Negative, unintended consequences of Ontario’s spring fee deal

The butterfly effect: one small change in a complex system can lead to unpredictable consequences, sometimes significant ones. From a historical perspective in the healthcare world, for example, the desire to alleviate suffering from chronic non-malignant pain may have allowed undue trust to be placed in the pharmaceutical company Purdue. This contributed to the overuse of opioids for chronic pain, the subsequent awareness of the negative unintended consequences, the development of guidelines and regulations on safer prescribing, the curtailing of the availability of prescription opioids and the coincident increase in availability of a toxic opioid supply on the street which, in turn, has contributed to the steady increase in overdoses and deaths. Also, the first moments of the pandemic saw our frontline heros lauded with the banging of pots and pans. We saw a deep collective concern for each other—our fellow human beings. Who, then, could have predicted that this sentiment would devolve into fatigue, anger and hostility two years later? In fact, the effect of the past on the present is usually extraordinarily difficult to predict. Read: Dr. Matthew Schurter: Forms ‘kill’ family doctors How then, could it be known that the effects of some changes to Ontario’s physician schedule of benefits for physician services under the Health Insurance Act (found in the footnotes of the most recent physicians services agreement) could lead to further erosion of the morale of family physicians, arbitrarily punish some family physicians who have an area of focused practice, create a disincentive to open or maintain a comprehensive family practice, and seed division between groups of family physicians? Step by step, here’s how it may have happened: Set out to control costs in the physician services budget. Create a fee-for-service cap, a disincentive for family physicians practicing in a capitation model to provide unrostered-patient-visits in walk-in clinics. Shift the financial disincentive for exceeding the cap on in-basket fee-for-service billings from physician groups to individual physicians. Assume that that there are many family physicians who are not available to their rostered patients and are, instead, billing fee-for-service in walk-in clinics. Use the blunt tool of a billing cap to discourage this. Ignore the fact that many family doctors have a special interest or a focused area of expertise and provide needed care to that population and bill OHIP fee-for-service. Fail to appreciate that having a focused practice may benefit not only patients but also can improve physician career satisfaction and reduce burnout. As a result, observe that many clinics begin restricting after-hours visits to rostered patients only. Do this at a time when 1.8 million Ontarians have no family physician (and are therefore unrostered). Consider where these hundreds of thousands of after-hours patient visits will happen if not in after-hours clinics. (Hint: many will go to the ER.) Try to ignore reports that ER wait times already are at record highs and reports suggesting the number of unrostered patients may double in the next few years. Punish those with a niche or focused practice. Create a massive financial disincentive for family physicians who currently spend some of their time providing focused care to a unique group of patients to continue to do so in a meaningful way. Restrict payment for these services by a cap on each physician. Effectively force comprehensive FPs to choose between their fee-for-service and comprehensive family practice. Consider this: If comprehensive family practice comes with lower earnings, more forms, more delegation from specialists, more patient complexity, more burnout, and more financial claw backs largely outside of physicians’ control (Yes, that’s you: “outside use” negation) which do you think many family physicians will choose? Sow division within the section of general and family practice by arbitrarily compensating some fee-for-service care but not others. In some cases, services which reside “outside the basket” like inpatient care, OR assisting, or FP-anesthesia are not subject to the cap. Services that involve billing codes that reside “within the basket,” such as addiction management, compensation is subject to a cap. Everyone deserves a family physician. As we see our ERs bursting with record-high wait times, family physicians leaving practice at an accelerated rate, and physician morale dropping, we must support family physicians and tear down unnecessary barriers to the practice of comprehensive care, not erect new ones. The cap on individuals rather than groups is ripe with unintended negative consequences for the healthcare system and should, therefore, be abandoned. Patients deserve better and so to do their doctors. Matthew Schurter practices family medicine in a FHO in Sunderland, Ont. and is a FP-anesthesiologist in Port Perry, Ont.

Negative, unintended consequences of Ontario’s spring fee deal

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