Is fee-for-service on the way out for Ontario FPs?

Barbara Sibbald

CMAJ 1999;161:861

In a bid to provide more comprehensive care for Ontarians while improving doctors' quality of life, the college is proposing a revamped primary care system that emphasizes prevention and treatment and features a multidisciplinary group-practice team that offers "24-7" service.

Although they were initially critical of the proposal, the Ontario Medical Association (OMA) and the Ministry of Health are now talking to the college about its ideas. Even the federal government has expressed interest. The college has invited more than a dozen organizations, including the OMA and a nursing group, to discuss its paper, Family Medicine in the 21st Century: A Prescription for Excellence in Health Care (www.cfpc.ca/ocfp). The final version will be presented to the college board in November.

"Some ideas are new and possibly revolutionary, but they need to be assessed and to evolve," says the college president, Dr. Walter Rosser. "It's ongoing work that will take at least 5 years to get in place."

The proposal calls for a rostering system in which patients register with a single family practice that has from 7 to 30 physicians, plus nurse practitioners and other health professionals such as physiotherapists. All the professionals in a practice wouldn't necessarily be in a single building — they would be linked electronically into a virtual group that will serve the same patient population. Together, says Rosser, they will provide patients with a "basket of services" ranging from obstetrical to palliative care that a single FP could not provide. Working in a practice network will also mean less on-call time for FPs and more opportunities to take time off. (A somewhat similar system, based on "independent practitioners associations," is already operating in New Zealand.)

Physicians would be expected to see large numbers of people for very short periods (6 to 10 per hour). The practice networks would also provide 24-hour phone triage and other expanded services designed to reduce pressure on overcrowded emergency rooms. In addition, the college proposes province-wide electronic records, such as those now being implemented in the UK.

Blended payments

Instead of paying doctors a fee for each service they perform, the college advocates a new "blended" payment that incorporates a base salary, overhead costs, incentives for providing needed services and a payment based on the amount of work done. Presently, 92% of Ontario's 12 000 FPs receive fee-for-service payments. The college, which represents half the physicians, argues that this model doesn't provide any incentive for comprehensive or community care such as hospital work, home visits and obstetrical services, which take considerable time but provide relatively low payments.

Rosser says blended payments have been "received quite well" by members. A survey indicated that although 90% preferred the fee-for-service system, 80% would accept blended payments. This system provides doctors with the stability and security they crave while "rewarding them reasonably" says Rosser, the chair of family medicine at the University of Toronto.

The OMA and provincial government initially criticized the proposal, saying it mimicked their own pilot projects. Not so, says Rosser. Those 5 projects are based on a roster system and do offer physicians different methods of payment, but the similarity ends there. "Our proposal is more comprehensive. We're reorganizing the whole system and integrating doctors with the hospital and public health. . . . The existing system is too fragmented. There's no coordination."

A survey of 300 Ontario adults conducted for the college by Market Facts Research found that 79% support the proposed system. In addition, 81% of respondents said they feel positive about family doctors working in teams to deliver service.

Shortfall of about 700

The college paper also expressed alarm at the declining numbers of FPs in the province. In 1980, about 1000 doctors became FPs in Ontario; in 1997, only 187 moved into the field. Rosser estimates that Ontario faces a province-wide shortage of 700 FPs; a provincial fact-finder is due to report on the shortfall this fall.

Rosser says it's hard to predict the number of FPs needed in the future, particularly because the college proposal calls for an increase in the number and use of nurse practitioners.

Despite this, the report recommends making it easier for out-of-province and out-of-country doctors to set up practice in Ontario, and calls for an increase in the number of spaces at medical schools for family-practice students. The ratio of specialty to FP first-year residency training positions, currently 62:38, should become a 50:50 ratio, the college says.

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© 1999 Canadian Medical Association or its licensors