Ontario has a new way of measuring how hard family doctors work. What does it mean for doctors and their patients?

he new “Continuity of Care” measure included in the new agreement between the Ontario government and its doctors has good intentions but comes with severe penalties and without necessary checks and balances. Without changes, doctors who become ill will be financially penalized; doctors who provide extra services such as after-hours care or diabetes or palliative care will be at risk. To protect themselves, doctors will remove patients from their lists, restricting patients’ access to care.Luckily, a lot of this damage can be prevented if the Ministry of Health and doctors work together to create a better system under the new framework.This past summer, the Ontario Medical Association (OMA) proudly announced an improved compensation model for Family Doctors called FHO+. FHO stands for Family Health Organization and is the dominant payment method for Ontario’s 15,000 family doctors. In this model, doctors are paid predominately by the year for each patient on their list (roster) instead of by each visit.The “new and improved” model (hence the +) was developed in conjunction with the Ministry of Health. It is intended to improve funding for family doctors and stop the death spiral in the numbers of doctors interested in practising family medicine. The cooperation between the OMA and the ministry was impressive given they were in the midst of arbitration on a three-year agreement.There are things to celebrate in this model. These include an hourly wage for family doctors on top of being paid yearly for each patient. This helps recognize the increasing administrative burden family doctors face. The deal also replaced the old way of measuring how hard doctors work called the Access Bonus, with a new measure called Continuity of Care. This is where the trouble with the agreement lies.The Continuity of Care measure is fairly simple. Every month the Ministry counts the number of times a selection of services called In Basket services are performed by the doctor or another group member. This is called inside use (good). They also count the number of times a patient is seen by an outside doctor not in the group. This is outside use (bad). The ratio of In Basket Services/Total Services is the Continuity of Care Measure. With this the ministry can tell if a doctor is providing enough services (inside use). Are they preventing their patients from going to outside doctors (outside use)?Both sides agreed that this measure, though flawed, is the way to proceed. They could not agree about what the acceptable limits for the ratio should be and what consequences would result from failure to meet those limits. That question was sent to the arbitrator who had complete discretion to decide how the new measure should be implemented. The ministry recommended that doctors should be forced to provide four In Basket services for every outside service (80% ratio) or suffer a 20% penalty of their salary for three months. The OMA suggested 2.66 In Basket services for every outside service (70% ratio) and at most a 10% penalty. Arbitrator William Kaplan, in true Solomon-like fashion, split the baby in half—three In Basket services for every outside service (75% ratio) and a 15% penalty. This is significant money. The penalty for an average doctor who is consistently below 75% could be more than $40,000 dollars a year.This represents the first time that an entire group of Ontario doctors has faced a significant penalty for failing to perform up to snuff. It is a sea change and should have deserved careful attention. Unfortunately, Kaplan is not Solomon and said nothing about the process or checks and balances. He created a bludgeon, a significant financial penalty without any administrative controls or due process.Another problem is how the ratio was defined. The parties chose for no apparent reason to only include In Basket visits provided by the doctor, not all visits provided by the doctor. The list of visits included misses out on crucial services such as afterhours care, afterhours calls, diabetes care and palliative care—the essence of continuity of care in family practice. They are exactly what the government is begging doctors to do. Yet, they are ignoring them. This unfairly penalizes a lot of very dedicated doctors.Here is an example: Suppose in a month a doctor provided 300 visits of all kinds, of which 240 were In Basket and the other 60 were not (such as palliative care, diabetes and seeing patients on weekends). There were 100 patient visits outside of the FHO as well.If all visits are included: 300 inside visits/ 300 inside +100 outside use = 300/400 = 75%. The doctor has no problems.If only In Basket are included: Subtract out the 60 visits for palliative care, diabetes and working weekends there are only 240 visits left. 240 inside visits/240 inside+100 outside = 240/340 = 70.5%. This doctor owes $9,000 in penalties for doing a better job!So, now doctors are faced with a system with no checks and balances that penalizes doctors for providing valuable and necessary services such as palliative care and diabetes care.Now doctors can face scenarios in which failure to meet the criteria by one patient can cost the same penalty as a doctor who fails by 500 patients. Is this fair or just?Where is the place for compassion? For example, I know of a doctor who went out of country for a week, became ill and was unable to return for two months. The same Ministry of Health official that would get paid disability if they were sick would give that doctor a hefty fine. Why did the arbitrator not insist on an appeals process when introducing such a dramatic consequence?The government estimates that 15% of doctors are likely to have problems under the new measure. Of course, doctors close to the penalty threshold and those who are generally concerned will begin to practice defensively as well. Overall, we would expect that 25-30% of doctors and their patients will be affected. This represents millions of patients.So, how does this affect the patients of Ontario?The continuity of care ratio in the new agreement has two parts—inside use and outside use. To stay safe a doctor can either increase In Basket services or cut down on outside services. To maximize the number of In Basket services, a family doctor can see a patient more often by limiting patients to the dreaded one issue per visit. Services that are simple, such as script renewal, now done remotely will be brought back to the office, leaving less time for more intense or useful services such as palliative care. Along with other incentives in the new model, more visits adds up to more income. A financial win for doctors but a loss of quality and convenience for patients.The best way for doctors to keep out of trouble is by limiting outside use. Every month, doctors get a list of which of their patients has seen an outside doctor. They then decide to either leave the patient on their roster list or remove them which gets rid of the outside use. If they remove the patient from their list, the patient loses privileges such as on-call doctors, and any nursing, pharmacist, social work or other services attached to the practice.Most of the time de-rostered patients are kept in the practice and not dismissed completely. Under the old agreement, this was true for several reasons. First, most doctors are nice people. Second, when the patient actually came in, doctors were paid in full to see them. Third, for most groups there were no restrictions to how many patients could be seen outside of the roster list. Finally, they hoped at some point to put the patient back on their roster list.Under the new contract, several things have changed. First, penalties are of greater concern, which makes nice less possible. Second, the new agreement pays a base hourly salary but only when seeing rostered patients. Non-rostered patients are now of little monetary advantage. Finally, the government now has the right to place an individual cap on how many services a doctor can provide to non-rostered patients, which could restrict how many non-rostered patients a doctor can carry. Now, it may be necessary to remove a patient completely from the practice.It would only be fair that doctors carefully monitor patients for a trend of outside use before removal. In fact, that is what the 2005 FHO agreement requires and what patients deserve. Doctors used to have six months to make this decision. The government reduced the amount of time to three months. Three months in reality translates to no time at all as doctors don’t detect the first outside use for at least one month. This forced doctors to make snap decisions to remove patients. Letters to the ministry suggesting that a three-month limit for this one code is too low and hurts patients, doctors and the government have been ignored.So, what is next? The Continuity of Care measure is due to start in April 2026. It is our hope the two parties will sit down and work out a fair and equitable way of balancing out the need for accountability and the effects that this measure will have on doctors, patients and the government’s goal of enrolling more and more patients.The two parties should:Give doctors six months to make up their minds about removing patients from their roster. This way they can see if the trend to a lot of outside use is temporary. This will mean better decisions from doctors and will keep them connected with their patients. The measure should capture all services relevant to continuity of care. This includes working weekends, palliative care and others. I believe they were excluded due to a lack of understanding of how outside use works.Recognize that the Continuity of Care measure is a measurement of virtue. It measures hard work in providing services that demonstrate a 24/7 dedication. It is not a monetary-based measure like the old access bonus. If we are going to fine people for not being virtuous, then the system should be fair, transparent, logical and compassionate. Add a one-two% fudge factor to what percentage is acceptable to allow for errors and variation. Consider a graded penalty, especially at the beginning. Create a panel that doctors can appeal to for unusual circumstances such as disability or illness. In the legal system, a speeding ticket is not given out for going one kilometre over the limit, the fine for 10 kms over is less than the one for 50 kms over and everyone has the right to meet with a prosecutor or judge to explain what happened. Why should doctors be denied basic justice?Continue to allow doctors the freedom to share their limits for the number of non-rostered patients they can carry with their colleagues who need it more. This is one way of keeping these patients attached to the doctor if not rostered. Otherwise, these patients may lose their doctor completely.Both parties have the ability to build on the framework provided by the arbitrator and turn the Continuity of Care measure into something that works for doctors, patients and the government alike.This article first appeared in Healthy Debate.Dr. Franklin Sheps has practiced Emergency and Family Medicine in Northern Toronto for more than 30 years. He is the group leader for the North Bathurst Family Health Organization.

Ontario has a new way of measuring how hard family doctors work. What does it mean for doctors and their patients?

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