More Problems with Limiting Entry to Capitation

I’m not sure if I’m being relentless of obnoxious in pointing out the problems that are being caused by the unilateral cuts made by the Minister of Health to medical care in Ontario.  One of the cuts announced in January of 2015 is a reduction in the number of physicians who will be allowed entry into capitated models of care.  These capitated models are called Family Health Organizations, or FHOs.

The total number of new entrants is being reduced from 40 per month to 20 per month and physicians will only be able to join FHOs in ‘high needs’ areas.  One could argue that the whole Province is in high need of good quality primary health care, but we will have to wait to see the Ministry’s definition.  It will be interesting to track high needs areas against Liberal held ridings.  Surely it would be abhorrent for medical care to depend on the capriciousness of patronage appointments.

It seems likely that cities with medical schools won’t be on that list.  So no new entrants to FHOs in Toronto, Ottawa or Hamilton amongst others.  I can’t wait to see what happens in Sudbury, one of the homes of the Northern Ontario School of Medicine.

In communities that are not defined as high needs a physician can enter a FHO as a replacement for a departing physician.  If someone dies or retires, they can be replaced

I believe that the ill thought out policy of the Government is aimed at young physicians and especially young mothers and fathers.  Let me explain.

My colleague, Dr. A (based on a real colleague) wants to retire after 40 years of practice.  He has worked hard and has a very large practice.  He works incredibly long hours to provide good care, arriving at the office at 7 am to see a few factory workers on their way to or from work.  He stays late and rarely gets a lunch.  His evenings are spent doing paperwork or working in his after hours clinic.  He practices in a Family Health Team and is paid through his FHO.  He is part of a team that includes a primary care nurse, a mental health worker and a physician assistant.

Dr. A wants to retire in a year.  He is smart enough to plan ahead and as part of his legacy he want to make sure that his patients are well looked after.  A common practice in Hamilton has been to identify a young physician, Dr. B, to take over the practice and work together for a year to smooth out the transition.  It’s a wonderful form of succession planning.  Drs. A and B work side by side to smooth our the change.  Dr. A is relieved that his patients are going to be patients of a well-trained young family doctor and Dr. B. gets to know that patients in a low pressure setting.  After a year each physician is happy that things will work out and a seamless transfer of care occurs.

But now, with the unilateral cuts to care imposed by the Liberal Government, Dr. B cannot enter the FHO until Dr. A leaves.  So the smooth transition is against the rules and Dr. A must look elsewhere.

Dr. A is persistent and lucky.  He finds 2 physicians who want to share his practice.  Dr. C is a new mother.  She has 3 young children, 2 of whom are in primary school.  The third is looked after several days a week by a family member.  Dr. C needs to work but ideally she would work 3 days a week so she can do all the things she want to do at home.  Dr. D would love to work in this practice but she has other irons in the fire.  She does work in long-term care facility and does some research as well.  Drs. C and D plan to job share and between them look after Dr. A’s practice.

There is a problem with this arrangement too.  A new physician can replace a departing physician in a FHO, but two cannot replace one.  No job sharing allowed.  Dr. C cannot work part-time in a FHO while her children are young and Dr. D cannot pursue non-FHO related activities.

My colleagues Dr. A finally finds a single replacement who gets no introduction to the practice and is willing to work the same crazy hours that he did.  Who needs a work/life balance?  Just work and quit complaining.

This is one example of the problems that will arise with a poorly considered Government imposed policy.  Isn’t it time the Government of Ontario and the Minister of Health sat down with real doctors, with the OMA, to negotiate an agreement that makes sense for patients, doctors and the government?

Scott Douglas Wooder, MD


7 thoughts on “More Problems with Limiting Entry to Capitation”

  1. The absence of a provision for job sharing is bad from a physician health point of view and especially so for physicians who are also caregivers to sick relatives or who just want to spend more time with their young children. There are also physicians who suffer from short term disabilities that require a graduated return to work. The root cause of this oversight, this shortcoming, is the lack of stakeholder consultation in guiding government policy. This does not seem to be restricted to just Dr. Hoskins nor to just the physician services agreement. It smacks of a fortress mentality and perhaps a well-defended denial that they need help.


  2. This has to be incredibly frustrating to doctors who try to make the transition to a new doctor as seamless as possible for all concerned – a win win win solution. How the gov’t can possibly think that their new rules make sense is just another indication of how disconnected they are from what primary health care is about. Have shared this on my FaceBook page – trying to build patient involvement.

    Liked by 1 person

  3. Thanks so much for posting this. I am a resident and also a Dr. B in your article. My family medicine preceptor is the Dr.A. We thought we had the perfect transition plan, my last year of training and first year of practice a joint effort and then we would proceed with gradual handover of the practice. This was ideal for both the physicians, but most importantly for the patients. They felt secure in having the new physician come in and learn the practice and get to understand their health concerns, while still having contact with their long time physician. This plan came to a sudden halt with the new Ministry rules. We are blocked from pursuing our transition plan. I am still scrambling to find a new spot to practice. I am sure I will land on my feet, but my patients (or rather who I thought were my patients) will be left behind.

    I will start a new practice somewhere, appearing one day to replace a retired physician who will disappear that same day. Handover will be a handshake and a computer password.

    I am so disappointed for myself, my fellow graduating physicians and for the people we promised to take of. I hope they know this is not what we would have chosen.

    The government has said this is merely a “pause” to reassess the structure of family medicine teams. Unfortunately they don’t realize this pause will have long term consequences for many people in this province, consequences that will not be easily undone.

    Liked by 1 person

  4. FHO’s are a great idea, however they cost the Government a lot!
    Not all physicians are ethical and you see examples of those that depart on an extended leave whether it is a holiday or maternity leave without coverage for their more than 5,000 patients whom they have registered and collected capitation fees! When these patients show up at clinics outside the FHO there is no negation!
    The MOHLTC can track usage from shadow billings and is aware of problems with accessibility for care in these models!

    With a hard cap on the Physician Services Budget one does not want FFS physicians subsidizing these models.


    1. Hi Dr Pabani

      Some of your assertions are very suspect.

      There is no chance that the scenario you describe would not trigger negation.

      It’s always easy to criticize others, but my experience is that most of us,almost all of us in fact, try our very best to help out patients. That’s true no matter what the payment model is.


  5. I am a family medicine graduate who chose to go to a rural area, went back to get more training (FP Anesthesia), to return to my community to find out I can probably no longer join the FHO.

    I am in a rural area, but no one can tell me if my area is “underserviced” enough to meet that undefined limit. So I wait in limbo, finishing my enhanced skills year, with patients waiting for me to be their doctor, with no idea if I can join the FHO.


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