How the PPSA makes family medicine worse?

As we prepare for the ratification vote for Ontario’s proposed physician services agreement (PPSA) from March 22 to 27, it is important that family doctors (especially those in F-models) think about unintended consequences of a ratified PPSA. This is intended to provide a different perspective than previously published posts. I would like to break them down into the following categories: Fighting amongst one another to become a FHO members Managed entry is back on with 720 new positions starting in April 1, 2022 and an additional 480 in April 1, 2023. That’s 1,200 spots. With over 3,000 family doctors not in FHO/FHT models but interested and about 1,500 new family doctor graduates every year. We may see more than 6,000 family doctors fighting for 1,200 FHO/FHT spots over two years. Fair fight? I wonder what happens to those clinics which close. I wonder how fairly the Ministry of Health (MOH) will decide who gets what spots. The PPSA makes inequality worse. Read: Dr. Alykhan Abdulla: What will medicine look like without any family doctors? Here are some extra accountability rules because we opened the FHO model If you have hired NPs or RN’s to deal with a big roster size (more than 2,400 patients) then your practice will be subject to “inquisition” review by bilateral committees (OMA and MOH). Whether you live in downtown Guelph or suburban Kingston or rural Collingwood all of your doctors in your FHO/FHT must work within a 5 km radius (more leniency in the distant north). So why have a team that covers a large geography? You now need six doctors to start a FHO. Or you can be smaller and work as hard as a 6+ doctor group. That’s fair! Each doctor needs to do after hours care weekly. Punch the clock. What’s the point of working as a team? Why be a big group that provides multiple locations greater than 5 km radius and more doctors supporting one another? Hurrah for team-based group practice but the MOH wants to know family doctors are in their offices and the team is home. There will be expectations to have same day or next access to services by a member of the FHO team for time sensitive conditions.Is that really good family medicine when patients as customers decide access and what is time sensitive? The PPSA fails us again. Pay less; work more There will be a repurposing of preventive care bonuses (Pap smears, FITs and mammograms) in April 2023 of about $8,800 maximum into yet undefined complexity codes or payments based on the CIHI grouper data only for FHO/FHTs (not CCM and FHGs for now). This was good primary preventive care and the financing helped support hiring office staff to reduce “burnout” of the doctors. Now who will be responsible for mammograms, FIT and Pap smears? Family doctors will still be responsible. Cancer Care Ontario sends letters to the patients to book an appointment with their family doctor to provide requisitions for testing and in office Pap smears. So same work; no money. They say the money will be repurposed to take on harder more complex patients. We are already seeing complex multi morbidity patients with a laundry list of problems that takes 20 to 30 minutes to see. The CIHI grouper does not classify a young mother with postpartum depression from a good area code as complex. It does not classify a drug addict at a private school as complex nor an ADD suburban eating disorder teen or a white transgender adult with a job. So family doctors must take on even harder patients, so maybe you recoup some losses. The PPSA makes this issue worse. Let us offer “aspirational” goals so we there are more reasons to be audited Every doctor with 1,300 patients needs to “aspire” to do 88 visits per week or 4,576 visits per year or 3.52 visits per patient. So why would you manage all their issues at twice a year for 20-30 minutes. If you took 30 minutes per visit you would be doing clinical face to face patient work 44 hours per week. Then you need to do another 22 hours of administrative work (on average 50% based on U.S. studies and higher in my experience) for a total of 66 hours per week. So the value of patient enrolled models is reduced to “aspirational bean-counting.” Smart! What’s even better now is that the MOH has more reasons to “aspire” to audit you. Are you seeing enough patients? Are you working enough after-hours clinics? Are you ensuring same day or next day services? Are you aspiring to invest in web booking for your patients? Are you doing your preventive screening even though you are not getting paid for them? More audits and more suspicion that family doctors are not pulling their weight. The PPSA makes FHO/FHT more like treadmill medicine. Stop family medicine subspecialties from competing against medical specialties The new PPSA will limit enhanced skills services to patients outside your registered FHO/FHT to only $55,590 per doctor. So your non focus designated family medicine subspecialist in your FHO/FHT who does sports medicine or CBT psychotherapy or palliative care or dermatological clinical care or care of the elderly or adolescent medicine or cannabinoid or addiction medicine (less than 50% of their practice so not focused designation) needs to stop providing these extra services to the patients of a community or FHO/FHT. The PPSA extends wait lists. Exaggerating gap between high and low medical specialties and worsening gender pay gap There will be a 1% across-the-board increase for all specialties in 2021 and 2022. Then in year three there will be a quarter of the increase to be across the board and three quarters based on the RAANI/CANDI model so no real improvement in relativity. If the differential between low specialties to high specialties is between 100-200% then one year of increased income transfer does nothing to the differential. It may lower the 100% to 200% differential by 2% to 3%. Progress? Plus the gender pay equity is a 30-35% pay reduction for women than their male colleagues, so this is not solved. In fact, women are at much higher representation in the lowest paid medical specialties (family medicine, psychiatry and pediatrics), so the gender gap actually widens. The PPSA makes inequity worse. More questions than answers Is there adequate investment in internet access to ensure equity for all geographies and all vulnerable Ontarians? What’s happening to the forced pay back on the forced loans given to doctors in spring 2020? So many unintended consequences to a single group: family doctors. Thank you PPSA—why would anyone want to be a family doctor now? Dr. Alykhan Abdulla is a family physician and the medical director for the Kingsway Health Centre in Manotick, Ont.

How the PPSA makes family medicine worse?

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