CFPC.PCForum.RuthWilson-Remuneration

Document Sample
CFPC.PCForum.RuthWilson-Remuneration Powered By Docstoc
					Primary Care Renewal in
   Ontario—Focus on
     Remuneration
   Ruth Wilson, M.D., C.C.F.P.
        November 2006
                                                      2
Outline
•   History

•   Ontario’s goals

•   Principles and elements of primary care renewal

•   The models and their progress

•   Barriers and facilitators
                                                            4
Principles of Renewal
•   Voluntary participation of providers and patients
•   Collaborative implementation with Ontario’s health
    care providers
•   New incentives to encourage and facilitate changes to
    ensure PCR goals are met
•   Alignment of primary care models
•   Patient enrolment
                                                                 6
    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
                                                                                                     7
                                    Physicians in Primary Care Renewal
                           7000
                                    Models
                           6000
Participating Physicians




                           5000

                           4000

                           3000

                           2000

                           1000

                              0
                             Jun-99 Mar-00 Dec-00 Sep-01 Jun-02 Mar-03 Dec-03 Sep-04 Jun-05 Nov-06



                             PCNs                            FHNs    FHGs
                           Number of Patients Enrolled (thousands)
       Ju
            n-
               9




                             1,000
                                     2,000
                                             3,000
                                                     4,000
                                                             5,000
                                                                     6,000
                                                                             7,000
                                                                                     8,000




                       0
                   9
       M
           ar
             -0
                   0
       D
        ec
              -0
                0
       Se
          p   -0
                1
       Ju
            n-
               0   2
       M
           ar
             -0




Date
                   3
       D
        ec
              -0
                3
       Se
          p   -0
                4
       Ju
            n-
               0
                                                                                             Patients Enrolled in PCR Models




                   5
       C
        ur
          re
             n     t
                                                                                                              8
 PHC Metrics by Model                                                                                                                 9


 Nov 2006
                       Primary Care Model           Groups Signed         Physicians Signed           Patients Enrolled

Family Health Networks                                               96                       1,002                       1,160,920

Family Health Groups                                                329                       4,497                       4,651,096

CCM Physicians                                                                                 349                         391,092

Primary Care Networks                                                12                        170                         299,335

Health Service Organizations                                         48                        160                         274,091

Group Health Centre                                                   1                         34                          60,884

RNPGA -1 (NGFP)                                                      14                         60                          13,113

RNPGA - 2 (CSC)                                                      25                         34

WHA                                                                   1                         11

St Josephs                                                            1                         13                           1,638

CHC Physicians                                                       54                        177

Other APP                                                             3                         39

                                            Total                   584                       6,546                   6,852,169
 PHC Metrics by Model                                                                                                                 10


 Nov 2006
                       Primary Care Model           Groups Signed         Physicians Signed           Patients Enrolled

Family Health Networks                                               96                       1,002                       1,160,920

Family Health Groups                                                329                       4,497                       4,651,096

CCM Physicians                                                                                 349                         391,092

Harmonized                                                          159                        698                         649,061
                                            Total                   584                       6,546                   6,852,169
Family Health Networks
       (FHNs)
                                                            12
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
                                                                              13
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 they’re 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
                          Number of Patients Enrolled (thousands)
       M
           ar
             -0




                      0
                             200
                                   400
                                         600
                                               800
                                                     1000
                                                            1200
                  1                                                1400

       Se
          p   -0
                1
       M
           ar
             -0
                  2
       Se
          p   -0
                2
       M
           ar
             -0
                  3
       Se
          p   -0
                3
       M


Date
           ar
             -0
                  4
       Se
          p   -0
                4
       M
           ar
             -0
                  5
       Se
          p   -0
                5
       C
        ur
          re
                                                                          Patients Enrolled in Family Health Networks




             n    t
                                                                                                  14
                                                          15
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
    patient’s permission)
                                                            16
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
                                                                          17
    Payment Overview
•    Base payment rate determined      •   Fee-for-service payments for
     by age and sex of patient             core services (10%)

•    Annual payment of $102.00         •   Fee-for-service for excluded
     per patient                           services

•    Some payments are made to         •   Premiums for obstetrics,
     individual physicians, but most       palliative care, house calls
     are made to the FHN
                                       •   New patient fee; after hours
                                           fee; plus several additional
•    Bonuses for achieving
                                           enhancements
     preventive targets
                                                                    18
    Benefits for Physicians
•    Income predictability       •   Shared on-call and coverage
                                     for each other
•    Increased revenue when
     providing broad-based,      •   Rewards for comprehensive
     comprehensive care              and preventive care

•    Patient commitment to see   •   Opportunity for improved
     FHN physician first for         organization and tracking of
     primary care services           clinical information using
                                     information technology
                                                          20
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
                                                                      21
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
                                                            22
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
                                                               23
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
                                                            24
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
    Special Premiums
NOTE: Special payments will be paid for either obstetrics or prenatal care, but not both

                                                                                                                                   Non-
     Premium                                              Description                                               Rostered      Rostered   PAID TO
                                                                                                                    Patients      Patients

                                                           GROUP A                                                    Premium Payment


 Hospital            Annual payment for meeting minimum level of provision of hospital care to rostered and                $5,000.0          Physician
                     non-rostered patients. Minimum level is $2,000/year.                                       0

 Obstetrics          Annual payment for meeting minimum level of provision of obstetrical care to rostered                 $3,200.00         Physician
                     and non-rostered patients. Minimum level is five deliveries in a year.

                                                          GROUP B

 Palliative Care     Annual payment for meeting minimum level of provision of palliative care to rostered and              $2,000.00         Physician
                     non-rostered patients. Minimum level is billings for fee schedule code K023 for four (4)
                     or more palliative care patients in a year.

 Office Procedures   Annual payment for meeting minimum level of provision of office procedures to rostered         $2,000.00                Physician
                     patients. Minimum level is $1,200/year. (See Section 1 for related codes.)

 Prenatal Care       Annual payment for meeting minimum level of provision of prenatal care to rostered             $2,000.00                Physician
                     patients. Minimum level is billings for fee schedule codes P003 and/or P004 during the
                     first 28 weeks of gestation for five (5) or more prenatal care patients in a year.

 Home Visits         Annual payment for meeting minimum level of provision of home visits to rostered               $2,000.00                Physician
 (other than         patients. Minimum level is billings for fee schedule codes A901 and/or A902 for one
 palliative care)    hundred (100) or more home visits to patients in a year.
                                                                        26
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)
                                                                27
Additional Special Premiums (cont’d)
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)
Family Health Groups
      (FHGs)
                                                                    29
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
                                                                                          30
    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
                                                                    31
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
                                                                         32
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
                                                                      33
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
                                                                       34
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
                                                                    35

    FHN and FHG physicians in small hospitals
Emergency Coverage                Nurse Practitioners (NPs)

•    Inducements to FHN and       •   Hospitals, FHNs, and other
     FHG doctors to provide           groups could apply for
     hospital ER coverage             ministry funding for NPs
     and/or anesthesia
                                  •   117 positions, targeted to
•    If more than 50% provide         underserviced areas
     regular, on-going
     ER/anesthesia shifts, they   •   11 FHNs associated with NPs
     can be exempted from
     after hours coverage
                           Number of Family Health Groups
       M
           ar
             -0




                       0
                           50
                                100
                                      150
                                            200
                                                  250
                                                        300
                                                              350
                   3
       Ju
            n-
               0   3
       Se
          p   -0
                3
       D
        ec
              -0
                3
       M
           ar
             -0
                   4
       Ju
            n-
               0   4
       Se
          p   -0
                4
       D




Date
        ec
              -0
                4
       M
           ar
             -0
                   5
       Ju
            n-
               0   5
       Se
          p   -0
                5
                                                                    Growth of Family Health Groups




       D
        ec
              -0
                5
       C
        ur
          re
             n     t
                                                                                     36
                           Number of Patients Enrolled (thousands)
       Ju
            n-
               0




                       0
                            500
                                  1000
                                         1500
                                                2000
                                                       2500
                                                              3000
                                                                     3500
                                                                            4000
                                                                                   4500
                   3                                                                      5000
       Se
          p   -0
                3
       D
        ec
              -0
                3
       M
           ar
             -0
                   4
       Ju
            n-
               0   4
       Se
          p   -0
                4
       D
        ec
              -0
                4



Date
       M
           ar
             -0
                   5
       Ju
            n-
               0   5
       Se
          p   -0
                5
       D
        ec
              -0
                5
       C
                                                                                                 Patients Enrolled in Family Health Groups




        ur
          re
             n     t
                                                                                                                        37
Family Health Teams
      (FHTs)
                                                        39
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
                                                           40
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
                                                                   41
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
Comprehensive Care Model
        (CCM)
                                                             43
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
                              44
Shortt’s analysis
•   Interdisciplinary teams

•   Information technology

•   24/7 access

•   Rostering

•   Payment systems
                                                                 45
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
                                                46
Facilitators
•   Political will
•   role of agency
•   support of provincial medical association
•   physician and peer champions
•   public support
                                                              47
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
                                                              48
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

				
DOCUMENT INFO