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Family Physician Negotiation Ruth Wilson, M.D., C.C.F.P NYSAFP Lake Placid, Jan 31 2009 Primary Care Score vs. Health Care Expenditures, 1997 Primary Care Score 2 UK DK NTH 1.5 FIN SP CAN AUS 1 SWE JAP 0.5 GER BEL 0 1000 1500 US FR 2000 2500 3000 3500 4000 Per Capita Health Care Expenditures Starfield 10/00 ‹#› Characteristics of Canadian PHC • • • • • • • 50% of MDs are GPs Public funding, free at point of access, private provision Fee for service has been dominant funding model Physicians own premises, employ staff 92% of Canadians have a GP; gatekeeper role Little public funding of other primary health care professionals Wait times and access issues ‹#› How are working conditions negotiated? • • • • • Provincial governments are main payers Governments choose to negotiate with provincial medical associations Payment and co-management issues are addressed FPs and other specialists negotiate together (except in Quebec!) Teams are composed of physicians, lawyers, and civil servants ‹#› Ontario’s Primary Care Renewal goals (2000) Improving access to primary health care Increasing patient and provider satisfaction with the health care system Improving quality and continuity of primary health care Increasing cost-effectiveness of health care services Common Elements of Renewal • Patient enrolment • Grouped/networked practices • Extended access hours • Enhanced use of information technology • Focus on comprehensive care services 7000 Physicians in Primary Care Renewal Models Participating Physicians 6000 5000 4000 3000 2000 1000 0 Jun-99 Mar-00 Dec-00 Sep-01 Jun-02 Mar-03 Dec-03 Sep-04 Jun-05 Nov-06 PCNs FHNs FHGs Date n0 t 5 04 p- C ur re n Ju Se -0 3 3 2 ar -0 n0 01 p- D ec M Ju Se -0 0 0 9 ar -0 n9 D ec M Ju Number of Patients Enrolled (thousands) Patients Enrolled in PCR Models 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Some elements of payment models What is a Family Health Network? • A group of at least 5 primary care doctors working together with other health care professionals to provide accessible, coordinated care to enrolled patients • After-hours care through a combination of on-call arrangements and a telephone health advisory service • A new method of physician payment • Voluntary for all patients and physicians Patient Enrolment Requirements To seek treatment from their doctor first, unless they are travelling or find themselves in an emergency situation To allow the Ministry to provide their doctor with information about services they have received from primary care doctors outside of the network and some preventive services To not switch the doctor they’re enrolled with more than twice per year However: patients are not required to enrol to continue receiving services, nor will they be refused enrolment due to their health status or need for services Telephone Health Advisory Service • After-hours • Nurse-staffed • Phones a physician when required, otherwise directs patient to self-care or hospital. (Pilots reported reduced advice call) • Report faxed next day to personal physician (with patient’s permission) Payment Overview Blended Model: Capitation + fee-for-service + lump sum payments + special premiums = blended model Blended approach allows FP to receive an increase in remuneration if providing broad-based comprehensive care Payment Overview • • Base capitation payment rate determined by age and sex of patient Bonuses for achieving preventive targets (Pap, mammogram, flu shots, childhood immunizations, colorectal screening • Fee-for-service payments for core services (10%) • Fee-for-service for excluded services • Premiums for obstetrics, palliative care, house calls • New patient fee; after hours fee; plus several additional enhancements Some observations • Cost control is partly by controlling access rather than by managed care • Canadian FPs also complain about paperwork, but our billing system is by comparison much simpler • Interest in Family Medicine is up—31% of medical students make it their first choice • Interests-based negotiations can work