Negation driving many Ontario family doctors to distraction

As a family doctor in Ottawa for the past 30 years, Dr. Alykhan Abdulla prides himself on the relationships he builds with his patients and the high quality of care that he and the 18 other doctors in his family health organization provide at three modern clinics in Canada’s National Capital region. But he sees red when patients who are enrolled or rostered with his clinic go to see other doctors at walk-in clinics or virtually through retail giants like Loblaws, generating fees that are deducted from the access bonus that he and his team colleagues receive from government for contractually committing to making themselves available to those same patients over the phone, in person and even virtually all day every day, including after-hours and weekends. “It’s absolutely infuriating,” said Dr. Abdulla, a comprehensive family doctor and a palliative, sports, cosmetic and travel medicine consultant. He is also a past chair of the OMA’s section on general and family practice, which represents all of Ontario’s 14,000 family doctors. “We spend a lot of time, resources and energy over many years developing pathways and building and maintaining relationships and brick-and-mortar clinics that provide our patients with high value health care,” said Dr. Abdulla. “But when a patient goes elsewhere the entire face value is paid out of the rostering doctor’s bonus. It’s Uber health care, it’s convenience versus appropriate—and it drives doctors crazy.” Read: Stop blaming family doctors For many if not all of the roughly 5,000 family doctors across Ontario who practice in family health teams and use the patient rostering enhanced fee-for-service model (eFFS), few issues are as irksome as the subtraction of another doctors’ fees from their access bonuses, a practice widely known as negation. Physicians in a capitation funding model, such as Family Health Organizations, are paid a fixed rate to provide services for each patient they enroll. What is called a “special payment” is given to doctors based on the success of providing a patient with the care they require. According to the Ontario Medical Association, this payment is roughly 20% of the capitation rate and helps ensure patients have access to their doctor when needed without having to seek care elsewhere. As part of the capitation enrollment process, patients must sign a form agreeing to contact their family doctor first when they need primary care, medical advice or treatment. When a patient seeks care elsewhere, such as through a walk-in clinic, the enrolling doctor’s access payment is deducted by the cost of that service. There are exceptions to this, such as visits to an emergency department or specialist. The mechanism has existed since 2003 in Ontario when patient rostering and access bonuses were introduced as part of a wave of new primary care models with different payment schemes and organizational structures designed to both entice and encourage doctors to shift away from traditional practice models and offer full and continuous care rather than making separate appointments for each medical issue, as they did in the traditional fee-for-service model. To encourage rostering, the government pays doctors fixed annual fees of between $71 (for kids around 10 to 14) and $619 (for patients 90 and over) but with most fees in the $120 and $145 per patient range. That is in addition to traditional fee-for-service billing and premiums for preventative care like Pap smears or mammograms and chronic disease management services. In return, doctors agree to a long list of requirements and responsibilities that they share with team members in a formalized relationship with enrolled patients. However, to ensure doctors fulfill their contractual obligations, fees are subtracted or negated from their access bonuses to pay for healthcare that rostered patients receive elsewhere. That provision has always rankled doctors. But a number of factors have raised their frustration over negation to a fever pitch in recent years. “Pre-pandemic this was difficult enough in an urban area like Toronto where MDs would come to your house at a moment’s notice for a house call and where there are walk-in clinics on every block,” said Dr. Christopher Sun, who is member of a family health team in Toronto. “Nowadays the problem is even worse with online walk-in clinics. Anybody who feels like chatting with a doctor in the wee hours of the morning can pick up their phone and see an MD. “How (Ontario’s Ministry of Health) thinks this is within the control of a (family doctor) or a reflection of access is bewildering,” added Dr. Sun. For his part, Dr. Elliot Halperin, a prominent family doctor in Georgetown, Ont. and a former Ontario Medical Association president who notably helped to create alternate funding arrangements and the access bonus 20 years ago, is saddened by all the negative spin over subtraction and its detraction from the benefits of the patient enrollment model. “We wanted to make the model fair and enticing to groups,” said Dr. Halperin, Ont. who has served on many medical association boards over the past 40 years. Describing himself as a former “dyed-in-the-wool, fee-for-service supporter,” he said the healthcare complexities arising from Canada’s greying demographics made it “obvious from the billing data we had access to—the first time the OMA saw our own billing—that the volume of business was declining and that was not good for a fee-based patient care model.” He said a capitation model that pays according to the age and sex of rostered patients helps to create better doctor-patient relationship because it allows physicians to spend more time with patients. But the notion of subtraction, he added, has become a fixation for many doctors. “Of the total amount billed for the codes to be included in the basket we found that, on average, for an individual patient, the patient’s own family doctor billed 80% of the total and other family doctors billed 20% of the total,” added Dr. Halperin. “This is the fundamental element that underlies the bonus: the 20% was not money that FPs had earned caring for their patients but rather it was money other FPs had earned and billed to the FFS pool.” The fact that the bonus is calculated using subtraction, he added, does not make it negation. “We could have used addition instead but it is more cumbersome,” said Dr. Halperin. “It never occurred to me that it would become so misunderstood and sometimes maligned as negation.” He acknowledged however that “a good analytical look” may be in order on the impacts that virtual and even phone consultations, which were recently added to negation, are having on the capitation model. He also understands the frustrations doctors feel when patients fail to respect the promises they make when rostered. “Doctors can’t control the behaviour of our patients, whom they legitimately expect to keep that pledge,” said Dr. Halperin. “It weakens relationships.” For his part, Dr. Abdulla said he would like the government to put an end to what he sees as the corporatization of virtual care. “If big retailers like Loblaws and Shoppers Drug Mart want to open physical locations for doctors’ offices, that’s fine with me,” he said. “But right now the playing field is not level because doctors from every province (except Quebec) can offer virtual care through these companies. It’s not fair and it’s not appropriate.”

Negation driving many Ontario family doctors to distraction

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