Ruth Wilson, M.D., C.C.F.P.

1
Primary Care Renewal in OntarioFocus on
Remuneration

• Ruth Wilson, M.D., C.C.F.P.
• November 2006

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Outline

• History
• Ontarios goals
• Principles and elements of primary care renewal
• The models and their progress
• Barriers and facilitators

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Ontarios Primary Care Renewal goals are...

• Improving access to primary health care
• Increasing patient and provider satisfaction with
  the health care system
• Improving quality and continuity of primary
  health care
• Increasing cost-effectiveness of health care
  services

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Principles of Renewal

• Voluntary participation of providers and patients
• Collaborative implementation with Ontarios
  health care providers
• New incentives to encourage and facilitate
  changes to ensure PCR goals are met
• Alignment of primary care models
• Patient enrolment

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Grouped/networked practices

• Extended access hours
• Enhanced use of information technology
• Focus on comprehensive care services

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A Brief History

• 1996 Steering Committee
• 1998 Pilots (14 Primary Care Networks)
• 2000 OMA/Ministry negotiations
• 2001 OFHN
• 2002 FHNs
• 2003 FHGs
• 2004 FHTs
• 2005 OMA/Ministry negotiations and the
  Comprehensive Care Model (CCM)
• 2006 FHO

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Physicians in Primary Care Renewal Models
FHNs
PCNs
FHGs
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Patients Enrolled in PCR Models
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PHC Metrics by ModelNov 2006
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PHC Metrics by ModelNov 2006
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Family Health Networks (FHNs)
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What is a Family Health Network?

• A group of at least 5 family doctors working
  together with other health care professionals to
  provide accessible, coordinated care to enrolled
  patients
• After-hours care through a combination of on-call
  arrangements and a telephone health advisory
  service
• A new method of physician payment
• Voluntary for all patients and physicians

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Patient Enrolment Requirements

• To seek treatment from their FHN family doctor
  first, unless they are travelling or find
  themselves in an emergency situation
• To allow the Ministry to provide their doctor
  with information about services they have
  received from family doctors outside of the
  network and some preventive services
• To not switch the doctor theyre enrolled with
  more than twice per year
• However patients are not required to enrol to
  continue receiving services, nor will they be
  refused enrolment due to their health status or
  need for services

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Patients Enrolled in Family Health Networks
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Telephone Health Advisory Service (THAS)

• For both FHNs and FHGs
• After-hours
• Nurse-staffed
• Phones a physician when required, otherwise
  directs patient to self-care or hospital. (Pilots
  reported reduced advice call)
• Report faxed next day to personal physician (with
  patients permission)

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Payment Overview

• Blended Model
• Capitation
• fee-for-service
• lump sum payments
• special premiums
• blended model
• Blended approach allows FHN physicians to receive
  an increase in remuneration if providing
  broad-based comprehensive care

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Payment Overview

• Fee-for-service payments for core services (10)
• Fee-for-service for excluded services
• Premiums for obstetrics, palliative care, house
  calls
• New patient fee after hours fee plus several
  additional enhancements

• Base payment rate determined by age and sex of
  patient
• Annual payment of 102.00 per patient
• Some payments are made to individual physicians,
  but most are made to the FHN
• Bonuses for achieving preventive targets

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Benefits for Physicians

• Income predictability
• Increased revenue when providing broad-based,
  comprehensive care
• Patient commitment to see FHN physician first for
  primary care services

• Shared on-call and coverage for each other
• Rewards for comprehensive and preventive care
• Opportunity for improved organization and
  tracking of clinical information using
  information technology

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Benefits for new physicians

• Guaranteed first year annual income of at least
  155,000 if you practice in an urban area, and at
  least 170,000 if you practice in a rural or
  northern area
• Immediately concentrate on practicing medicine
  without worrying about the business of setting up
  a practice
• Access to the support of seasoned colleagues
• Easy to integrate
• Roster patients on their own, or
• See the patients of other doctors in the network
  as a locum

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Payment Parameters

• Core services
• 57 codes (represent 80 of all billings by
  primary care physicians)
• 10 of the value of fee-for-service payments for
  core services to rostered patients

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Payment Parameters (continued)

• Continuing Medical Education (CME)
• Maximum payment of 2,400 per year per physician
• Access Bonus
• Approximately 20.00 per rostered patient
• Every six months
• For reducing core services provided to your
  patients by non-FHN doctors
• Template Amendment (effective date TBD)
• exemption for eye tests by GPs

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Payment Parameters (continued)

• Group management and leadership payment
• Payment of 1.00 per patient per year
• Annual maximum of 25,000 per FHN
• THAS on-call payment
• Payment for on-call availability during the
  Telephone Health Advisory Service hours
• 2,000 per FHN per month

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Payment Parameters (continued)

• Ceiling for included codes to non-rostered
  patients
• Pooled among all physicians in the FHN up to
  45,000 per physician
• Preventive care bonuses
• Up to 11,000 per year for achieving high
  compliance levels for preventive care to rostered
  patients
• Based on doctors reporting of services

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Payment Parameters (continued)
Hospital, reproductive, ER, office procedures,
palliative care, home visits and other excluded
codes

• 100 of fee-for-service payments for all non-core
  services to rostered and non-rostered patients

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Special Premiums
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Additional Special Premiums

• Seniors Care
• 10 extra for enrolled patients 65 - 74 (paid to
  FHN)
• After Hours
• 10 of value of fee code for enrolled patients
  (paid to physician)
• Mental Illness Care
• 1,000 per year for 5 - 9 enrolled patients with
  bipolar disorder or schizophrenia 2,000 for 10
  patients (paid to physician)

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Additional Special Premiums (contd)

• New Patient Fee
• 100 each per year for up to 50 new patients
  without a physician
• Extra 10 for new patients 65-74 20 for age 75
  and over (paid to physician)
• Newborn Care Episodic Fee
• Extra 12.50 for each of up to 8 intermediate
  assessment (A007) visits in first year of life
  (paid to physician)

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Family Health Groups (FHGs)
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Family Health Groups - Overview

• Minimum of 3 physicians
• Comprehensive care to Ministry-supplied roster
  and to registered patients
• Fee-for-service (FFS) billing
• 10 increase to 13 most common GP codes
• Additional premium payments
• After hours services
• Patient registration (enrolment)
• Telephone Health Advisory Services (THAS)
• All payments directly to individual physicians in
  the FHG

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FHGs - Payment

• Comprehensive Care Premium
• 10 premium on 13 codes to all patients on
  initial roster and to all registered patients
• Codes A001 - minor assessment
• A003 - general assessment
• A007 - intermediate assessment
• A888 - emergency department equivalent -
  partial assessment
• A901 - house call assessment
• E075 - geriatric assessment premium (i.e. extra
  10 added to the 20)
• G365 - pap smear
• G538 - immunization
• G590/591 - flu shots
• K005 - primary mental health care
• K013 - counselling
• K017 - annual health-child over 2

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FHGs - Payment (continued)

• Senior Care Premium
• 10 premium for General Assessment (A003) to
  registered patients aged 64 - 75
• Code Q065 claimable once per eligible patient per
  fiscal year
• After Hours Premium
• 10 premium on all after hours assessments (A
  codes) to
• registered patients
• Paid via Q012 code

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FHGs - Payment (continued)

• Palliative Care Premium
• 2,000 for palliative care (code K023) for 4 or
  more patients per fiscal year
• Applies to patients on initial roster and to
  registered patients
• Mental Illness Care Premium
• 1,000 per fiscal year for 5 to 9 registered
  patients with bipolar disorder or schizophrenia
• 2,000 per fiscal year for 10 more such patients

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FHGs - Payment (continued)

• New Patient Fee
• 100 each for up to 50 new (i.e. orphan)
  patients per fiscal year
• 110 for such patients aged 65 to 74 120 for
  ages 75 and over
• Doctor and patient sign declaration confirming
  orphan status

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FHGs - Enrolment / Registration

• No initial roster for non-identified doctors
• All doctors in FHG can register patients on
  initial roster and other patients
• Patient must sign registration form, even if
  already on initial roster
• Registration bonus payments to identified
  doctors
• 1,000 for registering 33 of patients on
  roster
• 1,000 at 66
• 1,000 at 100 of roster
• Registration bonus of 1,500 to non-identified
  doctors for registering 1,000 or more patients

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FHN and FHG physicians in small hospitals

• Emergency Coverage
• Inducements to FHN and FHG doctors to provide
  hospital ER coverage and/or anesthesia
• If more than 50 provide regular, on-going
  ER/anesthesia shifts, they can be exempted from
  after hours coverage

• Nurse Practitioners (NPs)
• Hospitals, FHNs, and other groups could apply for
  ministry funding for NPs
• 117 positions, targeted to underserviced areas
• 11 FHNs associated with NPs

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Growth of Family Health Groups
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Patients Enrolled in Family Health Groups
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Family Health Teams (FHTs)
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Family Health Teams (FHTs)

• Builds on existing primary care models
• Multidisciplinary team (doctors, nurses, NPs, and
  others as needed)
• Extended office hours and THAS
• Improved health system integration
• IT support through ePP/OMA

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FHTs (continued)

• Flexible - FHTs are not one size fits all
• Community and provider partnerships
• Local integration
• Patient focussed
• Evidence-based balanced approach
• Transparency and consultation
• Changes fostered through an incentive-based
  approach

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Where are we now?

• Of the 150 Family Health Teams announced
• 125 teams, in various stages of development and
  implementation, have enrolled patients and are
  currently providing care to more than 1.4 Million
  Ontarians of which 97,000 are new unattached
  patients.
• Of the remaining 25 FHTs, 15 are in a primary
  care model that is just starting to enroll
  patients and 10 are in a practice models that are
  moving towards an eligible FHT model.
• Currently, 66 teams have commenced operation and
  hired more than 268 allied health professionals
  including 71 Nurse Practitioners, 82 Registered
  Nurses, 20 Registered Practical Nurses, 26
  Dieticians, 31 mental health workers, 20 social
  workers and 8 pharmacists.
• 104 Business and Operational Plans submitted
  100 approved.
• Over the next few months these numbers will grow
  considerably as more teams become operational.

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Comprehensive Care Model (CCM)
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Comprehensive Care Model (CCM)

• New model recently negotiated by Ministry/OMA
• Available to any family physician who
• signs a CCM agreement
• offers enrolment to their patients
• provides one three-hour block per week of after
  hours care to their enrolled patients and
• bills fee-for-service
• 1.00 per month per rostered patient initially
• Participation is voluntary for physicians and
  patients

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Shortts analysis

• Interdisciplinary teams
• Information technology
• 24/7 access
• Rostering
• Payment systems

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Barriers

• Skepticism and cynicism
• Reluctance to work in a group/difficulty finding
  partners
• Developing governance agreements
• Delays in information technology
• Delays in funding / introducing multidisciplinary
  team

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Facilitators

• Political will
• role of agency
• support of provincial medical association
• physician and peer champions
• public support

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Conclusion

• Primary care renewal is worth doing
• There is an evidentiary vacuum within which
  policy and changes are made
• Health human resource issues have created
  additional challenges and opportunities
• Stay the course---good for patients, good for
  providers

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Conclusion

• Primary care renewal is worth doing
• There is an evidentiary vacuum within which
  policy and changes are made
• Health human resource issues have created
  additional challenges and opportunities
• Stay the course---good for patients, good for
  providers