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

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

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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

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SLIDE 1

4/20/2011 1

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

Dedicated to Doctors. Committed to Patients.

– FHT

  • Summary information
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SLIDE 2

4/20/2011 2 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)*

Dedicated to Doctors. Committed to Patients.

y g ( )

  • Family Health Networks (FHNs)

– Salaried models

  • CHC, RNPGA, etc
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SLIDE 3

4/20/2011 3

80% 90% 100%

Distribution of Family Physicians in Ontario by Various Models, April 2000 to March 2011

FFS FHG FHO

30% 40% 50% 60% 70% Percent of Family Physicians

Dedicated to Doctors. Committed to Patients.

0% 10% 20% Apr-00 Apr-01 Apr-02 Apr-03 Apr-04 Apr-05 Apr-06 Apr-07 Apr-08 Apr-09 Apr-10 Mar-11

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%

Dedicated to Doctors. Committed to Patients.

March 1 2011-MOHLTC

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SLIDE 4

4/20/2011 4

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%

Dedicated to Doctors. Committed to Patients.

March 1 2011-MOHLTC

Fee For Service

  • Very few Family Physicians (FPs) who provide

comprehensive care are in pure FFS (400) R l ti l FFS billi

  • Rely entirely on FFS billings
  • Do not roster patients
  • No group requirements
  • No After hours requirements
  • Very few incentives apply to FFS physicians

Dedicated to Doctors. Committed to Patients.

Very few incentives apply to FFS physicians

– Out of Office bonus

  • Most poorly paid comprehensive care FPs
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SLIDE 5

4/20/2011 5

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

Dedicated to Doctors. Committed to Patients.

p p

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

Dedicated to Doctors. Committed to Patients.

patients

– Mini cap rate of $30 per patient per year-age/sex adjusted

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SLIDE 6

4/20/2011 6

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

Dedicated to Doctors. Committed to Patients.

  • Unattached patient fees

– $100-$180 depending on age – $350 for complex vulnerable patients thru HCC

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

Dedicated to Doctors. Committed to Patients.

  • Not eligible to participate in Family Health Teams
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SLIDE 7

4/20/2011 7

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

  • f 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

Dedicated to Doctors. Committed to Patients.

and in basket service

  • Mini cap rate of $30 per patient per year-age/sex

adjusted

Family Health Organizations (FHOs)

  • 15% of SOB for shadow billing on in basket services

– Accountability measure

100% f SOB f i b k t i t ll d

  • 100% of SOB for in basket services to non-enrolled

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

Dedicated to Doctors. Committed to Patients.

  • 20% premium for after hours work
  • May bill for non-insured services

– WSIB, third party requests, non insured medical services

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SLIDE 8

4/20/2011 8

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

Dedicated to Doctors. Committed to Patients.

  • Unattached patient fees

– $100-$180 depending on age – $350 for complex vulnerable patients thru HCC

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

Dedicated to Doctors. Committed to Patients.

  • Eligible for EMR funding
  • Eligible to participate in Family Health Teams
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SLIDE 9

4/20/2011 9

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

Dedicated to Doctors. Committed to Patients.

  • FP expected to contribute to overhead
  • FHT funding is meant to cover ‘extra’ overhead

Sources of Income

Source FFS FHG FHO

Fee For Service 100% 100%

  • 10% FHG premium
  • 20% After-Hour

Premium

  • 15% on core to

enrolled patients

  • 100% on core to non-

enrolled up to $52,883 100% f

  • 100% of non-core

Capitation No No

  • Avg. of $132.25, age-

sex adjusted + 18.59% access bonus Comprehensive Care Management Fee No

  • Avg. of $29.40 per

patient per year, age- sex adjusted

  • Avg. of $29.40 per

patient per year, age- sex adjusted Bonuses

  • Preventive Care
  • No
  • Up to $12,800
  • Up to $12,800

Dedicated to Doctors. Committed to Patients.

Preventive Care

  • Out of Office
  • Special Payments

No

  • Up to $11,000
  • No

Up to $12,800

  • Up to $23,000
  • Up to $2,000

Up to $12,800

  • Up to $23,000
  • Up to $11,000

Unattached Fees No $100-$180 regular $350 complex $100-$180 regular $350 complex

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SLIDE 10

4/20/2011 10

Primary Care Special Premiums

Special Payment Criteria Payment Eligibility

Hospital Premiums

  • $2,000 in defined services
  • $2,000 in defined services*
  • $6,000 in defined services*
  • $5,000
  • $7,500*
  • $12,500*
  • Harmonized Models (FHN,

FHO)

Office Procedures

  • $1,200 in defined services
  • $2,000
  • Harmonized Models (FHN,

FHO) 1 2 FHO)

Prenatal**

  • 5+ patients
  • $2,000
  • Harmonized Models (FHN,

FHO)

Serious Mental Illness

  • 5+ patients
  • 10+ patients
  • $1,000
  • $2,000
  • Harmonized Models (FHN,

FHO)

Home Visits

  • 3+ patients & 12 visits
  • 6+ patients & 24 visits
  • 17+ patients & 68 visits
  • $1,000
  • $2,000
  • $5,000
  • Level 1: All GPs
  • Level 2: All GPs
  • Level 3: All PEMs

Palliative Care

  • 4+ patients

10 i

  • $2,000

$ 000

  • Level 1: All GPs

L l 2 All PEM

3 4 5 6

Dedicated to Doctors. Committed to Patients.

OMA ECONOMICS

Palliative Care

  • 10+ patients
  • $5,000
  • Level 2: All PEMs

Labour and Delivery**

  • 5+ patients
  • 23+ patients
  • $5,000
  • $8,000
  • Level 1: All GPs
  • Level 2: All PEMs

Long Term Care

  • 12+ patients
  • 36+ patients
  • $2,000
  • $5,000
  • Level 1: All GPs
  • Level 2: All PEMs

*Hospital Premium Levels 2 and 3 are only eligible for groups with a RIO Score > 45 **Can not receive payment for both Prenatal and Labour and Delivery

7 8

Alternative Payment Programs (APPs) and Alternative Funding Plans (AFPs)

  • APPs/AFPs are non-Fee-For-Service funding arrangements

between the ministry, the OMA and physician groups (with bet ee t e st y, t e O a d p ys c a g oups ( t hospitals typically being a cosignatory) designed around provision of specialized services at a particular location.

  • Around 250 APP/AFP arrangements across Ontario

Key characteristics

Dedicated to Doctors. Committed to Patients.

  • 2+ physicians
  • Specialist or Specialized Services (i.e. Emergency Departments)
  • Payment to a group
  • Non Fee-For-Service (may be blended)
slide-11
SLIDE 11

4/20/2011 11

APP/AFP in Hamilton Niagara Haldimand Brant LHIN

  • Hamilton HSC GIM Funding
  • JoNovh GIM Funding
  • Hamilton Academic Health Sciences
  • Hamilton Regional Geriatrics Program
  • Hamilton Academic Paediatric Association
  • Hamilton Civic Trauma
  • St. Peter's Medical Association

O t i M di l O l A i ti

Dedicated to Doctors. Committed to Patients.

  • Ontario Medical Oncology Association
  • Ontario Association of Radiation Oncologists
  • Ontario GyneOncology Assiciation

ED AFAs in HNHB LHIN

  • Hagersville West Haldimand General Hospital
  • Dunnville Haldimand War Memorial Hospital

p

  • Niagara Health System - Douglas Memorial
  • Niagara Health System - Port Colborne
  • Grimsby West Lincoln Memorial Hospital

Dedicated to Doctors. Committed to Patients.

  • Hamilton Health Science Corporation (3 sites)
  • Niagara Health System - Welland General Hospital
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SLIDE 12

4/20/2011 12 HOCC Payment Structure, Levels I-III

Physicians Payment Coverage (%) Levels I and II 1 $103,200 60% 2 $137,600 80% 3 $137,600 80% 4 $155,945 91% 5+ $172,000 100% Physicians Payment Coverage (%) Level III 1 $18,345 54%

Dedicated to Doctors. Committed to Patients.

2 $27,520 81% 3 $30,960 91% 4 $32,105 95% 5+ $34,400 100% Level Specialties Groups MDs Payment I

GP/FP 217 1946 $31,649,607

II

Anaesthesia, Cardiac Surgery, Cardiology, Cardiothoracic Surgery,

Participation in HOCC and Total Payment, March 31, 2009

Critical Care Medicine, ED Backup On-Call, General Surgery, Internal Medicine, Neurology, Neurosurgery, Obstetrics & Gynecology, Ophthalmology, Ophthalmology, Orthopaedic Surgery, Otolaryngology, Paediatric Surgery, Paediatrics, Plastic Surgery, Psychiatry, Thoracic Surgery, Transplant Services, Urology, and Vascular Surgery. 1,088 6,623 $165,527,861

III

Cardiac Surgical Assistant, Cardiology, Diagnostic Radiology, Emergency Medicine, Endocrinology, Gastroenterology, Geriatric Medicine, Haematology/Oncology, Hyperbaric Medicine, Nephrology, Neurology, Ophthalmology, Otolaryngology, and Respiratory Medicine. 312 1,602 $9,247,520

IV

Dermatology, Immunology, Physicial Medicine & Rehabilitation, Rheumatology, Nuclear Medicine, Interventional Radiology, Radiation Oncology Gynaecologic Oncology and Infectious Disease 142 $304 900 Dedicated to Doctors. Committed to Patients. Oncology, Gynaecologic Oncology, and Infectious Disease. 142 $304,900 TOTAL

1,617 10,313 $206,729,888

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SLIDE 13

4/20/2011 13 HOCC Groups, by Level, April 1, 2010

Group Structure (# Physicians) Level I – Number of Groups Level II – Number of Groups Level III – Number of Groups (# Physicians) Number of Groups Number of Groups Number of Groups 1 2 105 35 2 7 140 36 3 5 103 55 4 15 100 40 5+ 194 650 147

Dedicated to Doctors. Committed to Patients.