No obvious concerns for FPs in Ontario's PPSA fee deal save the 'commitments without plans'

Dear Colleagues: This is an open letter to discuss Ontario’s proposed physician services agreement (PPSA) scheduled to be voted upon by OMA membership between March 22 and 27. I went to the first town hall on March 3 and this is what I heard: The OMA board fully endorses this PPSA. We are told this is the best and final deal. We are told it is ground breaking. We are told this will only get worse in arbitration which is the consequence of voting down this PPSA. We are told the government is motivated based on the impeding June 2 election so our team strategically moved them forward on many items. No pressure. In summary, this “deal” provides no hard (or soft) cap on physician services based on utilization, continues CMPA subsidies until 2028, opens up alternate funding programs, supports hospital on-call coverage, increases parental leave benefits from $8,000 to $22,000, and allows for 4.1% to 5.6% physician budget increases over the period April 1, 2021 to March 31, 2024. It will help all surgeons, most specialists, most of those who work in hospital or ERs. It will help physician parents. It will help most Northern communities (though not specifically). The focus of my points below are really about only two items, as follows: family health organizations/family health teams and instilling a differential between comprehensive virtual care and limited virtual care. Let me explain these one at a time. Read: Dr. Alykhan Abdulla: What will medicine look like without any family doctors? Family doctor teams For FHO/FHT doctors, there are the greatest number of changes in this PPSA: There will be a repurposing of preventive care bonuses (Paps, FITs, and mammograms) amounting to about $8,800 maximum into yet undefined complexity codes or payments based on the CIHI grouper data. We are told there is no lost money here in totality but not for individual doctors. Managed entry is back on with 720 new positions starting in April 1, 2022 and an additional 480 in April 1, 2023 dripped monthly into the system. With over 3,000 family doctors not in FHO/FHT models and a desire of about 75% of them to move to these guaranteed income “salary” like models and about 1,500 new family doctor graduates annually, I see risk here. The size of the FHO/FHTs will be grown to a minimum of six doctors (with limited exemptions). The doctors will have to do more after-hours access individually attributed (and individually exempted) rather than based on the group. There will be attribution of FFS billing to each doctor to a maximum of $55,590 and not aggregated and shared in the FHO/FHT group. There will be expectations to have same day or next access to services by a member of the FHO team for time sensitive conditions (not yet defined). And my favourite, an “aspirational” target of 88 patients’ visits per week (60% in person) for 1,300 patients per doctor not attributed to the FHO/FHT group. This has been calculated by my friend Dr. Adam Stewart at around 3.5 patient visits per year (double the amount of work presently being done) and in my estimation “aspirational expectations” of 30 hours of clinical time (20 minutes x 88 patients) and typically an additional 20 hours of paperwork time (roughly 67% of the clinical time) for 1,300 patients. Virtual care For virtual care, it is being proposed that for comprehensive (defined as patient seen in person within 24 months, or signed a patient enrollment form or sent as a referral to a GP-focused specialist) virtual care there will be a reduction in its value from 85-95% for phone services, and paid at par for verified video services. There are no obvious concerns for fee-for-service family doctors, FHG/comprehensive care model family doctors and focused care designated doctors except in the aspects of virtual care limitations. If you work walk-in medicine then your limited virtual care consults by video will be $20 and by phone $15. It is only limited if the patient has not been seen in person in 24 months, not signed an enrollment form, or not referred for GP focused consultation and care. So this will likely only restrict corporate or walk-in virtual care until they find a way to get around it. I imagine they will ask patients to fill out an electronic enrollment form, charge fees or ask patient to be seen in-person annually. Virtual urgent care centres continue until Sept. 30, 2022. The down side uncertainties are based on “commitments without plans” for the following: There is a “commitment” to implementing OMA’s FAIR relativity model which re-confirms that specialists will continue to get 7% extra income per year of their training or 21% higher incomes compared to generalists. This is because specialists on average train for three extra years to get their Royal College certification. This FAIR model does not accept any extra or ongoing training generalists take, any value to the healthcare system for preventing or delaying disease, any proven comparator groups for this 7%/year estimated premium, and that some Royal College specialties now have shorter programs. There is a “commitment” to modernize the schedule of benefits to take steps to achieve gender pay equity. This is a massive issue that continues to pay women doctors about 30-35% less for the exact same work or their male counterparts. There is no plan. There are no deadlines. There is a “commitment” that all permanent payment increases will be allocated 25% to the base payment of all section/groups and 75% allocated in direct proportion to the CANDI/RAANI composite score. There is a magnitude of 100-200% differential in income between physician groups. The example is a 1% increase lowered to 0.75% increase on a family medicine code A007 $36.85 x 0.0075 is 28 cents increase vs. the 1% fee lowered to 0.25% on an ophthalmologist cataract extraction fee #E140 $397.75 x 0.0025 is 1 dollar. I cannot see income disparity (otherwise known as relativity) to be settled in the near future. Dr. Alykhan Abdulla is a family physician and the medical director for the Kingsway Health Centre in Manotick, Ont.

No obvious concerns for FPs in Ontario's PPSA fee deal save the 'commitments without plans'

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