Summary of OMA Proposed Model
Essential Features

Feature Proposed OMA Model
Patient registration with a solo provider, group or agency Patient selects primary care physician (GP/FP); contractual relationship with minimum commitment of 6 weeks; may reverse the procedure in 10 working days to a maximum of twice per year. Physician initiated, not government. Enhances patient-physician accountability.
Application of Technology Critical tool to permit primary care reform initiatives to occur (rostering, networks etc.): consistent with MOH "Smart System" initiatives.

3-Stage Implementation Process:

Stage 1: Utilization of existing deployed technology

Stage 2: Implementation of Electronic Patient Record (EPR)

Stage 3 Implementation of Data Management

Underlying Principles of Information Technology
Defined service standards Provision of 24-hour response options, such as after-hours clinic for rostered patients; 24-hour telephone information access to result in decreased ER visits and therefore ER expenditures. Increased access to information in acute care situations.
Tools for quality improvement Develop the concept of a Primary Care Network and implement community linkages focusing on:

  • the development and implementation of clinical practice guidelines or guidemaps - developing guidelines with ICES/Coalition on PCR.
  • decision tools for common primary care encounters
  • drug prescribing
  • screening for disease prevention
  • sessional fee for education
Coordinator of care as the gatekeeper Most responsible provider (MRP) is appropriate coordinator of care - coordinates referral process; integrated funding structure supports referral to AHPs for additional care.
Population-based payment method Reformed Fee-for-Service (RFFS) Model Components:

  1. Bench Mark Threshold (BMT):
    BMT = roster size (# of patients per roster) x capitation (pro-rated, risk-adjusted payment);

  2. physician paid FFS in office setting until individual BMT (individual threshold) is attained;

  3. additional earnings potential above BMT external to office setting paid by FFS but remain subject to clawback if clawback continues, e.g. OB, ER, nursing home/institutional care visits, surgical assists, house calls, palliative care, anaesthesia services;

  4. no negation of BMT for additional specific services exempted from Bench Mark Threshold;

  5. except for urgent, emergent care, for services obtained by patient outside rostered practice, patient payment required.
Population-based primary care data analysis
  • Support funding following the population;
  • FFS payment made directly to provider not regional boards or DHCs;
  • conceptual linkages using information technology of practices (either solo, group or organizations) such that data may be collected locally, regionally or provincially to move in the direction of population-based health care.
Performance Goals
  • Performance goals, exemplified by preventive screening (mammography, etc.) essential, as identified by the Task Force on the Periodic Health Exam

  • CME financial bonus for 50 hours per annum:
    $5,000 - urban physicians
    $10,000 - rural and under serviced area physicians

  • Comprehensive health care model for promoting timely return to work

  • no direct economic incentive but enhanced servicing of rostered patients achievable

  • performance goals attainable and supportable by FFS because:
    1. access promoted;
    2. retains encounter data for comparative purposes; and
    3. encourages performance standards and objectives expected in model
  • Information technology crucial for appropriate patient recall for preventive screening or follow-up/monitoring

  • Population data potentially established.
Global Budgets
  1. Primary care/specialty care services included in one globe. Shared overlap in globes, e.g. GP anaesthesia services, GP Psychotherapists.
  2. BMT - exempt clawback for defined negotiated term.
Payment incentives to address performance/distribution and patient accountability
  1. No negation, all incentives, e.g. incentive for BMT service exemptions, e.g. ER, OB deliveries, anaesthesia, services, surgical assists; risk-adjusted pay differences/monthly fee per patient (e.g. HIV, palliative care, long-term care institutions, nursing homes).

  2. Distribution addressed because:
    1. physician with too few rostered patients will move to areas of potential expansion within BMT;
    2. finite population to roster;
    3. individual maximum earnings determined by BMT plus number of exempted services provided = to maximum negotiated cap;
    4. maximum roster size (i.e. number of patients/roster) determined by BMT billings reaching maximum negotiated cap.
Incremental Service Integration Incremental evolution of this process. Solo, group or organizations may ‘hire' AHPs; physicians encouraged to work together to provide complement of primary care services through economic incentives; team relationships supported; development of Primary Care Network: coordination in community with formal link through hospital when necessary. Integrated Services Funding (ISF) proposed to link physicians with AHPs.
Economic incentive for integration of primary care Solo practitioners to move functionally to ‘group' with other practices via economic incentives such as increasing rostering size; multi-disciplinary teams encouraged through budget restructuring resulting in integrated organization (Integrated Services Funding model).
Electronic Patient Record Limited EPR crucial. Continuity of care emphasized. EPR-information follows patient to all interactions within the health care system; is available in office of GP/FP or most responsible provider (MRP).
General Practitioner Fundholding Explore with pilot projects. Not advocated at present.
Practice structure: solo, group or agency Can be a variety of structures, e.g. solo, group, or organizations; can evolve to group with additional providers but may not be grouped in one physical location (e.g. groups may cover more than one geographical area - functioning is grouped.

Rostering Details
(for illustrative purposes only)
  1. Once the patient has rostered for six weeks, the patient may change physicians to a maximum of twice per annum, thus allowing up to three different physicians in year one.

  2. Rostering is physician-initiated but will require enthusiastic government support and educational efforts directed to the public.

  3. Six-month time frame to complete initial rosters after application for RFFS.

  4. Patient and physician expectations to be clearly articulated in contract which is to be retained by the physician with a copy to the patient.

  5. Parent and/or guardian to sign for minors or others deemed incapable.

  6. De-rostering to be functionally the reverse of rostering and equally clear in its effect on both parties.

  7. Patients who refuse to roster remain access services which are part of the FFS pool.

  8. Initial roster data to be transferred to MOH database via electronic means, a new concept, for example through an add-on to the billing process.

  9. De-rostering, i.e. change to be allowed via manual application and process at the discretion of either party.

  10. Initial proof of roster status via hard copy i.e. membership card, etc. (to be developed).

  11. Mature system: proof of roster status via information code on health ("smart") card validated in real time at encounter (point-of-service entry).

  12. Disputes on rostered status to be settled by a local mechanism to be developed.

  13. Misuse or misrepresentation on roster status by either party to be treated as fraud with appropriate sanctions.

  14. Temporary roster change to be allowed/required for extended period of absence from normal geographic area within Ontario (allowed) or out of province (required) beyond four weeks.

  15. Family physicians may elect not to roster and remain on FFS subject to arrangements which will continue to be negotiated with government.

  16. A new fee code may be added for the initial rostering interview.

Information Technology: Cost-Effective Application to the Delivery of Health Care

Although computer-based information systems have been developed and implemented in the health care environment, numerous articles in the literature caution that they are not a panacea. Nevertheless, the introduction of informatics and its application in incremental stages is critical to the success of the reform initiative. The stages of incremental changes and the principles for informatics are outlined in the summary of the OMA Proposed Model - Essential Features.

The OMA's proposed strategy for stability in primary care reform is based on the assumption that (a) health care must be provided more effectively and more efficiently, and (b) that the health care global budget for physician core services is to be no less than $3.805 billion until 1998. It is imperative that accountability and predictability are factored into the reform process in order to ensure support and compliance.

Reformed Fee-For-Service Model - Advantages

  1. Individual - funding follows patient
    Bench Mark Threshold = roster size x capitation (pro-rated, risk-adjusted payment)
    Exempted: specific services (e.g. ER services backed out)

  2. Physicians (solo/group) bill FFS to achieve Bench Mark Threshold (BMT); BMT is individual threshold.

  3. Contracted rostering essential regardless of payment to address distribution/utilization. Rostering can be physician-driven with government support.

  4. Achievable in globe of $3.805 billion but no separate globes tied to specialty care.

  5. Non-rostered population can remain on FFS/CHC (e.g. special needs groups such as the homeless and the mentally ill).

  6. Non-rostered physicians can remain on FFS.

  7. Rostering physician can have more than one rostered population (e.g. underserviced areas where physicians divide their time to provide care for two communities).

  8. Alternative Health Providers can be part of a primary care rostered practice or agency.

  9. Legislation must include mechanism whereby point of service entry is endorsed by government, i.e. no contravention of Canada Health Act if patient pays for primary care services outside the rostered practice if obtained for non-urgent care solely for convenience.

  10. Advantages of FFS system retained (e.g. productivity, tracking of data).

"TOP TEN" Lists
Reformed Fee-for-Service (RFFS) Model

RFFS Model: Merits for Physicians

  1. Predictable target for work on yearly basis (income)
  2. Promotes role as coordinator of care.
  3. Reduces episodic, casual use of primary care system.
  4. Promotes group practice (improved cost and quality).
  5. Rewards full service family practitioner (ER work, obstetrics, etc.).
  6. Promotes more equitable distribution of physicians improving underserviced area support.
  7. Potential to free-up locums from oversupplied area.
  8. Promotes better feedback from consultant encounters.
  9. Potential for downstream managed care opportunities.
  10. Informatics implementation enhanced, with improved workplace environment.
RFFS Model: Merits for Patients

  1. Improved access in areas of relative geographic and/or undersupply.
  2. Improved quality due to better coordination of care.
  3. Improved access out of regular hours including telephone advice.
  4. Potential for reduced costs to system and resultant spinoffs.
  5. Information guided care improvement including prevention strategies.
  6. More coordinated specialty care.
  7. Informatics-driven drug utilization/interaction improvement.
  8. Reduced opportunity for fraud and abuse in the system.
  9. Avoids potential under servicing of other managed care proposals.
  10. Retains access incentives produced by FFS while avoiding potential for overservicing.
RFFS Model: Merits for Government

  1. Predictable funding for primary care.
  2. Funding follows population.
  3. Patient choice and access preserved.
  4. Encounter information intact.
  5. Doctors motivated to follow patients i.e. funding/redistribution.
  6. Coordinated referral process.
  7. Reduction of duplication (quality up, cost down).
  8. Continuity of care improved (walk-in, episodic care reduced).
  9. Incentives for primary care providers to set up group practices.
  10. Prepares ground for informatics-brokered integrated primary/secondary health care system.
RFFS Model: Merits for Specialists

  1. More appropriate indications for referral.
  2. Better referral information.
  3. Fewer duplications in referral, investigations, and treatments.
  4. Formalize referral process for alternative health care providers.
  5. Potential for more pervasive use of technology for improving information transfer between GP/FPs and specialists.
  6. Reduced risk of clawback to FFS pool.
  7. Reduced need for administrative expenses inherent in regional funding models.
  8. Better distribution of GP/FPs to provide support to specialists in underserviced areas.
  9. Encourages GP/FPs to assist surgical colleagues in the OR.
  10. Maintains incentives for family physicians in the delivery of emergency, obstetrical and anaesthesia services.
RFFS Model: Potential Difficulties

  1. Public acceptance of rostering with contractual commitment and its consequences.
  2. Payment by public for elective services outside roster within geographic limits.
  3. Administrative costs incurred by rostering borne by government, by physicians, by software vendors.
  4. Mobile nature of Ontario populace.
  5. Geographic definition of roster area (commuters).
  6. Patient/physician de-rostering; frequency and problems.
  7. Proof of roster status - no card, no care/patient pays(?).
  8. Small roster practices.
  9. GP Psychotherapy/part-time practitioners/senior physicians.
  10. Transfer of roster on retirement, etc. - asset or not?
Return to Primary Care Main Menu
[ Return to Home Page | Feedback | Other Health-Care Sites ]