Primary Care Compensation Models Scott D Wooder, MD Honorary - PDF document

4/20/2011 Primary Care Compensation Models Scott D Wooder, MD Honorary Treasurer, Ontario Medical Association HNHB Board presentation April 20 2011 Outline • Brief information about physician costs in relation to health budget • Numbers in various primary care models • Some high level detail about payment models – FFS – FHG-FFS based blended model – FHO-capitation based blended model – FHT FHT • Summary information Dedicated to Doctors. Committed to Patients. 1

4/20/2011 Some Basic Statistics On Ontario Provincial Spending • Health budget 2010/11 = $ 45.6 Billion • Physician budget 2010/11 = $ 9.7 Billion (21 % of Health budget) • Physician NFFS budget 2010/11 = $ 2.2 Billion (22% of Physician budget) Dedicated to Doctors. Committed to Patients. Primary Care in Ontario • Main Primary Care Options for GPs – Fee For Service (FFS) Fee For Service (FFS) • Comprehensive Care* • Focused Practice – FFS Based Blended Models • Comprehensive Care Model (CCM)* • Family Health Group (FHG) – Capitation Based Blended Models • Family Health Organizations (FHOs)* y g ( ) • Family Health Networks (FHNs) – Salaried models • CHC, RNPGA, etc Dedicated to Doctors. Committed to Patients. 2

4/20/2011 Distribution of Family Physicians in Ontario by Various Models, April 2000 to March 2011 FFS FHG FHO 100% 90% 80% 70% Percent of Family Physicians 60% 50% 40% 30% 20% 10% 0% Mar-11 Apr-00 Apr-01 Apr-02 Apr-03 Apr-04 Apr-05 Apr-06 Apr-07 Apr-08 Apr-09 Apr-10 Dedicated to Doctors. Committed to Patients. Number of PEM Physicians by Model Number of physicians percentage Family Health Org(FHO) 3497 45.84% “Harmonized” 696 9.13% Total Capitation 4193 54.97% Family Health Group 3073 40.29% CCM 315 4.13% Total FFS 3388 44.42% Total 7581 99.39% March 1 2011-MOHLTC Dedicated to Doctors. Committed to Patients. 3

4/20/2011 Number of Enrolled Patients by Model Enrolled patients percentage FHO 4 818 383 50.72% Harmonized 568 551 5.98% Total Capitation Based 5 386 934 56.70% FHG 3 723 205 39.19% CCM 390 403 4.11% Total FFS Based 4 113 688 43.30% Total 9 500 542 100% March 1 2011-MOHLTC Dedicated to Doctors. Committed to Patients. Fee For Service • Very few Family Physicians (FPs) who provide comprehensive care are in pure FFS (400) • Rely entirely on FFS billings R l ti l FFS billi • Do not roster patients • No group requirements • No After hours requirements • Very few incentives apply to FFS physicians Very few incentives apply to FFS physicians – Out of Office bonus • Most poorly paid comprehensive care FPs Dedicated to Doctors. Committed to Patients. 4

4/20/2011 Fee For Service • Many focused practice FPs practice in FFS – Sports medicine, GP psychotherapy, pain, addiction • Other focused practice FPs have alternate payment plans – Palliative care, HIV, care of the elderly, long term care, ED • Many physicians practice comprehensive care and spend some time in focused practice p p Dedicated to Doctors. Committed to Patients. Family Health Groups (FHGs) • FFS based blended model • 100 percent of billings of Schedule of Benefits (SOB) p g ( ) • 10% premium for certain ‘comprehensive’ fee codes • 20% premium for after hours work • Comprehensive Care Management fee for enrolled patients patients – Mini cap rate of $30 per patient per year-age/sex adjusted Dedicated to Doctors. Committed to Patients. 5

4/20/2011 Family Health Groups (FHGs) • Preventative Care Bonuses of up to $12 800 – Pap smears – Colorectal cancer screening with FOBT – Mammogram Mammogram – Influenza vaccination – Childhood vaccination • Out of Office Bonus of up to $23 000 – Home visits, long term care, labour and delivery and palliative care • Special Payments of up to $2 000 – Prenatal care, hospital care, office procedures, serious mental illness • Unattached patient fees – $100-$180 depending on age – $350 for complex vulnerable patients thru HCC Dedicated to Doctors. Committed to Patients. Family Health Groups (FHGs) • Must form Groups – minimum size 3 • Must provide after hours availability for scheduled and unscheduled visits • Number of 3 hour blocks vary by size • Eligible for EMR funding • Not eligible to participate in Family Health Teams Dedicated to Doctors. Committed to Patients. 6

4/20/2011 Family Health Organizations (FHOs) • Capitation based blended payment model • Main source of income is base rate of $132.25 (average) modified by age and sex for a defined basket of services – No disease modifier to base rate • Access Bonus of up to 18.59% – Lowered dollar for dollar every time another FP bills OHIP for and in basket service and in basket service • Mini cap rate of $30 per patient per year-age/sex adjusted Dedicated to Doctors. Committed to Patients. Family Health Organizations (FHOs) • 15% of SOB for shadow billing on in basket services – Accountability measure • 100% of SOB for in basket services to non-enrolled 100% f SOB f i b k t i t ll d patients – Up to $53 000 per year • 100% of SOB for out of basket services – deliveries, ED and hospital work, palliative care • 20% premium for after hours work • 20% premium for after hours work • May bill for non-insured services – WSIB, third party requests, non insured medical services Dedicated to Doctors. Committed to Patients. 7

4/20/2011 Family Health Organizations (FHOs) • Preventative Care Bonuses of up to $12 800 – Pap smears – Colorectal cancer screening with FOBT – Mammogram Mammogram – Influenza vaccination – Childhood vaccination • Out of Office Bonus of up to $23 000 – Home visits, long term care, labour and delivery and palliative care • Special Payments of up to $11 000 – Prenatal care, hospital care, office procedures, serious mental illness • Unattached patient fees – $100-$180 depending on age – $350 for complex vulnerable patients thru HCC Dedicated to Doctors. Committed to Patients. Family Health Organizations (FHOs) • Must form Groups – minimum size 3 – Formal governance agreement and Lead Physician Formal governance agreement and Lead Physician • Must provide after hours availability for scheduled and unscheduled visits • Number of 3 hour blocks vary by size • Eligible for EMR funding • Eligible for EMR funding • Eligible to participate in Family Health Teams Dedicated to Doctors. Committed to Patients. 8

4/20/2011 Family Health Teams (FHTs) • Family Health Teams do not have funding for physician compensation • The FP brings his own funding through a FHO • • Exception are the relatively small number of FP employees of Community Exception are the relatively small number of FP employees of Community Governed FHTs • Main advantage to the FP practicing in a FHT is funding for allied health professionals and the overhead associated with the allied health professionals • Funding for administration • • FP expected to contribute to overhead FP expected to contribute to overhead • FHT funding is meant to cover ‘extra’ overhead Dedicated to Doctors. Committed to Patients. Sources of Income Source FFS FHG FHO Fee For Service 100% 100% •15% on core to •10% FHG premium enrolled patients •20% After-Hour •100% on core to non- Premium enrolled up to $52,883 •100% of non-core 100% f Capitation No No Avg. of $132.25, age- sex adjusted + 18.59% access bonus Comprehensive Care No Avg. of $29.40 per Avg. of $29.40 per Management Fee patient per year, age- patient per year, age- sex adjusted sex adjusted Bonuses - Preventive Care Preventive Care -No No -Up to $12,800 Up to $12,800 -Up to $12,800 Up to $12,800 - Out of Office -Up to $11,000 -Up to $23,000 -Up to $23,000 - Special Payments -No -Up to $2,000 -Up to $11,000 Unattached Fees No $100-$180 regular $100-$180 regular $350 complex $350 complex Dedicated to Doctors. Committed to Patients. 9