Why is the Government of Ontario Targeting New Family Physicians?-part 2

In my last post, I talked about how the Government’s decision to restrict entry into capitated models of care and into Family Health Teams was an unreasonable targeting of young family physicians and their patients.  Today I want to explore how two more unilateral decisions by the Government will have a negative impact in new Family doctors and will prevent them from entering team based care.

The Government has removed all rostering fees, except for patients who have complex medical needs and has ended a program called Income Stabilzation or IS except in ‘high needs areas’.

Why were rostering fees introduced?

They were introduced 10 years ago at a time when well over a million people in Ontario did not have a family doctor.  Rostering fees were introduced to encourage family doctors to accept more new patients and to encourage new graduates to enter Patient Enrollment Models or PEMs.

At the time few new grads were making a commitment to have a traditional family practice.  The fees were very succesful and now most new grads set up comprehensive family pratcices within 3 years of finishing their post graduate training.

The fees help with finding the capital necessary to set up an office.  Equipment, leasehold improvements and other up front costs are very expensive for new physicians who on average have over $100 thousand dollars in student debt and young families.

And by the way, because of a growing population with more complex needs, we still have 900 thousand unattached patients in Ontario.  So the need has not gone away.

Income stabilization is meant to help transition new physicians into capitated practice.

When physicians enter fee for service, they can generate an income right away.  Every new patient they see, every patient they see for a colleauge generates a fee.  But in capitation, there is no fee.  The patient enters the practice and the physician starts to recieve an average daily fee of under 50 cents per day.  Once a physician has 1000 or so patients on her roster, that’s fine but in the initial months of practice, while the numbers slowly creep up, the physician does not generate enough income to even cover the cost of practice.

Income stabilization is a monthly payment made to new physicians in capitated practice so that they have an income while their practices grow.  There is an accountability built in to ensure that the new physician just doesn’t sit around, collecting the fee without working.  There is a monthy roster target that needs to be met in order for the IS payments to continue.

Without Income Stabilization and without new patient rostering fees, it will be very difficult for new Family Medicine grads to enter non-fee for service practice.  But as we saw yesterday, the Government is OK with that.  They are limiting the number and lcoation of new grads who can enter capitation anyway.

This triple shot at new grads, limiting entry into capiation and Family Health Teams, eliminating rosterng fees and ending Income Stabilization is a clear indication that the government wants to go back to the bad old days of fee for service-a model they pretend to dislike.

Scott Douglas Wooder, MD

Next I’ll talk about the missed oppurtunity to reform the system

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Government Takes Aim at New Family Physicians-Why? (part 1)

I was one of the many people who had a hand in developing policy around Primary Care Reform. As a negotiator for the Ontario Medical Association, I had a bigger role in implementing that policy across the province. We worked in partnership with the Ministry of Health, the Ontario College of Family Physicians, the Section of General and Family Practice and PAIRO (now PARO), the group who represent residents. We always consulted PAIRO to make sure that none of our policies hurt new graduates

We were successful in changing Primary Care and today capitated care models are the most popular models of care in Ontario. Family Health Organizations (FHOs) are the natural successors to Primary Care Networks and Health Service Organizations (HSOs), which pioneered primary care reform.

When people argue that physicians need to abandon fee-for-service, I am always puzzled. Many more family physicians practice in FHOs than practice in fee-for-service based models.

Consider three important facts:

  1. In order to practice in a Family Health Team, physicians must either accept a salary or practice in a capitated practice like a FHO. Most choose the latter option.
  2. Family Health Teams use teams of health professionals, including family physicians, nurse practitioners and primary care nurses, to provide patient focused care
  3. Every Family Medicine Resident in Ontario trains in a Family Health Team

Why is the Government of Ontario blocking entry into FHOs and FHTs for most new graduates and most young family physicians?

In 2012 the OMA and the Ministry of Health agreed to limit the number of new physicians entering FHOs to 40 per month. Twenty spots were for people willing to set up practice in high needs areas and twenty spots were for the province as a whole. The OMA was confident that every physician who wanted to practice in a capitated model, a FHO, would be able to do so. We understood that there might be a delay of a few months but it seemed like a reasonable compromise.

In 2015, the Government will cut the number of new physicians able to enter FHOs to 20 per month and all 20 spots will be reserved for high needs areas.

The Government will decide where those high needs areas are, but it is certain that larger Urban areas like Toronto, London, Ottawa and Hamilton and the rest of the 905 area will not be included.

New family medicine graduates will have a difficult choice. They can practice in high needs areas and perhaps be able to enter a FHO. They can practice in Toronto, but only in fee for service or a walk-in clinic. Or they can wait for people like me to leave practice. That’s one way to get young people interested in the obituaries.

The government is abandoning it’s commitment to team based care and making Ontario a very unattractive destination for new family doctors. Medical Students, Family Medicine residents and new Family Physicians feel abandoned by a government who told them they were the cornerstone of the health care system and now view them as an unnecessary expense.

Has the Government abandoned Primary Care Reform? Probably not. I think they are out to save money and don’t really care how they do it.  They don’t care what the impact is on our patients.

Our young colleagues deserve better and so do their patients.

Scott Douglas Wooder, MD

Next, I’ll look at why the cuts to rostering fees and income stabilization are another shot at young family doctors.eat young

Government Cuts to Physician Fees and Services

The Ontario Medical Association and the Government of Ontario, represented by Minister Eric Hoskins, have not been able to reach an agreement on a Physician Services Agreement. The OMA Board of Directors unanimously rejected the Government’s final offer that included a 4.8% cut and more cuts to follow if the cost of health care increases in the next 3 years.

Most of our members are quite happy that the OMA Board rejected this open ended series of cuts, but some of our members did want us to accept. They want to help their patients and their government out of a jam. I agree with this sentiment, but cannot support an agreement with a government who wants complete, unconditional victory with no chance to mitigate drastic cuts by working cooperatively with Doctors.

“The OMA wants you to believe that doctors in this province can’t provide the same level of care as last year unless they receive a pay raise and we simply don’t agree,” Eric Hoskins, Ontario Minister of Health. CBC news Jan 15 2015

Hoskins has also said that doctors who work roughly the same number of hours this year as last and bill roughly the same will have the same income.

Is either of these statements true?

Well of course they are not true. The Ministry of Health is cutting all fees in the schedule of benefits and all similar payments to doctors by 2.65% effective February 1 2015. So if a doctor works and bills the same this year as last, her revenue will automatically be cut by 2.65%. In addition the Government has targeted decreases to family physicians, general medicine internists, nephrologists, cardiologists, gastroenterologists, rural physicians, new physicians and physicians who provide on-call services in hospital. This large group of physicians, almost everyone in other words, will get even bigger cuts.

On average, Ontario physicians are looking at 4.8% in cuts.

An Ontario physician who works about the same this year as last and bills roughly the same way will have a revenue cut of 4.8%. Since most overhead costs are fixed, their income cut will be much higher.

To help the Minister and the Government out of their fiscal mess, the Doctors of Ontario have offered a 2 year freeze on all fees and asked the government to live up to their responsibility to fund the increasing growth in the system.

Under such a freeze, NO physicians would get a ‘pay raise’. If they worked the same this year as last, their income would be the same. That’s a true freeze.

So why is this important?

For starters, honesty is important. We cannot have a productive discussion about health care reform unless the government is being completely honest and transparent.

Our Doctors know that the Province is in economic trouble and would like to help. In 2012, Ontario’s Doctors worked with the Liberal Government to find $850 million in saving with a mixture of evidence based reform and fee cuts. Our members were confident that their patients’ access to quality care was being preserved and that their own personal sacrifices were respected.

A cut is a cut. Cuts may be justified in the short term to help the Province get back on its feet. But the Government has to be honest. No group should have to endure the double indignity of a large income cut while being told that they are greedy.

Let’s have an honest discussion about physician payments. It’s the only way to get everyone working together to fix a broken system.

Scott Douglas Wooder, MD

This is the first of a series of posts about the Government’s unilateral cuts. I focused on the big picture today. Next I’ll look at how some targeted cuts will negatively effect patient care