November 3, 2014 - According to a recent report compiled by the Ontario Medical Association, 4,266 physicians, (52 per cent of all physicians today), and roughly 8.6 million patients are committed to a practice in an interprofessional primary care model.[i] The IPC model of healthcare was designed for several reasons, but primarily to provide patients with improved integrated access to care during evenings and weekends, and to encourage physicians to accept new patients. This innovative model was contingent on transforming the methods in which primary care is funded. As the Ministry of Health and the Ontario Medical Association collaboratively move forward in its primary-care reform initiatives, there is a need to take a balanced view of not only the needs of the province’s physicians with those of the patients, but to access the systems accountability to taxpayers as well. Consequently, it is important to identify the payment methods currently in use, determine what so far might be problematic, and provide evidence-based recommendations in an attempt to monitor the vitals of such an essential system.
Currently, a physician’s income under the IPC model is derived through mixed funding, which combines the methods of fees for service, capitation, and bonuses. This reimbursement strategy offers incentives for patient-centered care as well as population-orientated preventative care. Fees for service is a payment option where services are unbundled and paid for separately. Physicians receive additional fees for visits by patients who are younger than 1-year-old and for those who are over 75 years old. According to a publication in the Annals of Family Medicine, they also collect fees for providing hospital care and special annual payments for reaching volume targets for intrapartum care, prenatal care, home visits, palliative care, and office procedures. On the other hand, capitation payments are fixed amounts paid for each enrolled patient, based only on age and sex. This method does not consider the patients’ health condition and health care needs. Therefore, the physician is paid the same for healthy patients (who require few or no medical services during the year) as for patients of the same sex and age who have multiple medical conditions. This situation can encourage physicians to de-enrol patients requiring complex medical care, because physicians can receive more funding for providing these patients with medical services under the fee-for-service payment model. To a physician it makes more sense to collect supplementary payments provided for patients that are considered “hard to care for” or individuals with chronic diseases, such as diabetes, a serious mental disease, and heart failure. Subsequently, bonuses or incentive fees are paid out for preventative services, such as pap smears, colorectal cancer screening, mammograms, and influenza immunizations.[ii] Codes for each preventative service are submitted to the billing agency to determine the percentage of registered patients receiving the preventative procedure. Physicians can also bill for sending reminders endorsing preventative services as well.
Differentiating and accounting for the types of payments made under the alternate funding arrangements within the IPC model can be complicated. This fact was substantiated in a report performed by the Auditor General of Ontario in 2011. Due to the complex nature of available funding methods it is challenging for the Ministry of Health and Long Term Care to monitor physician compensation paid through these arrangements or the extent to which the physicians have actually provided services required by their contracts. Although the Ministry intended alternate funding under the IPC model to be more generous than the traditional fee-for-service model, the Ministry has not tracked the full cost of each alternate funding arrangement since the 2007/08 fiscal year.[iii] Even though the Ministry has some initiatives under way, it has not yet conducted any formal analysis of whether the expected benefits of these potentially more costly alternate funding arrangements have materialized. In another review conducted in 2013 by the Canadian Alliance for Sustainable Health Care for the Conference Board of Canada, it was also indicated that there has been inadequate or no reporting of detailed costs of primary care delivery by an IPC team in Ontario, and as a result, there can be no manner in which to conduct a comprehensive return on investment analysis. It was additionally noted that these difficulties and lack of reporting stems from the variation in costs of delivering care across practices due to the size and type of population services; the types of population serviced; the types and quantity of services and programs provided; the costs of facilities and overhead; and how staff, including the care providers, are paid.[iv]
As a result of numerous reviews conducted in Ontario on IPC models and alternate funding methods there have been significant observations made and productive recommendations offered to help direct and elevate some of the complications. These suggestions were formulated in an attempt to steer this enhanced health care framework towards an accountable future. According to the research conducted, one of the most important challenges in optimization of IPC teams is the lack of consistently collected, reported, and meaningful performance data. Acknowledging that there is no one-size fits all solution, these overlapping proposals from the sources cited below aimed to ensure that alternate funding arrangements for family physicians in IPC teams meet the goals and objectives, and prove cost effective while improving patient care access. The Ministry of Health and Long-Term Care (Ministry) should initiate the following practices:
- Any new alternate funding arrangements as well as any new amendments to current agreements, should be fully costed prior to negotiations.
- Track expenditures for new initiatives under future agreements and compare to projected costs to identify issues for review.
- Continually monitor the number of patients who do not see their physician they are enrolled with, and determine whether continuing to pay physicians the full annual capitation fee for these patients is reasonable.
- Review the number of patients being de-enrolled by their physicians to determine whether a significant number of these patients are in a hard-to-care-for category, and, if so whether the current financial arrangements should be revised.
In a follow up report conducted in 2013 by the Auditor General of Ontario it was found that for the most part, the recommendations made regarding alternative funding methods are still under review, and that most data sets and resources required have in fact been collected, but require further analysis at this time. In defence, the Ministry did claim that during the 2012 negotiations with the OMA, it proposed moving towards a single capitation payment model that would cover more clinical services than before. The Ministry also proposed to simplify the types of payments under various contracts. However, negotiations with the OMA did not result in any changes in the types of arrangements, or the list of services covered under each type of arrangement. During the same round of negotiations, the issue of physicians being paid a capitation rate for patients they seldom or never see did not result in any reduction in capitation rates for these patients.[v]
This leaves the question as to whether IPC teams are delivering a good return on investment and adding high value to the health system, and as health care sustainability worries build, what’s needed now is cost-effectiveness research to confirm how the IPC approach is saving money system-wide.
[iv] Improving Primary Health Care Through Collaboration – Briefing 3 – Measuring the Missed Opportunity (June 2013). The Conference Board of Canada and the Canadian Alliance for Sustainable Health Care.
Authored by Cheryl Reid, Policy Analyst with Northern Policy Institute in Thunder Bay, ON.
The content of Northern Policy Institute’s blog is for general information and use. The views expressed in this blog are those of the author and do not necessarily reflect the opinions of Northern Policy Institute, its Board of Directors or its supporters. The authors take full responsibility for the accuracy and completeness of their respective blog posts. Northern Policy Institute will not be liable for any errors or omissions in this information, nor will Northern Policy Institute be liable for any detriment caused from the display or use of this information. Any links to other websites do not imply endorsement, nor is Northern Policy Institute responsible for the content of the linked websites.