FHO+: The good, the bad and the reality on the ground

Over the past couple of months, family physicians across Ontario have started experiencing the reality of the new FHO+ model in day-to-day practice.The goals behind the reform are understandable: improve access, support continuity of care, encourage after-hours coverage, and create more accountability in primary care.These are important goals, and family physicians should absolutely be part of improving the system. Some aspects of FHO+ deserve recognition. Organized after-hours coverage matters. Continuity of care matters. Accountability matters. But as implementation unfolds, many front-line physicians are beginning to identify operational consequences that may not have been fully appreciated during policy design.The efficiency problemOne of the biggest concerns is the relationship between productivity and compensation efficiency. Under FHO+, physicians are now heavily constrained by hourly and monthly thresholds tied to direct patient care time. In practical terms, physicians can work harder, see more patients and still experience a significant reduction in compensation efficiency. The unintended consequence is that the model may discourage efficiency during regular clinic hours.A physician who develops efficient workflows, uses technology effectively,and safely improves patient throughput may actually feel penalized for doing so. That creates a concerning signal within primary care. Healthcare systems should reward:safe patient access;continuity;quality;responsible innovation;sustainability;and burnout prevention.They should not unintentionally encourage physicians to slow down to remain within operational thresholds.The hidden mental burdenOne of the least discussed consequences of FHO+ is the cognitive burden it creates for physicians throughout the day. Doctors are now not only thinking about patient care, they are also continuously tracking:direct care hours;monthly hour accumulation;reimbursement thresholds;after-hours eligibility;continuity metrics;outside-use implications;and whether additional work will still be compensated fairly.That constant background calculation creates mental fatigue. Family physicians already operate in an environment of nonstop decision-making: clinical care, inbox management, staffing issues, documentation, urgent requests, abnormal results, hospital follow-ups and administrative work. Adding another layer of continuous operational tracking changes the psychology of practice itself. Instead of focusing entirely on patient care and clinic efficiency, physicians may begin constantly asking themselves: “Am I crossing another threshold?” That is not a healthy foundation for sustainable primary care.The bigger problem: complexity itselfThis discussion is larger than FHO+ alone. It reflects a broader pattern in healthcare reform. With each reform cycle, the Schedule of Benefits seems to become increasingly complex rather than simpler.New rules. New modifiers. New exceptions. New thresholds. New formulas. New tracking requirements. Yet very rarely do reforms focus on reducing front-line operational complexity for physicians. And complexity itself has consequences, It increases cognitive load, administrative dependency, billing anxiety, operational inefficiency and eventually burnout. Complex healthcare systems may be unavoidable. But complex systems still require simple front-line workflows. That principle is often overlooked.Continuity of care should be managed by the system, not punitive billing rulesContinuity of care matters. Family physicians understand that better continuity leads to better long-term outcomes, fewer fragmented records, reduced duplication, and safer patient care. But enforcing continuity through increasingly complicated physician payment penalties is not the right approach. A simpler and more effective solution already exists. If the Ministry of Health wants to strengthen continuity of care within capitation models, the responsibility should sit primarily with the system itself, not through constant billing complexity imposed on physicians.For example: If a rostered patient repeatedly seeks care outside their enrolled medical home beyond a defined threshold, the ministry could automatically review or remove the patient from the roster. The patient would be notified directly by the Ministry of Health not by the physician. This creates clear accountability while avoiding unnecessary tension between doctors and patients. Most importantly, it removes one of the major hidden burdens currently placed on family physicians: constantly monitoring continuity metrics, outside-use calculations, and roster penalties while simultaneously trying to run busy clinics.Continuity of care should be encouraged through smart system design and patient accountability, not by forcing physicians to navigate increasingly complicated billing formulas and penalties. Doctors should focus on delivering care. The healthcare system should focus on managing the system.The human side nobody talks aboutMost family physicians are not trying to maximize billing. They are trying to:keep clinics financially sustainable;reduce patient wait times;manage inbox overload;supervise staff;complete documentation;respond to urgent patient needs;and avoid burnout.When systems unintentionally penalize high-functioning clinics for being efficient, morale suffers quickly. And eventually, patients feel the impact.A better path forwardPrimary care reform is necessary. But reforms work best when governments collaborate closely with front-line physicians who actually operate clinics every day. The goal should not simply be measuring physician hours. The goal should be:maximizing safe patient access;improving continuity;reducing unnecessary administrative burden;supporting sustainable family medicine;encouraging innovation and operational efficiency;and protecting physicians from burnout.Ontario has extraordinary family physicians who want the system to succeed. The question is whether the system is being designed in a way that allows them to succeed, too.Dr. Wael Guirguis is a family physician practising in Mississauga, Ont.

FHO+: The good, the bad and the reality on the ground

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