The OMA and its members believe that primary care reform is essential to maintain timely and cost-efficient care. To this end, the OMA considered the following:

1. The Environment

2. The Objectives

3. Strategic Considerations for the OMA

4. Payment Models:
   opinion research from all physicians:

   84% of physicians support fee-for-service
   62% of physicians support blended funding

5. A New Model for Primary Care Reform: Reformed Fee-for-Service

6. Conclusions

1. The Environment

• preserve comprehensive universal core coverage
• preserve professionalism
• preserve intra- and interprofessional relationships
• address the acute care shift to the community
• position physicians as competitive caregivers offering a service
• address fiscal and political uncertainty
• achieve predictability of health care expenditures
• achieve predictability of income and professional stability for physicians

1. health policy changes should be incremental and interdependent in their effects on other policies
2. health policy should be patient-centred
3. health policy should articulate the balance between communitarian values in health insurance versus individual wishes and expressions of autonomy
4. health policy should promote explicit clinical management systems
5. health policy should promote fiscal and clinical accountability
6. health policy should have flexibility to encourage innovation in accountability criteria and provider incentives
7. health policy should anticipate implementation issues, mid-course corrections, and input from those directly affected.

As the OMA began its discussions on how to achieve stability in health care while initiating reform strategies, the following Statement of Principles was developed to outline the core values of the OMA's position while initiating a strategy for reform:

1. The OMA supports physician choice of payment plan. A process should be developed that facilitates responsiveness of the system to the needs of the profession, the public, and government.

2. To encourage responsible use of the health care system, the OMA supports a mutually-agreeable relationship between a patient and family doctor of his or her choice.

3. Every Ontarian is entitled to reasonable health care access to a family doctor of his or her choice where possible.

4. Whereas the family doctor assumes responsibility, the physician is best able to provide comprehensive, continuous primary care services and should remain as the principal coordinator of access to publicly-funded medical services.

5. Consideration should be given by the OMA and government to redistribution initiatives to address access to primary care services in areas of need.

6. The OMA endorses the use of informatics to create a provider-based patient database with the family doctor of his or her choice to promote screening, periodic health exams and appropriate ongoing care.

7. The OMA, in conjunction with government and appropriate professional associations, encourages collaborative relationships between family doctors and other health care providers.

8. Family doctors must be provided with physician practice tools to enhance the quality and effective delivery of primary care services. These tools include guidelines and guidemaps to assist the profession in the management of primary care services.

1. aging population
2. technological advances
3. economic conditions/socioeconomic impact
4. epidemiological trends (e.g., HIV)
5. physician redistribution
6. hospital restructuring (cost-shifting is the consequence to the OHIP pool)

2. The Objectives

1. represent the different interests of the membership, i.e., professional as well as economic interests;
2. represent the needs of our patients;
3. suggest a constructive plan for reform which meets long-term objectives;
4. be a part of the solution, i.e., to effect reform proactively.

3. Strategic Issues

• utilization with incentives
• distribution of physician human resources
• introduction of private funds
• payment methods versus mechanisms
• physician satisfaction
• policy direction

4. Payment Models

5. A New Model: Reformed Fee-for-Service

Bench Mark Threshold (BMT)	=	roster size x pro-rated payment per patient (paid to physician by FFS)
Additional income potential	-	earned by exemptions from FFS pool

Total OHIP billing = BMT (individual threshold) + exemptions from FFS pool

Bench Mark Threshold earnings:		exempt from clawback
Exempted services:		subject to clawback (if clawback instituted)

Specific service exemptions for primary care practitioners from the BMT but not from the income threshold might include:

As well, the OMA recognizes the need to address gaps in accessing care; indeed, the Physician Advisory Group is concerned that hospital restructuring may result in an acute care crisis in the provision of primary care services. It is proposed that different fees be made available to primary care physicians for providing high-needs patients, such as HIV or palliative care patients, or acute care needs in order to be responsive to this impending crisis.

The Reformed Fee-for-Service model will:

• enhance the coordinator role of the primary care physician
• improve the management responsibilities and capabilities of primary care physicians
• allow for the incremental introduction of specific ethically-justifiable managed care responsibilities.

Although government has decreed that utilization of health care services must be controlled in order to comply with the fiscal realties of the province, the focus to date has been on controlling physician services. The profession agrees that it is imperative to make health care delivery more efficient and effective, and acknowledges the responsibility physicians must bear in ensuring that the system is managed appropriately. However, the profession also recognizes that the system cannot work if it remains open-ended for patient utilization. It is essential that the public shares responsibility for controlling health care utilization, and therefore ultimately expenditures. Patient enrollment with a family practitioner's roster is essential for the coordination of care.

Consequently, the adoption and implementation of patient rostering with a contractual arrangement is central to the primary care reform strategy envisaged. Rostering to a general or family practitioner will help to:

• avoid duplication of services
• create efficient referrals
• constrain certain patient abuses (e.g. self-referral, double-doctoring)
• promote continuity of care, which improves efficiency, outcomes and strengthens the doctor/patient relationship
• address physician distribution

Implicit in the rostering model proposed is the requirement for patient commitment by means of contractual agreement. Patients and physicians would be free to exercise choice in their selection/approval of a provider or patient, but rostering would require a contractual agreement between the physician and patient, and the opportunity to de-roster would only be available after a defined period of time. In this manner, the primary care physician can effectively coordinate patient care and thus avoid the fragmentation of patient services which presently occurs, and serve as a gatekeeper to secondary and tertiary services. This system will not only enhance patient care, but also more efficiently control health care utilization.

As a fundamental component of primary care reform, it is essential that the details for rostering, de-rostering and maintenance of the database necessary to implement this system are clear and applicable in the real world. Because rostering represents a significant departure from the open-ended system currently enjoyed by the public, it will require the enthusiastic support of government and a significant public education effort. Although the Physician Advisory Group has outlined a number of the details such a rostering system would encompass, it is suggested that further specifics will be developed through pilot project evaluations and consultation with other jurisdictions which have mature rostered systems.

Under the reformed fee-for-service model proposed, the public would assume financial responsibility for non-emergency care if such care is obtained outside the rostered family practice (RFP) and within the defined geographic proximity if it is accessed merely for convenience. Practitioners would be required to provide 24-hour response, but could do so by means of a group call practice, i.e., solo practitioners could join together to provide after-hours response coverage in a shared-care arrangement. Such coverage would not only reduce the frequency of visits to hospital emergency departments and walk-in clinics, but would also enhance patient satisfaction by improving access to after-hours care. In addition, instituting such shared care for after-hours coverage encourages functional grouping of previously solo practitioners, and thus physicians would be not be forced to assume an unreasonable burden.

Principles of Reformed Fee-for-Service

1. Preserves universal core coverage.
2. Retains professional autonomy.
3. Preserves positive aspects of fee-for-service system (i.e. incentives incorporated to ensure service).

6. Conclusions - Why Reformed Fee-for-Service?

In order to measure the effectiveness of this model, the OMA recommends that pilot projects be implemented in several distinct geographic regions. Strict criteria for evaluation must be adopted to assess the positive and negative aspects of this reform proposal.

In Canada, the desire to control burgeoning health care expenditures has resulted in the tendency to equate reform of the current system with "wholesale change." Yet this is analogous to throwing the baby out with the bath water. In reality, reform of the system can be accomplished by maintaining the positive aspects of the current FFS system while introducing changes to control the system's open-ended nature.

There is reason to be concerned by the efforts in Canada to embrace radical change to the system as a panacea. As exemplified by the reaction to the report commissioned by the Advisory Committee on Health Services (ACHS) entitled A Model for the reorganization of Primary Care and the Introduction of Population-Based Funding, (the "Kilshaw Report") which was presented to the Deputy Ministers of Health in September 1995 in Victoria, BC, the move to population-based funding as the only possible option for ‘curing' the ‘ills' of the current system was roundly condemned as lacking compelling supportive evidence and instituting the incorrect belief that one solution could be applied to all problems. Rejection of this model by such organizations as the CMA, OMA, and BCMA cited the fact that adoption of a population-based funding approach, linking patient and population health, would "[transfer] the risk from government, as a third-party payer, to the physician as provider" Physicians would thus bear the brunt of payment responsibility, which, although reducing the risk for government, would doubtless precipitate either widespread under servicing of the patient population or massive relocation to other jurisdictions, namely, the United States, which would in itself leave patients stranded in terms of accessing physician care.

Change in health care policy is a phenomenon stretching across all of the OECD countries. Canada is not alone in its review of the factors affecting health care services. According to Richard R. Saltman, this reform process can be attributed to three external factors:

1. demography (aging population);
2. technology (invasive as well as certain imaging costs related to non-invasive activity);
3. economics (e.g. capping on total expenditures for health services).

1. increased efficiency, i.e., more productivity for the same amount of money;
2. increased effectiveness, e.g. health service outcomes;
3. responsiveness to patient preference, not only in terms of patient choice regarding physician or hospital, but also with respect to participation in the clinical treatment decision.

This discussion paper exemplifies the OMA's endeavours to identify a way in which to balance the needs of fiscal restraint with a method of primary care remuneration and organization. The OMA believes that the proposed Reformed-Fee-for-Service model is a responsible effort to participate constructively in the debate on health care reform.

The panacea for health care reform in Ontario does not lie in a completely overhauled method of remunerating physicians and organizing care, as transformative policy change is not necessary. Primary Care Reform: A Strategy for Stability is constructive insofar as it addresses distinguishable problems and offers solutions while retaining the values inherent to the Canadian health care system.

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Referrals

(services) As defined in Chapter 3.
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(transfer)Capitation - A Wolf in Sheep's Clothing, BCMA, November 1995.
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