OMA/MOH Negotiations: Part Deux

My last blog post raised a few very specific ideas within primary care that I hope to see addressed in the upcoming negotiations between the OMA and the Ministry of Health.

While I love practical minutiae, I think it’s also important to step back and address some of the larger issues of how primary care is organized and funded.

First it is vital to clearly delineate the accountabilities within the system, which are currently blurred to the point of being non-existent. From a funding standpoint (for care deemed clinically necessary, third party care excluded), there should only be two lines of accountability, one between the insurer (government) and policy holders (patients), and the other between the insurer and care providers (physicians). Patients should not be financially accountable to physicians, nor vice versa, and their relationship should be strictly clinical. I’ll explain later why this is important.

Patients in Ontario (and Canada, for that matter), generally do not fully understand the fact that their taxes are paying into a health insurance policy, and that like any insurance policy, there are benefits, expectations, and restrictions to the type of care that their insurance covers. I don’t blame patients for this. The fault for this lack of clarity lies with the insurer (government), who is understandably fearful of the political ramifications of being seen to “restrict” care by enforcing any semblance of limitation on “insured care”. Second opinions, two visits for the same issue in one day, anything goes!  But can you imagine Anthem or Aetna in the US demonstrating this type of ambiguity with what their  policies cover? Tax payers don’t want to pay more taxes to cover increasing costs, so we need to have open discussions around what is medically necessary and appropriate. Clear answers are needed to the question of what does the insurer guarantee to patients, and what expectations are there of patients. Physician organizations can and should be engaged to provide their objective expertise to guide what should be covered by a provincial insurer, but the reason that there can be no physician-patient financial accountability is that physician recommendations and behaviour may be seen as being influenced by financial motives.

And the provider-physician accountability? Not as clear as you would expect. Should be pretty simple, too. Agree to a framework of what is covered by the insurer, what the expectations are of physicians, and compensate appropriately for the insured care that is provided. But rather than having a strict framework guide physician activity, we often have physician entrepreneurs stretching the boundaries of what the current loose framework intended. House calls for non-disabled patients, specialist clinics that bring stable patients back repeatedly for routine follow-up with expensive imaging tests, and niche clinics opening up for any new market that they identify (eg. “biochemistry nutrition clinics”, “functional medicine clinics”, “cannabinoid medicine clinics”, etc.). With many of these clinics, the horse is coming before the cart. The physicians have a OHIP billing number, and it’s essentially a blank cheque to bill the government for any semi-clinical interaction with patients, until the CPSO or the ministry deems the clinic’s practices egregious enough to intervene (which is rare).

So where am I going with this? I have a fairly radical plan for how primary care funding could be re-organized.

First we need to address the issue of the “access bonus” for those in a FHO model with negation for family physician billings outside of their FHO. The initial rationale for the concept was innovative: use the outside billings as a surrogate marker for the degree of access FHO physicians are providing. With better access, patients should be seeking care elsewhere less frequently. Unfortunately, it has proven to be a poor surrogate in many areas of the province, including areas without a walk-in clinic (ER visits don’t contribute to negation, physicians get their total access bonus regardless of actual access) and the GTA where commuting patients will seek convenient care at a walk-in rather than attending the after-hours clinic their FHO is providing (FHO provides the access, still gets negated). But apart from the inequality of the system, this mechanism is fundamentally flawed because it violates one of the principles of accountability I raised earlier. Lines of financial accountability should not exist between patients and physicians. In the case of the access bonus, it has strained many physician-patient relationships as physicians have often clumsily attempted to educate patients about what the access bonus/negation issue entails, while the patient hears “You are costing me money by seeking health care”.  This is not healthy for these relationships. We need a new system.

Here we go.

First, take the FHO/FHG/FNH models and replace them with two capitation “tracks” that family physicians can decide between for their practice. Track 1 would see 80% of their income from capitation fee, with a 20% fee-for-service shadow billing for patient encounters. Track 2 would see a 60/40 split. Depending on which Track a physician chooses, they would be locked in for 3 year periods (the math involved in switching between tracks more frequently would be a nightmare). Capitation figures would be adjusted based on a formula of patient complexity, the data of which would be taken from the accurate EMR coding of patient problems (with agreed-upon standards of what makes a patient eligible to be given a certain diagnosis/problem).

Next, when a patient is rostered to a family physician, within a 30km radius of their provider they are only insured to see their provider group. If a patient chooses to seek care at a walk-in or other family physician within that 30km radius, it would not be an OHIP-insured service, while outside of that radius it would be insured (on vacation, visiting family, work, etc.). There would have to be point-of-care OHIP validation available in real-time for walk-in providers to determine whether the patient visit would be insured or would be patient-pay. For those without valid OHIP cards who present for care, there would also have to be a live ministry-run system available for dealing with issues of coverage during all clinic hours.

If a patient repeatedly is seeking care outside of their provider network/radius, it is the INSURER (the province) that then can de-roster the patient and make that patient a “fee-for-service patient” (that is, each service covered by OHIP is paid as fee-for-service, not covered by capitation rates). The ministry would then be incentivized to attempt to find the patient a primary care group that is closer to the patient’s geographic area, as the province does like the relative cost-certainy that capitation models bring.

For physicians in these new capitation “tracks”, there would be NO cap on fee-for-service billings provided to patients who have been excluded from capitation by the ministry, as the fact that they are “fee-for-service patients” is out of their hands (there is currently a cap on these billings for capitated physicians).

There would also be no further clawback on access bonus payments. The payments would all be made in full to all physicians, but with strict accountability for after-hours clinic availability (7 days a week, 3 hours/d), and adequate patient access for new-onset complaints (3rd next available appointment within 24 hours). For those in rural areas, providing scheduled after-hours care through emergency departments would be allowable if negotiated directly with the LHIN. If physicians are found not to be meeting the access requirements, there would be a tiered warning system, with repeated violations ultimately resulting in termination of their capitation contract, reverting the physician to an exclusively fee-for-service model. Some physicians may see these requirements as oppressive, but if we are going to create a model whereby payments are essentially guaranteed and patients are restricted from seeking care elsewhere, we must provide them with impeccable access to our services.

(There would also have to continue to be a significant financial advantage for physicians to be in a capitation “track” model over a fee-for-service model to provide the incentive to stay within the organized capitation system.)

Patients themselves can opt to be “fee-for-service patients” within a practice and the province, but then would not be guaranteed the provisions of access to after-hours clinics or the 24-hour clinic appointment guarantee.

So there’s my preliminary framework. Lots of work still to be done (and I’m sure exceptions and situations I haven’t considered), but I hope we can start moving our system forward with some new innovations, because the current blurred lines of accountability are frustrating both patients, physicians, and the government.

2 thoughts on “OMA/MOH Negotiations: Part Deux

  1. Franklin Warsh

    The current blurred lines of accountability can’t be frustrating both patients, physicians, and government, because three is too many for “both”.

    In all seriousness, some very good ideas here. Curious if the working relationship b/w OMA and MOH is anywhere near positive enough to rebuild the FHG/FHO arrangements. No doubt many of the rank-and-file are too busy screaming “%$# you, pay me!” after all the cuts to be willing to horse-trade with the Ministry. But if Nixon can go to China…



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