Cost-effectiveness of Family Health Teams
I've talked about productivity and motivation in another journal entry way back when but the issues surrounding these two important variables are getting more significant and deserve another mention, particularly as information filters out about the lack of cost-effectiveness of Family Health Teams in Ontario.
A recent article in the Ottawa Citizen on May 5 by Lynne Cohen, an Ottawa-based lawyer and journalist, was titled, "We Need More Workaholic Doctors, Not Fewer".
As her story goes, she had a "workaholic cardiologist father" (her term not mine) who died back in 1990. She links "dedication" with the "health care crisis" suggesting that it is lack of dedication and fewer hours worked by physicians that is causing problems for publically funded health care. In her opinion, doctors seeking work/life balance are the crux of the problem.
Although she is way off the mark and perhaps demonstrating the bitterness that may occur in children (even grown up children) with absentee fathers, I don't believe her view is unique.
But really, doctors are people too--with children, other lives beyond medicine and much to contribute to society besides treating the sick and preventing disease, although I'll agree that the last two items are fairly significant.
If we look back to the caps in Ontario, the claw-backs, the Medical Review Committee (MRC), the medical schoool cut-backs, we can see that it was certainly government's intention to have doctors working less. In an environment when productivity is seen as an economic burden to the system, do you really think that doctors would feel encouraged to be workaholics?
And even if they did, it is frequent that the resources their patients need are not available including diagnostics, cancer treatments, mental health support and on an on.
Some people including politicians and various colleges including the Ontario College of Family Physicians where the CEO is nurse Jan Kasperski) would like us to believe that capitated teams with other providers are the panacea to all that ails primary care from insufficient numbers of family physicians, to improved patient outcomes, to improved cost-effectiveness and productivity. But some proof is emerging that this is not the case.
A study assessing how family health teams are doing is being conducted by University of Ottawa professor Dr. William Hogg. Reported in the Ottawa Citizen, April 29 by Randall Denley, "Family Health teams need a checkup", Dr. Hogg is reported to have said that instead of increasing doctor capacity, doctors in FHTs are seeing patients just as they always have. Any increased efficiency is eaten up by the meetings that these multi-disciplinary practices require.
While doctors and patients like the teams, "this approach costs more, substantially more. "
Randall Denley indicates that the government will soon begin a five-year study of the pluses and minuses of family health teams. He writes, " The fact that they cost more without increasing productivity seems like a big negative."
I am concerned that by the time this study is completed, a new Ontario Premier will be in charge, the study will be forgotten and in the meantime fee-for-service...probably the most productive system around...will have died off.
Who cares you ask? If doctors are gravitating to teams (now remember that docs have always worked in teams, virtual or not) and to the higher pay in these new and ?improved teams. What happens after they turn out to be gobbling up oodles of cash? Six hundred million on 150 health teams is a fairly significant amount...just to get them going. What happens after that? What happens to all the orphaned patients as FFS doctors close up shop, unable to find replacements and cast adrift up to a couple thousand patients each?
Independent nurse-led clinics are not likely to be able to do the job with nurse practitioners seeing 7-12 patients a day (several times lower than what a typical family doctor would see in a day) at $86,000 to $100,000 no overhead plus benefits, referrals to specialists will increase swamping the sinking specialist boats too.
And as much as some groups have a "hate" on for walk-in-clinics and urgent care clinics, they do keep orphaned patients out of the ER quite well. Even if all the walk-in clinic docs switched to comprehensive family care, there are not likely to be sufficient numbers of them to absorb all the orphaned patients.
So it is clear to me that fee-for-service must be preserved because of its value in terms of productivity. The idea that salaried physicians working with less efficient nurse practitioners will be able to carry the health care load is misguided. But nobody asked me. I guess we'll just bumble along to the next provincial election with a tanking economy and the next Health Minister will take over along with his "eager to please the voters" Premier. Wonder who it will be and if they will care. Maybe Hugh McLeod will take the provincial lead....he was at the OMA gala as an invited guest/chief MOHLTC negotiator for the government after all, during OMA/MOHLTC negotiations no less.....nahhhhhh, he knows better.
I'll post some of the significant links in the comments section.
Enjoy.
Merrilee Fullerton
107 Comments
Reader Comments (107)
http://www.ocfp.on.ca/English/OCFP/About%20The%20OCFP/JanBio/default.asp?s=1
Randall Denley
The Ottawa Citizen
Tuesday, April 29, 2008
The dedicated family doctor who works on her own provides a type of care that is becoming extinct in this province, a victim of government incentives and young doctors' preference to work in group practices. With no one to take over these solo practices, thousands of patients a year are cast adrift in the system. The salvation for these "orphan patients" was supposed to be the family health teams that the provincial government has been vigorously touting since 2005. When the initiative was launched, Premier Dalton McGuinty predicted that doctors working in teams with nurses and other health professionals would be able to see 50 per cent more patients.
Three years later, it hasn't turned out that way.
University of Ottawa medical professor Dr. William Hogg is one of the few researchers in the province assessing how the family health teams are doing. He reports that there is no evidence the health teams are taking on more patients than doctors in other forms of practice. "That's a bit of a disappointment," he says.
The government is paying people such as pharmacists, dietitians, mental health workers and nurse-practitioners salaries to work with groups of doctors. The theory was that some of the doctors' work would be redirected, increasing doctor capacity. Instead, doctors are seeing patients just as they always have, Hogg says. Any increased efficiency is eaten up by the meetings that these multi-disciplinary practices require.
That's not to say the system doesn't have advantages. Patients feel the doctors spend more time with them and the other medical professionals improve the quality of the practice, Hogg says. While both doctors and patients like it, "this approach costs more, substantially more. You get a better product, but at a higher price."
It's difficult to get clear figures about the cost of family health teams, although the government did say it would spend $600 million to set up 150 teams. A health ministry spokesman was unable to explain the $600-million figure, although $204 million was spent on health teams in the last fiscal year. The government will soon begin a five-year study of the pluses and minuses of family health teams. The fact that they cost more without increasing productivity seems like a big negative.
It's easy to see why doctors favour a group practice. In family health teams, doctors are paid a blend of fees for service and fees for having a patient on their lists. Doctors like the collegial atmosphere and the presence of others who can fill in when they are sick or on vacation.
Total compensation per doctor is about 30 per cent higher than what the fee-for-service doctor makes working alone, Hogg says. It doesn't take the intellect of a medical school graduate to determine that a huge salary incentive and less-stressful work is a good deal.
Even doctors working as a group, but without the other health professionals, make about 11 per cent more than the traditional family doctor.
Data from a 2007 national survey of medical students and residents show that less than one per cent of prospective family doctors want to go into solo practice. Group practice is the preference of 45 per cent, with another 19.5 per cent interested in a family health team type of practice. This is partly a lifestyle choice. Younger doctors don't want to work as hard as their predecessors.
Knowing that, one has to ask why the provincial government is providing an incentive to practice in groups when that's what most doctors intend to do anyway. It does help attract doctors to family practice by paying them more, but that could be done for all, not just those in groups.
While the family health teams have been good for doctors and even better for those in the allied medical professions, not enough attention is being paid to traditional family doctors and their patients. When the family doc retires after having worked more hours for less money, he is left with a business he can't give away. Patients are forced to scramble to look for a doctor who actually takes patients and are faced with paying a substantial fee for records transfer. Medical records companies charge $100 for this service, including "shipping and handling."
The government loves incentives for doctors. How about an incentive to get someone to take over a practice and save patients all the dislocation? Maybe it would be an opportunity for some of those international medical graduates we can never quite get into the system. In a typical 1,500-person practice, just the cost of the records storage and transfer would provide $150,000 to attract a new doctor, and the money wouldn't even be the government's. Instead, the government is paying incentives to eliminate the most cost-effective form of practice. That doesn't make sense.
Contact Randall Denley at 596-3756 or by e-mail, rdenley@thecitizen.canwest.com
Lynne Cohen
Citizen Special
Monday, May 05, 2008
So, according to a major survey, "medical students and residents say work-life balance is a priority for them," (April 28 Citizen). Where's the news? I wrote on this exact issue 20 years ago for the Canadian Medical Association Journal, two years before my workaholic cardiologist father died in 1990.
According to the Citizen piece, Andrew Padmos, CEO at the Royal College of Physicians and Surgeons, says: "Suddenly, people realize that the old way of doing business is no longer tenable. If you don't lay down the parameters, you will be burned out, depressed and distracted."
The 2007 survey involved 2,800 medical students and 730 second-year residents. Just about every single one of them says finding "balance" between medicine and personal life is important.
In other words, the next generation of doctors don't want to have to work as hard as the previous one. That is a terrifying concept. Why? Because the previous one -- now in their 50s and mid-60s -- has always had that balance, and more.
Trying to convince the public they need even more "balance" is a trick to make us believe they are overworked and toiling away as hard as their teachers did. Don't buy into it. It's a lie. Just imagine if doctors today spent even less time working. It would translate into even more shortages and longer wait times for patients.
In my 1988 CMAJ article, I interviewed one of my many physician cousins, now in his mid-60s, and even back then he was going on about balance in life. Crediting women's liberation, he said: "Male doctors 20 years ago were not even open to the idea of talking about their families. It was not acceptable among colleagues. Now, men in all professions have no choice about changing diapers, and most want to." He added: "Time with children is golden."
One of my best friends has a physician husband in his 60s. He has never worked on Friday, or Saturday, or Sunday. By the way, this particular specialist has more accolades for my dad than he does for any of his present-day colleagues. Do you think my late father's overriding dedication to medicine has something to do with it?
In the mid-1980s, I knew a half-dozen doctors who spent as much time on triathlon training as they did practising medicine. One of them raced with me in the Hawaii Ironman Triathlon in 1985. He told me for the CMAJ article that he spent 40 hours a week working, and 40 hours a week training. Now that's balance.
When my 19-year-old daughter was treated at CHEO for a chronic illness, her physician, a woman in her late 30s, was already taking off one day a week, over and above weekends. Her work days never went past 5 p.m. That is already part-time, and she is a specialist. I don't think Canada can afford -- financially or health-wise -- to train specialists to work part-time. What a waste.
Indeed, like this CHEO doctor, women physicians all over Canada have been leading the way in banker's-hours medicine for 25 years.
So please, don't try to convince me and the unsuspecting public that doctors today are overworked and need "balance." If they had any more balance they'd be scales.
When I did interviews for my article, Canada's retiring doctors -- including my father -- grumbled about the newer recruits' preoccupation with "keeping a life balance." Such a concept did not exist when his generation took up medicine. At that time -- seems hilarious now -- physicians worked when needed, not according to a "life balance" schedule.
Of course in those lost days, doctors were held in high esteem and considered important healers, not just well-paid public servants.
Yes, my dad was a workaholic. His only hobby was reading. His only exercise was grand rounds at the hospital. He worked an 85-hour week, as did all his friends and colleagues.
Interestingly, there was no health system crisis then.
Do you think there is a connection? Highly dedicated doctors ... effective health care. Hmm. Makes you wonder.
Okay, I admit, our families sacrificed. Still, I have cherished photographs of my dad helping my brother learn to walk and helping me ride a bicycle. And of him on the beach in New Hampshire reading medical journals.
My dad often raced out at midnight or later to meet patients in the emergency room. Many of those patients and their families will tell you, even today, it meant the world to them, and definitely enhanced their well-being.
Hey, now there is a novel concept.
Lynne Cohen is an Ottawa-based lawyer and journalist.
The MOHLTC's negotiating team during past contracts has hired members of the OCFP Executive committee (i.e past presidents) to sit at their table and advise the government on strategy for full implementation of PCR. MFO has alluded to having all the players at their disposal and I am sure there are currently OCFP persons down in the bunker enjoying the flowers too.
The per diem is great to travel to and from the hinterland to the back rooms of Queen's Park, meanwhile you still collect your patient capitation fee and your team members continue to see your patients.
Do you think any FFS physician can afford to abandon his or her practice for a week at a time especially when locums to cover one's practice are scarce as hen's teeth? Hence there is no FFS physician input ever at the table and the plan progresses undisturbed along its intended ideological pathway.
Canadians' respect for doctors grows, declines for other professionals
By Patrick Sullivan
Fourteen years after it conducted an identical survey, pollster Angus Reid has determined that not only is medicine still the most respected name in a list of eight professions, it is also the only one that enjoys more respect now than it did in 1994. All other professions experienced declines during this period - some of them drastic.
The online survey of 1,015 adults showed that 94% of Canadians have either a "great deal" or "fair amount" of respect for physicians, up from 91% in 1994. This compares with:
* police, 83% (90% in 1994)
* teachers, 83% (89%)
* judges, 72% (79%)
* clergy, 61% (76%)
* journalists, 49% (73%)
* lawyers, 44% (57%)
* politicians, 25% (37%)
The numbers are particularly interesting for the medical profession because they show across-the-board increases in respect even though the health care system was in a state of upheaval during many of the 14 years between polls and still faces numerous problems.
In 2008, physicians' respect ranking ranged from a high of 96% in British Columbia to a low of 93% in several provinces. No other profession scored a single ranking at or above 90%.
CMA President Brian Day thinks the results show the value of physicians' face-to-face relationship with their patients. "The physician-patient relationship is built on trust, and I think this trust is responsible for the levels of respect seen in the poll," he said.
But trust is clearly lacking in some other professions. Liberal MP Bob Rae told the Toronto Star that politicians got a black eye in the survey because "everybody [in politics] spends too much time running everybody else down."
The online poll has a margin of error of ± 3%, 19 times out of 20.
Forward any comments about this article to: cmanews@cma.ca
© Canadian Medical Association or its licensors 2008
here's the link
http://www.scohs.on.ca/bins/content_page.asp?cid=12-130-8593-8595&lang=1
I hope it is the latter.
The lesson has been learnt...those burnt have taken their foot off the throttle and have begun to smell the roses...to live lives much like the rest of the population...and liking it...never to go back to the bad old days when they worked from dawn to dusk, never taking time off and taking no vacations...their children watched them work and decided to get an MBA instead...their younger colleagues took one look at them and decided there and then to emphasise quality of life over everything else...the wholesale decrease in productivity was a goal set by the pointy headed...they achieved it...so why are they now complaining?
One wonders what blowback the physicians of Joseph Brant hospital in Burlington will experience for revealing their C. dificil outbreak was so deadly. Look at what happened to the government physician out in Alberta who suggested certain cancers in his community might be related to the tar sands next door,..a College complaint launched by the Feds. You can be sure other government employed docs took notice and will not speak out before thinking about losing their job and perks. Once we physicians become fearful to speak the truth while on the MOHLTC's coin, and rather feel we must parrot the MOHLTC's scripted news releases, this high degree of professional respect will begin to erode.
Personally I think once we become seen as employees of the state, rather than independent professionals as we have been in the past,our rankings will slip into the range of teachers and police. One patient last week summed this feeling up when I asked why he had left our neighbourhood FTH? He replied, "because they are government doctors and keep the hours of bankers."
Funny how once something grows through its formative phase into a more mature form, if it's not privately owned or no sense of real "ownership" -- the payroll just runs --productivity can be right out the window. Noone goes hungry as a result of so-so performance, or, really good performance, but in really small batches. There are no real consequences.
FFS still has that private entrepreneurship drive about it. And it requires a particular kind of work ethic that is no longer the norm. But it had its downside, too. Marriages were casualies of 90-hour work weeks; children didn't know their parents; docs dropped like flies around 55 or 60.
That PCR would depress patient volumes on average was entirely predictable. And that probably suits the MOHLTC just fine. Fewer patients processed, fewer referrals deeper into the system.
Alphabet groups can have their upside. Saner pace of work for one thing. And productivity does not have to go; all depends upon how you staff. I like a solid work ethic. Making no appointment is better than maing a bad appointment. Don't hire anyone who doesn't like to get their hands dirty with the real work. Sometimes it takes a while, but you can find them.
If an FHT is formed of people who are of the above description, it will be productive (and there are a good number). If the FHT is just flung together without a view to a solid set of commonly-understood values, and individuals of like work ethic, rationalization of service quickly sets in through inertia. Most organizations are somewhere in the middle of this. And a good deal of time and energy is wasted in internal struggles.
I don't know why I'm wasting my time stating the obvious here except to make this point: Putting "teams" of professionals together in a complemental model has a great deal to be said for it if it's done properly and with care. But its potential cannot be realized unless its professional complement all respect their coworkers and everyone knows what the real work to be done is and they can get to it. That "sense" of "owning" the job each one of us does and being responsible for the outcomes is alike to the entrepreneurial spirit and is what keeps the place hopping in a productive manner for physicians and others alike.
And THAT is precisely what is missing from many of these venues. The result? A kind of apathy born of leaving an organization to just "tumble up" as bes it can, that turns the work into just a job with predictable results for patient through-put and quality of work. Rationing reigns. The "satisficing" theory of the firm lives. Productivity never has a chance.
Excellent points. Sometimes it is helpful to clearly state what many would think to be obvious.
The productivity within teams could certainly be enhanced with "ownership".
I don't think any doctor really wants to go back to the days when doctors' families suffered in their absence with divorce, mental illness etc. although I'm sure some still do but perhaps not for so long.
The young doctors appear to want the environment of a team and this is fine and well. Teams are good for many things. Doctors have always worked in teams but set up in slightly different ways. But "ownership" may not be the same as being responsible for "outcomes" since it is difficult to measure and assess what the outcomes should have been equally across the board because of many social and genetic variables.
Health outcomes are arrived at through many different variables...not just whether the patient had a FOBT, screening mammogram, PAP or stress test. It would be simplistic to think that achieving a certain percentage of patients being screened is somehow a "positive outcome".
And it all depends on the "outcome" desired. Is it the better outcome for the patient, the politician or political party or the collective population that we are after?...because a positive "outcome" could be quite different depending on the perspective.
How does one evaluate performance indicators as positive or negative if ultimately the success of the tool will lead to more patients needing more care for more years (because if we are successful in health care, more patients will age, needing more health care for more things--patients who would have died from their heart disease at age 75 now go on to need various joints replaced..not once but twice, to need repetitive eye procedures and cancer treatments...all very good for the individual...not so good for the health care budget...and probably neutral for society unless our health care tax burden continues to steadily erode other societal needs).
It becomes quite a continuum of ongoing increasing funding.
And is anybody asking the patients what they want or is this decided for them too....? Maybe one day patients will decide what they will die from. Will they care about "performance indicators"? Probably not.
Thanks for the insightful contribution BBA. Hope you will consider joining us again.
NP's in the FHT create as much work as they take on so the net benefit is zero -- for the record my wife is an NP and I believe they should have independent practice but in the context of the FHT it may not be helpful
FHT's get 2%(?) of the FFS as an incentive. This is a total and complete joke -- it costs more to administer the paperwork than get the "bonus"
There is no incentive to follow up with patients that don't do it themselves. When I asked the FHT how they followed up on people that forget to call back the response was "why would I want to create more work for myself".
My solution -- adjust the fee schedule to 20-30% of FFS. This will give the gov't the predictability they need for budgeting and the FHT's the financial incentives that promote young doctors to work more hours.
By the way, I hold advanced degrees in primary care service delivery operations research and know how the outcome measurement game is played. Regrettably, its use almost always outstrips its actual utility.
And Ian, an NP of my acquaintance keeps whining that she wants to be "employed." "But I thought you wanted to be free-standing professionals!" said I. What she really means is that she wants the perks, but not the responsibilities, I think, especially not things like overhead expenses, a payroll to run, etc...No entrepreneurial spirit there at all. Sad.
Checked on the master list of "acceptable" options - just looked at the top five:
1. Politically acceptable
2. Doesn't create effective negative lobbying group
3. Budgetable
4. Confirms central control
5. Rewards groups that support reelection
Central doesn't have list of plans over the next year, just principles that maximize political survival. Following the top 5 rules usually works
known as C. difficile, according to a study of 44 Canadian hospitals done by
the Public Health Agency of Canada. But Ontario Health Minister George
Smitherman was forced to acknowledge yesterday that he has no idea how many
of the province's 157 hospitals are grappling with C. difficile......
Mr. Smitherman vowed to introduce mandatory reporting of such infections by the end of the year.
---------------------------------------
Ah yes, that will certainly solve the problem, (for him possibly by makimg it some else's)
In particular, Decter says, median wait times for cancer surgery fell by 17 per cent, from 24 days to 20 days, between August 2005 and December 2007. That is the amount of time on average it takes 50 per cent of patients to have surgery after the decision to perform it is made.
---------------------
And this was the good news! Let's give it up for cancer care.
If you now have a potentially terminal cancer diagnosis, your wait for definitive surgical cure has shiftedfrom just over 3 weeks to just under 3 weeks.
How would this be measured BBA?
It is clear that some forms of prevention will yield excellent results for the patient but what should they be reasonably expected to do?
What is the physician's responsibility and what is the patient's?
from the Toronto Sun
May 9, 2008
Too much boozing, smoking, sunning
By BEN SPENCER, SUN MEDIA
You probably knew it -- you just didn't want to hear it.
Ontarians are heightening their risk of cancer by drinking, smoking and
sunbathing too much.
A report by Ontario's Cancer Quality Council also reveals wait times for
chemotherapy in Ontario haven't improved, despite the province more than
doubling its spending on the cancer treatment.
In a clear incentive for Ontarians to become more active, the council says
about half of all cancer deaths are related to tobacco, diet and physical
activity.
Michael Decter, the council's chairman, said the overall quality of
Ontario's cancer system is good, but there's room for improvement.
"Far too few people are being screened for cancer, obesity rates are rising,
Ontarians are drinking more alcohol than recommended and are spending too
much unprotected time in the sun," he said.
The report found 32% of men and 15% of women report drinking more than
health guidelines recommend.
Meanwhile, the $176 million the provincial government injected into
chemotherapy last year -- up from just $72 million in 2003 -- appears to
have had little impact on wait times.
While radiation and cancer surgery wait times have gone down, chemotherapy
wait times remained steady for the past four years, according to the report.
Health Minister George Smitherman said his government has made progress but
finds it challenging to reduce wait times for chemotherapy.
"Wait times for radiation and cancer surgery continue to fall significantly
across Ontario.
But the health system is barely keeping up with chemotherapy demand,
screening rates are far from ideal and people are still engaging in too many
activities that carry cancer risks.
That is the decidedly mixed message found in the Cancer System Quality
Index, Ontario's annual report card on the disease.".........cut
............
In particular, Decter says, median wait times for cancer surgery fell by 17
per cent, from 24 days to 20 days, between August 2005 and December 2007.
That is the amount of time on average it takes 50 per cent of patients to
have surgery after the decision to perform it is made.
Even those waiting the longest for surgery, the lowest 10 per cent, saw
their wait times drop 30 per cent, from 81 days to 57 days, over the same
period.
As well, Decter says, wait times for radiation treatments continue to fall,
although the success of improved access programs is not uniform across the
province. Still, 83 per cent of people needing radiation got it within
nationally recommended time frames in 2007.
That is a 30 per cent improvement over a three-year period, says Terrence
Sullivan, head of Cancer Care Ontario.
But much more needs to be done, Decter says, particularly in personal
behaviour changes that could help reduce the 50 per cent of cancers deemed
preventable.
"Smoking rates have come down, but there are other risk factors, exposure to
sun, diet, alcohol consumption and exercise that are all still problematic."
While cancer-screening rates are going up, Decter says, they are still at
lower levels than are found in other jurisdictions. For example, only 50 per
cent of women are being screened for breast, cervix and colorectal cancer,
he says.
"We're getting up towards the 20 per cent level (in colorectal screening)
whereas a few years ago we were at 10 per cent," he says.
Decter says that demand for chemotherapy is growing, but the median wait
time of 25 to 38 days has remained stable over the past four years.
Health Minister George Smitherman tried to put his best spin on the data
about chemotherapy wait times.
"Even with an expanding number of people requiring the service, we've put in
enough resources there to make sure that wait times don't increase," he told
the Star's Rob Ferguson.
"It's true that wait times have not been reduced for chemotherapy. But it's
not true that access hasn't been enhanced. There are more patients. Yes,
this is a real struggle."
Is dropping a wait time from 81 days to 57 days significant to the patient especially when it has taken billions more federal money for these kinds of initiatives?
I suppose it is if you can show improved outcomes as BBA indicates. But has it?
And what is a patient doing while they are waiting for their cancer surgery? How does this wait affect them? What can they expect as our population ages and as Ontario's economy stalls? Can they expect additional funding for all areas just to hold wait times as they are?
more groups wade in...
FHT's get 2%(?) of the FFS as an incentive. This is a total and complete joke --
What FFS are they basing this on. My understanding was that Ontario government did not want to include pure FFS in FHTs.
How is the FFS within the FHT you describe structured?
Just so you know, having worked with NPs in the past, I value their abilities, however I do not think that they are really a solution when Canada is potentially going to be short 78,000 to 113,000 nurses(CNA numbers). Who will do the nursing.
As far as nurse-led independent clinics, although it would be nice for them, it could be the death knell for family medicine as provided by physicians. This won't be a good thing because the productivity and ability to deal quickly with minor problems will be potentially lost..(which is what this thread is all about-productivity)
My understanding is that NPs within FHT the going rate is about 86,000, no overhead plus benefits. My understanding is that they see between 7-12 patients a day in a typical family practice setting (not running diabetic clinics etc.). The average family doctor according to studies makes about $124,000 no benefits and would see on average 5-6 patients an hour (in an 8 hour day they could see between 40-48 patients). Now you tell me which will cost more to provide primary care overall.
I should mention here that as patients present with more complex conditions associated with the aging of our population, that family docs are not likely to be able to maintain this pace either and provide care in a way that is satisfying to them and the patient. Certainly we will need to have other providers...but it would be a shame to lose one of the most efficient types of primary care provider-the family doctor-as nurse practitioners move into the field.
Young doctors are just not choosing family practice anymore. There are many reasons. I just don't see the independent nurse-led clinics providing cost-efficiency compared to physician led clinics..and I'm not even touching on what happens to specialist referrals with this set up.
What will we have in 20-30 years?
Before I commit the time to this, are we asking a serious or a provocative question?
I have seen this combined system work nicely in the emergency on AFP where the group receives a lump payment from the MOHLTC but it is paid out in a combined lower hourly rate plus a significant FFS portion. What a lot of these groups found was that if the doc is working on a straight hourly fee the productivity dropped substantially compared to when the department was on pure FFS. The combined hourly/FFS model seems to bring the productivity back up yet still ensures a decent level of remuneration when things slow down.
I am sure the FHT models could be tweeked in this direction to get the patient flow moving again. The problem might be that the NPs do not want to leave the salary model so one is still left with a big bottleneck.
That would be the pilot equivalent of flying as far into the collision as possible. Some are less sure that even this is meritorious.
As Conrad Hilton once said, "I am certain of few things. Perhaps one might be that the shower curtain goes inside the tub."
Society cares for the ill to the extent it elects to support it. If roads, education, policing and public services are deemed more important, it has made a decision.
BBA is right, you can only deliver care to the person before you. Divided loyalty to the public purse is not what I expect in my doctor's care.
Nursing staff are trained on a model almost the antithesis of the medical model from some points of view. Volume of patient flow is not in the framework. But, there are nurses whose pattern of practice reflects the ability to push the volume through, and, in primary care, it is particularly important to look for these.
I have known NP's who can do the same. They are few and far between. There seems to be a view out there that patients want a good deal of time spent with the provider i.e. the NP. In urban areas where almost everyone works, that ain't the approach that works -- except maybe for with some older folks. Time is often equated with quality of results. The two do not always correlate.
I remember having a fight with the MOHLTC Community Health Branch when it wanted CHC policy on appointment lengths to provide the patient with 1 1/2 hrs of the doc's time. I DON"T THINK SO!!!! Neither did the docs. So we sat down (I was the ED at the time), and we settled on what they thought was a reasonable time. We went back to booking in increments of 15 minutes. Everyone was happy. We did a crude assignment of case weights for each of the 2,000 patients as we went. We put stickerson the file. Red for "really time intensive", yellow for ""medium weight", and green for "usually in and out". Staff booked appointment length accordingly. Occasionally you got a surprise.
So. Realist, I can produce all the fancy quantitative measurements you want, but, at the end of the day, it's about the patient- provider encounter. Because that's where the old rubber hits the road.
Did I mention this is not always a popular view with my colleagues and acquaintances in managed care?
Those poor FFS docs once the backbone of the productive primary caresystem are going to retire or leave the province over the next 5 years as their pool of funding dries up. Currenlty most WICs and urgent care centres in the GTA and Ottawa are exploding at the seams with patients who cannot get into their various alphabet group physicians on a timely basis. Now the problem has become staffing these WICs and urgent care centres since there are fewer and fewer FFS docs available. Those who are working don't need more work, and the alphabet group docs won't work in these facilities basically because they don't need the money. It is comforting to know that as the FHT/FHO/FHN docs collect their salary and are allowed to increasingly dip into the FFS pool their patients who cannot access timely appointments are being cared for by the very docs the MOHLTC is trying desperately to starve out of existence. Now that is one jagged little pill to swallow heading into the weekend. How ironic.
Sorry for being so brazen here, but all I can come up with is "No sh*t, Sherlock. What was your first clue?"
We almost got to a point where C. difficile, MRSA, VRE and other non-reportable conditions became reportable in a priority manner...
Until a train from the west was quarantined after a death and 10 people suffering from flu like symptoms. Bet your bottom dollar that everything will be placed on hold until this is resolved.
In a way it is a good thing that this happened in isolated northern Ontario. Imagine the panic if the train made it all the way to Union Station?
God speed to all.
Of course we all know the government's strategy is to divide and conquer and to pit one group against another so I will refrain from falling into that trap.
Suffice it to say that those of us on pure FFS who take full ownership of patient problems and still offer service with a smile will be history in less than 5 years.
First, there is a difference between being a salaried physician (CHC physicians and FHT physicians who choosed the salary model) and being remunerated through a capitated practice such as a FHO or FHT.
I think I have pointed out before that the capitated practices can bill OHIP to a maximum cieling prescribed in our contract. But this blend was not invented in the current round of PCR, The HSO's also had a blend. There are two reasons one might want this, first, you might not roster a patient on the first visit, second, a percentage of your population might be transient so rostering is not a sensible option. But in both cases, you still want to be paid for your work.
You might choose to remain FFS or go to straight salary if you work with an almost exclusively transient patient population. And, in this case, you will not be in a position to measure anything really meaningful in terms of outcomes. Volume might be one indicator to pay attention to, and what the diagnostic codes tell you about what you are seeing.
The capitated practices, once again, as I said in a previous post, are negated, in the case of the FHO, $0.50 on each dollar of outside use. So what you gross is sometimes quite a bit more than what you net.
In a capitated practice, you are only remunerated to the extent that you actually see patients. Small roster and 1/2 hour average appointments, you just might make your mortgage payments. Large roster, and you pump the volume, the better you do. Physicians in the latter category often don't have the time to do other things, and so, they do not have opportunity to bill much OHIP.
The FFS physician is free to generate as much revenue as he/she can work. The circumstances of the FHO physician are not so free. He/she is confined to the basket of services prescribed by contract for a flat (prenegated) rate per individual.
As for the OHIP ceiling, if our physicians did not have this, they would not be working the after-hours, urgent care, and ER's that they do.
Shadow billings are a poory proxy for productivity measurement for many reasons, not the least of which is that not everyone is faithful about doing their billing, especially on a day like yesterday with about 40 patients having gone through the office between prescriptions written, charts to be completed, and a bloody meeting.
Just to add salt to the raw nerve, this drift from alphabet to FFS is supported by both central and the OMA. In essence, the FFS pool is the "private" sector to the alphabet groups. As that pool gets drawn down, raises/increases that can not be gotten from redrawing contracts, can be gotten by dipping back into the FFS pool with central's approval. The best of both worlds (for now).
ELB:
THe train trapped in Northern Ontraio allows central to sign - we will dispatch experts and solve the mystery. Another positive spin for central. SARS has prepared us - we have teams to disperse.
Outside of government monopoly such as Ontario Health [Care] Light [but dirty], what other enterprise rewards those who are less productive and effective and penalizes those who are more productive and more effective?
Why did you write this, because it is totally incorrect?
"In a capitated practice, you are only remunerated to the extent that you actually see patients. Small roster and 1/2 hour average appointments, you just might make your mortgage payments."
On the contrary, a capitated practice is exactly that - payment per head of rostered patients and not dependent on seeing patients. The average FHO payment per head is $140, so, with a roster of say 1,500 patients, one is taking in approximately $210,000 without ever seeing any patient.
Well obviously one cannot get away without seeing at least some patients, so the Ministry gives an incentive of 10% of the FFS fee (not 2% as someone earlier wrote). This is for rostered patients for something like 119 services (covering most of the services one would provide).
In addition, for non rostered patients or anything outside the 119 code basket, one is allowed to earn $48,000 FFS payments in addition which pays for the WIC work that some alphabet physicians also do on the side.
Hope that sets the record straight.
So in the next contract the public will only see a 2 percent increase to FFS and capitation fees, whereas they won't see the increases in the shadow billing incentive percentage, the increased FFS pool dipping caps, the CME rebates, THAS pager stipends, the IT cash dollops to the non-FFS alphabet groups, etc.
The 50 percent outside use clawback is unique to FHO, and will likely be converted back to 100 percent with the new agreement.
The FHN model is similar, but most FHN groups are transitioning to FHO, as that is the MOHLTC-preferred payment model (and pays better!).
The northern and CHC models have somewhat less lucrative agreements, mitigated somewhat by the retention of additional funding, already in place.
And GHC (Sault Ste Marie) has it's own model, FHO-like, but with much better cap rates and a large basket of core services.
In my corner of the world I do not see a stampede by these physicians to join a FHN/FHO/FHT model.
In order to truly create HMO Ontario the FHG and CCM docs need to be transistioned to one of the capitation or salary models. Will this occur with the next contract and if so what stick/carrot will be used?
Any hints/advice for someone looking to make some long range decisions?
http://fhs.mcmaster.ca/physicianassistant/
NPs are being pushed for independence and the term "collaboration" is used which is definitely not supervision.
NPs can also prescribe from a list of drugs and they have their own scope of practice independent from physicians.
PAs can prescribe based on the need identified by the supervising physician and the flexibility with type of delegated care is quite helpful. Different medications may be required in long term care homes vs other settings such as diabetic clinics, family practice settings or the ER.
Mostly PAs have some kind of health care background and even IMGs who are in Canada already and unable to find medical residencies with which to fulfill licensing requirements can train as PAs and get into the workforce applying their skills fairly rapidly after a 4 month course.
Main thing to remember about PAs is that they are supervised by a physician and can provide delegated care in a variety of settings and do not seek independent care.This format is truly "collaborative" and not a mechanism to obtain independent care status.
Even better is that PAs do not remove nurses from the nursing pool where we are expecting a Canada wide shortage of between 78,000 by 2011 and 113,000 by 2016.
Do I like the idea of PAs to contribute to physician productivity? I certainly do. Meeting with CAPA (Canadian Association of Physician Assistants)in the very near future.