect the changes in volume of services and changes in demographics since the 1999 base year.
The impact of recalibration to the foundation principles behind the calculation of an appropriate capitation rate would result in a change from $165.41 to $120.89 per enrolled patient based on the current basket of included services. This estimate is based on the 2015-16 OHIP utilization and population statistics.
Effective April 1, 2019, reduce the base capitation rate paid to FHO physicians by 33.3% of the resulting gap between the current capitation rate and the appropriate, recalibrated capitation rate (e.g. reduced by $14.84 per enrolled patient based on the current basket of included services).
When the government and OMA first created the FHO model, the capitation rate was calculated by taking all of the expected total billings for each demographic (age and gender), and averaged them out to give an appropriate capitation rate per patient. FHO physicians are paid the capitation rate per patient, plus 15% of the value of fee-for-service billing (called shadow billing).
What the government is claiming is that the value of the services that FHO physicians are providing is equal to $120 per patient (when they calculate the value of current fee-for-service billing), roughly $45 lower than the projected number of billings, and their likely contention is that this is due to a combination of worse access to visits and decreased patient demand.
But let’s think about this. Do we really think that, in an era where patients are requiring more and more care, and we know that overall utilization is rising, that demands on FHO physicians have suddenly dropped by 27%? Did walk-in visits rise by 27%? Did non-urgent visits to ER rise 27%? The answer to those questions is no, they did not.
We know exactly why the value of billings dropped for FHO physicians. Because part of the rationale in moving to a capitation model was to find efficiencies. Doing virtual care (which is not billable), emails with patients (which are not billable), patient portals (which are not billable), and phone calls with patients (which are not billable), are incentivized in a model where physicians do not rely on face-to-face encounters to make money. And patients generally love this type of access to physicians.
But look at how the government has manipulated this. They have created a model which created incentives to do patient care that was not billable, then used the lack of billed services to argue for FHO physicians being overpaid for less work.
Let me be clear to the government. You cannot possibly implement any of the accountability measures detailed in points B-L if you reduce the overall payments to FHO physicians. It simply won’t fly, physicians will simply revert to FFS, return to treadmill medicine where every patient is dragged into the office for every small issue, and the entire system will implode before we even get started.
But is there a modification to the capitation rate that can be made? Of course there is, because there are a handful of FHO physicians who have used the capitation rate to allow themselves to spend far less time in the office, since they get paid regardless of their attendance (especially in areas where there are no walk-in clinics to count towards outside use negation). We all know that there are some FHO physicians who are spending very little time in their offices doing direct patient care.
Instead of having an average cap rate of $165 per patient, reduce the cap rate and increase the shadow billing percentage. Attempt to make it a 60/40 split (60% cap, 40% FFS) or 70/30 split. Incentivize physicians to see patient volumes at a slightly higher rate than they are right now, but maintain the overall predictability of the capitation rate. Don’t allow the system to completely collapse by driving all physicians away from the FHO model with an obscene 9% reduction to the capitation rate and no counter-balancing measure.
B) Increase to FHO Mandatory Group Size
By April 1, 2019 all PEM groups must be comprised of at least six physicians. This will allow for appropriate coverage and access for patients weekdays, evenings, weekends, and during holidays or short term leaves of absence.
For groups in smaller communities that cannot achieve six person groups, special consideration can be negotiated with the Negotiations Branch of the ministry.
The ministry recognizes that all physicians in a FHO may not be on the same geographic site. Howe ver they should be relatively proximal to facilitate meaningful patient access. All sites must also offer cross coverage to each other and have a shared electronic medical record (EMR). They must offer shared after-hours care for patients rostered to that FHO and coverage for any physician leaves regardless of site.
The ministry needs to be careful with this one. There are plenty of high-functioning FHOs across the province with 4-5 physicians that are providing quite good access, and simply do not have the physical space (or interested physicians) to expand to 6 physicians. The special consideration they mention in the proposal should be quite flexible as to not force physicians to abandon entire patient rosters simply because they cannot meet the size requirements.
As for the shared EMR, I agree in principle with the interconnectedness of a shared EMR within a FHO, but we have to understand that there is a significant associated cost (both money and staff time) of transferring across EMR providers. This may be a proposal where existing FHOs are given a period of 5 years or so to meet this requirement, or that they are grandfathered to remain on separate EMRs (with a requirement that they merge should any physician change EMRs or if any vendor goes defunct).
I agree with the requirement of “shared after-hours care for patients rostered to that FHO and coverage for any physician leaves regardless of site”
C) Daytime Hours Requirement
For an average roster size of 1,300 patients, groups will provide nine (9) units of care sometime between 0600 and 1700 daily, Monday to Friday. A unit of care is four (4) hours.
During the four hour unit it will be expected that on average services will be provided, face-to-face, to 12 patients.
Since this is a group endeavour, the averaging of the services provided to patients will be measured quarterly (over a three month period) for the entire FHO group.
For FHOs where the average roster size is either above or below 1300 patients, the parties should establish appropriate pro-rated changes to the required daytime Monday to Friday hours.
Also, to ensure that patients have access to the hours of service of their physician’s group, the hours of service will be posted in the office, on-line and shared with the Local Health Integration Network (LHIN).
First, let me say that I understand the underlying motivation here. As I stated earlier, some FHO physicians are simply absent from their office more often than not. And a logical response to that would be to mandate physicians to spend specific time requirements in their offices. (Trust me, I’ve wondered about this same type of proposal many times over the past few years as a possible solution.)
But there are many ways that time requirements can be problematic. How many more units of care will need to be provided if the roster is larger than 1300 patients? I have 2200 patients on my roster, I work Monday-Friday, full-time hours, and have very little ER and outside use. My patients can get in for same-day appointments every day. Will I have to work 11 units a week? 12? What if I am simply efficient at servicing my roster?
If the cap rate from point A is fixed, and points F, G, and H are implemented (with some modifications that I will mention in subsequent sections), the opportunity to game the system nearly vanishes, and physicians who do not show up to work will not be able to meet the FHO requirements (and will make very little money). It will weed the abusers out, and remove the need to start nitpicking hours worked, which will be a nightmare for the ministry/LHIN to police (as they are already failing to police the minimal requirements that already exist with FHOs).
For an average roster size of 1,300 patients, FHO groups will provide at a minimum one three hour unit of evening care Monday to Friday and three hour units every third Saturday or Sunday, sufficient and convenient to serve enrolled patients.
The required number of units will be prorated either up or down depending on the total group roster.
Completely agree. And I’ll go a step further, the weekend requirements should move the Friday evening clinic and include both Saturday and Sunday clinics.
E) End the Patient Enrolment Model (PEM) After-Hours Exemption
FHN and FHO groups will no longer be given an exemption from providing after – hours to enrolled patients. The ministry will continue to pay all capitation payments and physicians will fulfill the contractual obligations while meeting the obligation for evening, weekend and holiday coverage as required in the agreement.
Physicians can continue to undertake other clinical work but it will not obviate the group’s requirements for the after hour coverage in the contract.
Again, the rationale is there. Many groups have received exemptions from providing after-hours clinics, but while these were likely intended for rural areas to account for physicians who would be working in multiple clinical settings, these exemptions are sometimes being abused by physicians working in urban and suburban settings.
But this proposal would have to be looked at sub-LHIN by sub-LHIN and group by group, as implementing this would be nearly impossible in already under-serviced areas where physicians are already strained to provide the level of care needed for their community. If having them staff an after-hours clinic means no coverage for hospital wards or ERs, then adjustments will absolutely need to be made.
F) Requirement for Prompt Access to Appointments for Acute Concerns
Effective April 1, 2019, where a patient’s FHO physician is not available during weekday hours, the FHO will provide a patient presenting with a time-sensitive condition the option of seeing another FHO physician (whether face to face or virtually as clinically appropriate), or as clinically appropriate an allied health provider affiliated with the FHO, on the same or next day, or an after-hours clinic that day or the following day.
FHOs are encouraged to consider including the following illustrative examples as time sensitive conditions:
a) significant new or worsening pain (including pain caused by recent injury),
b) new onset or change in symptoms of infection including fever, rashes, gastrointestinal changes, urinary changes, respiratory changes,
c) exacerbation in chronic conditions (for example back pain, heart disease, lung disease or abdominal or gynecological disease),
d) concerns regarding pregnancy and newborns and infants,
e) decompensation in mental health or substance use, or
f) time sensitive prescriptions that cannot be managed in other ways.
but would not include:
a) annual health exams and preve ntative screening visits,
b) completion of forms (for example tax disability, insurance, school trips/camp), or
c) routine follow up of chronic physical and mental health conditions.
FHOs are encouraged to provide education and training to staff with responsibility for setting appointments related to these time sensitive examples.
Completely reasonable. No argument here at all.
G) Adjust the Maximum Special Payment (MSP) to Reduce Outside Use (FHO & FHN)
Effective April 1, 2019, a mend the primary care FHN and FHO contracts to change the Maximum Special Payment provision (Access Bonus) to recover negative access bonus payments dollar for dollar.
This is likely to be a proposal that is heavily criticized by FHO physicians in the GTA, where their patients are highly mobile and frequently attend walk-in clinics for convenience, while the FHO physician works at an under-utilized after-hours clinic. But while frustrating, the solution can be to de-roster the patient as they are not abiding by the terms of the FHO contract (while still keeping them as a patient). And if many patients are doing this, de-roster the offenders, and open up the roster to more patients.
But to offset the ill will this will create with GTA docs, let’s finally fix the codes that are counting against outside use. Walk-in docs should not be billing A003s on rostered patients. Nor K005 or K013 for non-planned counselling or mental health sessions. And a complex laceration is not something that should be expected to be done, thus should to be negated. And a “consult” done by another family doc who doesn’t have a focus practice designation (*cough* cannabis and pain clinics *cough*) should not be counting toward outside use.
H) Inclusion of Emergency Department Usage in Outside Use (FHO & FHN)
Effective April 1, 2019, recover the Emergency Department Best Managed Elsewhere (EDBME) services from the Access Bonus Payment at a service value equal to the A007 and A888 when the ED service is rendered during regular office hours Monday through Friday , 8am – 5pm.
There is no change the current listing of the limited service codes currently considered.
Once again, I understand the rationale. Some FHO physicians encourage their patients to attend the ER rather than walk-in clinics when the physician is away, as to not incur outside use negation.
I agree with this proposal but with two important modifications: i) we need to better define EDBME services (done bilaterally with OMA and ministry with what can reasonably be seen in a primary care office) and disseminate these definitions openly, and ii) a mandate must exist to all ERs that if a patient arrives with a problem deemed EDBME, that the patient is informed that their family physician is mandated to be available to see them, and their physician will be charged the value of the ER visit. I know that this will still not provide nearly enough patient accountability, but I think it’s a first step to educating patients about the financial consequences of their care decisions.
I) Quality Improvement Plans
Extend the requirement for all primary care physicians to participate in quality improvement activities. This will include the following supports for those in the FHN and FHO:
• All FHNs and FHOs to complete an annual QIP and submit it to HQO similar to other current primary care models such as CHC
• OMA and HQO to work together to develop a QIP model that can be utilized by other primary care mode ls such as FHN, FHG and FFS.
• Each FHN and FHO group should have members (including physicians) with skills in quality improvement (such as provided by the Improving & Driving Excellence Across Sectors (IDEAS) Advanced and Foundations training program)
• Access to data management/ EMR support (such as the Quality Improvement Decisions Support Specialists currently provided to FHTs)
• All individual physicians, regardless of model should receive the HQO Primary Care Practice Improvement Reports. These provide standardized metrics, and audit and feedback supports including practice- and group-level data on these metrics .
I like it. (This shouldn’t surprise you if you’ve read any of my other blogs. We do QI in our office for fun, with no formal supports like they receive in FHTs). But this underscores why you simply can’t cut the capitation rate in point A as they have proposed. You can’t expect physicians to do all of this QI work, for less overall money. They will all simply jump to FFS work. Fix the cap rate, get all FHO docs doing great QI work and improve clinical care. Everyone’s happy.
J) Add A888A (Emergency Department Equivalent), G590A (Influenza Agent), A002A (18 month well baby visit) to the basket of included codes
Effective April 1, 2019:
A888A to be included as an “ in basket ” included Fee Schedule Code, eliminating incentive for its use. The A888A would be paid at zero dollars with the Blended Fee for Service premium paid at 15% of the fee value and would continue to be billed in conjunction with the Q012 premium paying at 30% of the fee value.
A002A to be included as an “ in basket ” included Fee Schedule Code. The A002A would be paid at zero dollars with the Blended Fee for Service premium paid at 15% of the fee value.
G590A to be included as an “ in basket ” included Fee Schedule Code. The G590A would be paid at zero dollars with the Blended Fee for Service premium paid at 15% of the fee value.
Yes, I completely agree that we need to adjust what is in basket and what is out of basket. We want to incentivize family docs to do as much in their offices without referring off to others (expensive consult fees, more fragmentation, etc.).
So sure, put the A888A and A002A in the basket. It will cost us money, I know, but there’s give and take in this negotiation. Don’t remove the influenza vaccine. Pharmacists already make more than family docs to give the vaccine, which has led many family docs to stop giving the vaccine. And since we know that vaccination uptake is much higher when the patient has a positive relationship with the provider, taking influenza vaccinations out of family physicians’ offices (which is what putting it in basket will do) will result in a plunge in the vaccination rate.
And while we’re fixing the baskets, take most procedures out of basket to give family docs incentive to not refer off so frequently. It’s cheaper to have family docs do cryotherapy, punch biopsies, wound repair, joint injections, IUD, etc.; this should be a no-brainer. The current bonus for meeting a certain yearly total of procedures aren’t providing enough of an incentive, as doing very few procedures maximizes that bonus easily, and going above and beyond that threshold doesn’t give additional marginal benefit.
K) Eliminate Cumulative Preventative Care Bonus
End the Cumulative Preventative Care Bonus effective April 1, 2019.
Below is a list of the current bonuses and premiums, by category with expenditure amounts for the 2015 – 16 fiscal year :
Cumulative Preventive Care Bonus – (FY15 – 16 $55.0M)
1. Influenza Immunization – target population, patients over age 65
2. Pap smear – target population, women between the ages of 35 and 70
3. Mammogram – target population, women between the ages of 50 and 70
4. Childhood Immunization – target population, patients between ages of 18 months and 2 years
5. Colorectal Cancer – target population, patients between the ages of 50 and 74 years
Colorectal Cancer Screening Premiums
1. FOBT Distribution – All models ($2.947M)
2. FOBT Completion – CCM/FHG/GP Only ($0.031M)
The rationale for this one is likely a 2014 study done by Dr. Tara Kiran’s group that showed that “pay-for-performance had little to no improvement in screening rates despite substantial expenditure”. So easy decision, right? Remove the incentive?
Hold on a second. We have a new study from September 2018 in the New England Journal of Medicine out of the UK which showed that removal of financial incentives was associated with an immediate decline in performance on quality measures. So while rewarding performance may not be improving measures, removing the rewards may certainly result in a decline in screening rates.
I realize that from the government’s standpoint, they may feel that they are funding both Cancer Care Ontario (CCO) and family physicians to do the same screening work, but let me be crystal clear. Relying on CCO to drive cancer screening will be a complete disaster. They are still sending cervical screening invitations to patients who have had hysterectomies. They don’t have adequate data on patients who require more frequent screening. And quite simply, patients are less likely to respond to screening invitations from a 3rd party than they are from their family physician.
Here’s a compromise. Keep the total amount of the bonuses, but redistribute. Take out the childhood immunization metric. We are already emotionally pained when parents refuse vaccines, despite our best efforts at communication. Don’t compound our pain through financial penalties. Reduce the maximum payment to each of the remaining 4 metrics. And add some new metrics, rotating them out every few years, based on where the OMA and the government agree that improvements are needed (medication review, pneumococcal vaccination, abdominal aneurysm screening, BMD screening, etc). And we need to change the measurement of the metrics to rewarding process rather than outcome (see my blog here on that topic). Keep things nimble, keep family docs excited about these metrics, give them good EMR tools to do this work, and you’ll see some exciting stuff with how well we step up to the challenge.
L) Discount Applied to Services Billed Outside of Enrolling Group
A discount of 25% be applied to the fee value of all services provided to PEM enrolled patients when the service is provided by a physician outside the enrolling group.
The discount to be implemented at the start of the final year of the agreement and ongoing.
Not sure I understand the rationale here to be honest. The physician outside the enrolling group (often a walk-in) is simply seeing patients as they come, and has largely no control over whether they are rostered to another physician or not. They have no ability to refuse to see the patient, so I am not quite sure why the walk-in doc is only being paid 75% of the fee when this is largely a product of patient convenience (as the other proposals will ensure the FHO docs is actually available, which they currently aren’t guaranteed to be).
So my final message to government. There are plenty of FHO physicians out there doing good work, who are reasonable, and want to find a solution. Put forward a reasonable proposal before you leave an entire generation of family physicians jaded beyond repair. Your arbitration proposal may have been some sort of scare tactic to wake up family docs, but it was unnecessarily harsh. Let’s fix the FHO model, and open them up to all physicians regardless of geography to remove this two-tier system we have right now of FHO and FHG/CCM physicians. Do the work the Liberals couldn’t, and cement a legacy of good quality primary care in Ontario.