Question about Family Physician Shortage

[Guest macMDstudent]

What I have heard (take this with a grain of salt because its second hand hearsay) about the COFP is that they are primarily a group of family practice docs who bill their cap and then some each year, essentially the top end of income earners of family practice docs in Ontario that do high volume practices. They like fee-for-service because they do well at it, and are therefore reluctant to change. What the COFP doctors want (according to the doctors I know that refuse to join them and remain behind the OMA) is an increase to the fee-for-service rates that are being paid and the cap lifted so they can make more money. They don't truly seem to be interested in primary care reform. Again, this is just the views I have heard from the MD's I know and have worked with.

 

From reading the COFP press releases, I didn't see anything of what they were for other than increasing the pay scale. They make it clear what they are against, though! I didn't see any groundbreaking ideas from them of how primary care could be reformed, but just reason's why what has been come up with so far (i.e. FHG's, FHN's) won't work.

 

As far as the payments in a FHN work, not every patient is worth the same. Remember in a previous post I said the OMA and the OMHLTC worked together to analyze the billing patterns of the average family practice? It is true that the least a doc can be paid per patient is just under a $100 per year. But that is the lowest payment. It only gets higher for older patients, because they are the ones who statistics showed used the MD services the most. So a senior citizen I think earns the MD about $300 per year. Plus the doctors still get 10% of the old fee-for-service code for every visit for all the patients who are rostered. The "shadow billing" is not shadow at all, it is just 10% of the same codes (A007, etc). The well baby checks are made up for by the vaccination bonuses, since babies come in several times in the first year for their shots but the capitation system doesn't give them any extra for that. So this helps make up for that. Once kids get out of the toddler years, their visit frequency usually goes way down. It stays down for most people through middle age when it starts to go up again and then the older population is in the doctors office very frequently with complex problems. This has all been accounted for in the FHN capitation calculations. As the president of the OMA said, "every month you get a raise as your patients have birthdays."

 

Not every patient in the doctors practice has to be rostered or be "booted out" and be without a family doctor at all. Their is a provision for family doctors to continue to bill fee-for-service for non-rostered patients (patients who decide not to join for whatever reason). Keep in mind, those patients will not have access to the FHN walk-in clinic for rostered patients that each doctor in the group takes turns running every night and weekend. Those patients who don't "sign up" also don't get the on-call doctor number that gives them 24/7 access to the group of physicians. It is essentially a phone line like Tele-Health Ontario, but only available to rostered patients of those practices after hours. If the nurse who takes the call thinks it is an urgent problem, arrangements will be made to meet the doctor at the hospital or the office.

 

As far as vacation coverage, don't forget that under fee-for-service, the doctor who sees your patient while you are away wants at least 50% of the fee (some locums won't work for less than 60% of their billings). If the average overhead to run an office is 35-40% (which includes rent, staff salaries, utilities etc. that must be paid whether you are working are not!) that means your vacation pay is 0-15% of your typical weekly earnings. Some doctors actually lost money by taking vacations if the locum+overhead was more than the total billings while away! Not very good!

 

Under FHN, if you go on vacation, the doctor in your FHN who sees your patient gets 10% of the old fee-for-service fee (as is usual for billing all FHN patients), while you are on the golf course and you still earn your same monthly capitation payments for all your patients, whether another doctors sees any of your patients or not. Yes, you have to see more patients of other doctors in your FHN while they are on vacation and you are working, but that evens out and on average you are way ahead, with more time off. For most non-urgent conditions, most people will wait until their regular doctor gets back if the vacation is only one week anyway. For this reason, many doctors never took more than one week off at a time. Now they are taking 2 week or longer holidays and able to truly unwind for the first time in years.

 

As to why most family doctors make more with the FHN system is because it has been calculated to give the average family doctor a raise, that they have been asking for and deserving for years. So the FHN system is really trying to kill 2 birds with one stone: give the average family doctor a raise; and reform primary care so that the gatekeepers (family docs) are more available through collaborative group efforts and keep people out of expensive emergency rooms after office hours.

 

As of now, the FHN only incoporates physicians. It is not like a community health centre which is multidisciplinary. It is interesting to note that of all the stakeholders in health care (patients, doctors, allied health workers, and government) the physicians are the most reluctant to change, according to surverys I have seen in the Medical Post.

[Guest UWOMED2005]

Just to be the devil's advocate (this is not necessarily my opinion), some would say an across the board increase of FP's fees would be primary care reform and could go a long way to relieve the shortage. Why? How? The idea is that such an increase would lessen any flood of FPs to the US, and perhaps draw FPs out of insurance consulting, methadone clinics, and other areas that take them away from standard family practice, where the greatest shortage appears to be.

 

And I think one of the greatest reason more Docs aren't signing up is TRUST. As one doc I was talking to yesterday put it, "Every few years they bring in a new program for family docs. They all involve signing some sort of contract, and as soon as you do they're liable to clawback your renumeration to 'help alleviate the current health care crisis' and you're up the creek without a paddle because there is a contract."

 

Once again, that is not my opinion and may not have any validity to it, but if that is the opinion held by many family docs, any new payment plan that is not of obvious benefit to family docs and easily escapeable (ie no contract) will fail.

 

Plus the whole thing is pretty complicated. If I was a busy family doc who didn't have the time to go through the nitty gritty of FHNs, I'd probably stay with the status quo. Considering the TRUST thing as well, I'd be inclined to be extremely dubious of the government's marketing campaign surrounding this and be a little more inclined to agree with dissenters such as the COFP.

 

It does not surprise me Physicians are the most reluctant to embrace the FHNs and FHGs. However, if FHGs and FHNs are still around when I graduate (and I choose family) I will definitely be investigating them thoroughly. I myself am not a great fan of fee for service.

[Guest macMDstudent]

Good points! I think this shows why there is no quick 'n' easy answers here for primary care reform, other than throwing buckets of money at it and increasing the numbers of family doctors. What could be the role of nurse practitioners (RN-Extended Class; or RN(EC)) to help with the shortage of doctors? Again, there has been a significant problem in how to integrate them, because the Ministry won't give the RN(EC)'s their own billing numbers, but family doctors literally can not afford to pay them and are concerned about liability issues with the CMPA.

 

As I have said before, the docs I know that are in the FHN are happy to have switched. They too are concerned that the terms of the agreement may change, but they do have an "out" clause in their contracts if their are significant changes or unforseen obstacles.

 

Time will tell, but I think that the a rightful gripe of the MD's is that the government ultimately holds the upper hand because they control the $$$. If the government is trying to push for FHN's by making them so much more attractive than fee-for-service that it makes no sense to stay FFS, that really is no choice in the long run is it?

 

Something interesting to keep in mind is this whole shortage could be avoided by simply having a massive increase in medical enrolment (which of course is too expensive to ever really happen). In most western European countries, the physician:p opulation ratio is at least twice as many doctors per 10,000 population as we have here.