‘Extraordinarily insulting:’ Ontario’s new acuity payment will cost physicians more money, says family doctors union

A new payment model that adds an extra fee for complex patients but eliminates existing bonuses and fee-for-service allowances for certain primary care physicians in Ontario is a “complete disaster” that will likely take away more money than it gives and could lead to patients missing important tests, according to the founder of the Ontario Union of Family Physicians.“This is creating a lot of uncertainty,” Dr. Ramsey Hijazi told the Medical Post. “The goal was to pay more for the complex patients but the unfortunate part is they’re basically only using the funding that they’re saving on the preventive care bonuses to allocate to this, so family physicians are not going to get more money by doing this. Not only that, this introduces a whole level of complexity to family physicians to determine how to bill for these patients.”The Ontario Medical Association told its members on March 11 that, after two decades in the works, an acuity payment model is ready to roll out on April 1 for doctors who practise in family health organizations or networks. Under the new model, physicians can adjust their usual capitation fees for rostered patients with complex conditions.The actual dollar amount for acuity payments would be determined by the complexity of each payment, which in turn would be based on which “band” the patient belongs to in the Canadian Institute for Health Information population grouper.“The new acuity modifier model will improve equity in physician remuneration by rewarding physicians to care for more complex patients,” the OMA said in an email to the Medical Post. “The needs of individual patients within each age-sex group vary widely. For example, patients in the 90th percentile can be 10 times more resource intensive than patients in the 10th percentile within the same age-sex group, yet physicians currently receive the same payment for all patients in the same age-sex group. A healthy 60-year-old female has the same payment as a complex 60-year-old female with numerous chronic conditions.”But this “reward” for FHO and FHN physicians may not necessarily mean more money for the extra work typically required to care for complex patients. At best, doctors would get an additional $10 for the most complex “band one” patients, said Dr. Hijazi.At the same time, they’ll be losing the payments they’ve received in past years for getting patients screened for colorectal cancer and ensuring they go for scheduled mammograms and PAP smears, as well as for influenza and childhood immunizations.Doctors who put in extra hours outside their clinics—to work in an emergency department, for example—would also no longer be able to benefit from pooled fee-for-service limits. As of April 1, these limits will be applied to each individual physician.“As outlined in the 2021 Physician Services Agreement, all of the funds from the preventive care changes are reinvested into the acuity payment,” the OMA wrote in its email. “$32.6 million dollars is being repurposed, meaning the per-patient impact is small. Over the whole system, this is a neutral change.”Read: Extra money for extra work: Ontario docs in some types of primary care groups to get acuity payments for rostered patientsFor doctors who have redesigned their clinic workflows to help ensure patients get the recommended tests, the changes brought on by the new payment model may be not-so-neutral. Ottawa-area family physician Dr. Alex Duong said his clinic has, over the last decade, re-configured its electronic medical records system and changed workflows to enable staff to call patients and remind them to get their tests done.“So the money we get that helps pay for all that is going to disappear,” he said.Dr. Duong also pointed to content on the OMA website that said the healthcare resources needs of the 90th percentile of patients in the age-sex groupings of Ontario’s current capitation model were 10 times more intensive than the needs of patients in the 10th percentile of the same age-sex group.“If you actually look at the CIHI population grouper model, you can see this difference in healthcare utilization between the bottom decile and upper decile,” he said. “Basically, the acuity payment is equivalent to a dollar per multiplier.”With the switch from pooled to individual fee-for-service limits, doctors who go over the allowable maximum billing for fee-for-service work will not be paid for that extra work, said Dr. Hijazi.“Under the current model if you’re in a group of 10, you could pull that limit together. So if there was only one or two physicians in the group who did emergency or hospitalist work, it would be hard for them to go over that limit because the whole group limit would be applied,” he said. “Now if you go over that individual limit, you’re not going to get paid. That’s a disincentive for family physicians who put in that additional work outside the clinic. It’s really not a good decision at all.”The OMA said this was also a concern within the association.“That’s why the implementation of individual fee-for-service limits has been delayed until April 1, 2025, to give the OMA and (Health) Ministry more time to develop criteria in which exemptions can be granted,” wrote the OMA. “The OMA insisted that moving to an individual fee-for-service cap could not occur without establishing an exemption process for physicians that would ensure patient safety and continuity of care. The OMA will continue to advocate to make sure proper safeguards are in place to make sure physicians are protected and supported.”Read: Ontario Union of Family Physicians declares Red Alert for family medicine in OntarioBoth Dr. Duong and Dr. Hijazi said they’re worried about the additional administrative work that would be needed to assess each patient for level of complexity and to bill for the acuity modifier.In its March 11 email to doctors, the OMA invited FHN and FHO physicians to complete an optional, self-directed online course about CIHI’s population grouper methodology. The course, which counts towards two continuing medical education credits, is broken into two one-hour modules.“I find it really just kind of ironic that the OMA and the Ministry of Health are championing the improvement of administrative burden for family physicians and then they do something like this,” said Dr. Hijazi. “Even though this is supposed to be revenue-neutral, it’s going to end up costing physicians more money. Not only do we have to take the self-directed course, but now we have to dedicate much more time in terms of sorting out which patients are more complex. And that’s for a difference of $10 a year for the most complex patient.”Many doctors he’s spoken with are "extremely outraged" by the incoming acuity payment model—and by what some consider to be a failure by the OMA to advocate effectively for its members.“I think it’s really extraordinarily insulting that the Ontario Medical Association that we pay thousands of dollars in dues to every single year had a whole task force to spend time, energy and our own money to come up with this policy,” said Dr. Hijazi. “It’s just going to create more work for us, it’s so insulting.”The OMA noted that “there is no action needed by physicians for the acuity modifier payment as calculation and payments will be made automatically. Calculations for patient acuity will be measured using CIHI’s population grouper methodology.”When it comes to how the elimination of preventive care bonuses might affect patient outcomes, that’s something that remains to be seen, said Dr. Duong. While a 2014 study concluded that payment incentives had little to no impact on cancer screening rates, “ten years have passed since then and we’ve basically built our EMR systems around trying to get people to adhere to (screening) guidelines . . . I have a feeling this (removal of preventive care bonuses) will lead to lower screening rates which will, unfortunately, lead to more cancers or cancers being detected later.”Read: As family doctors our prescription for residents is to not set up a practice in Ontario

‘Extraordinarily insulting:’ Ontario’s new acuity payment will cost physicians more money, says family doctors union

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