To All Ontario Family Physicians
June 16, 2003

Don’t Be Duped!

FAMILY HEALTH GROUP CONTRACT:

A FLAWED RESULT FROM A FLAWED PROCESS

Many of you who are in fee-for-service (FFS), may be struggling with the decision of whether or not to form FHGs.  We hope the following will help as you decide what is in your best interests.

Signing on to FHGs Weakens Our Position for Negotiating a Proper Deal

What The COFP Suggests You Consider Doing

We recommend that family physicians do not sign FHG contracts as negotiated by the joint OMA/MOHLTC Physician Services Committee (PSC), until an adequately compensated and properly negotiated model, based on our Comprehensive Care Network and the OMA SGFP (Section of General and Family Practice) proposal is developed and ratified by family physicians.  The COFP recognizes that a properly negotiated contract is fundamental; and central to the negotiations with whichever government is in power for the 2004 Master Agreement.  We will continue to fight for the rights of family physicians.

We are very much aware that sitting tight is not easy when we are all struggling to keep our practices viable.  However make no mistake, if large numbers of family doctors accept this seriously flawed contract in haste, then there will be no incentive for the OMA/MOHLTC to pursue proper negotiations in 2004 for us.  In other words, if there is significant signup to FHGs, the burdens we struggle with daily will not be lessened but compounded, and the discipline of family practice in Ontario will continue its steady decline.  If you sign up for the small incentive, then that is likely all that you will get for years to come.

Points to Consider

1. We are all aware that demand for our services continues to rapidly outstrip supply.  By signing on to FHGs, family doctors will be inadvertently weakening their substantive negotiating position.  There is absolutely no reason for family doctors to accept a pittance for comprehensive care and on call services; at the precise moment when their existence has been recognized as being worthy of compensation.   Our consultant colleagues have done well without being compelled to sign medical services contracts or being required to be managed by yet another bureaucracy.

Why must Ontario family physicians sign a legally binding service contract to receive any significant increase from our current dismally low funding level when our specialist colleagues receive one without having to sign such a contract?  Especially as that ‘increase’ does nothing to address the huge disparity of net income between FPs and specialists.

Average Family Physician net income is only at 55% that of Specialists*

*Based on the SGFP Section presentation to the OMA Board OMR Jan 2003, Table V, page 23

2. For many family doctors FHGs may give the illusion that they are a relatively painless way to perhaps increase gross billings.  At first glance it may seem foolish or counterintuitive to sit tight when we are all struggling to keep practices viable.  Yet the argument that "We are already doing it, so why not take the money?” does not justify giving away (see below) the value of our services by signing a binding service contract that as yet has not had a proper legal analysis made available.

3. The current government has shown no commitment to make family medicine in Ontario sustainable.  The COFP recommends that family doctors ignore the current government’s offer and demand a proper negotiation with whatever government is in power when the 2004 Master Agreement is negotiated.

4. Remember, there can be no real negotiation possible unless one is willing to walk away from an offer that is flawed and should be substantively improved.

Background Facts You Should Know:

1. The OMA Board signed the 2003/4 Memorandum of Agreement with the MOHLTC to create FHGs before it was even presented to OMA Council.  They also did this without proper consultation with the Section of General and Family Practice.  Neither Council nor the Section was even aware of the FHG contract entity prior to the OMA Board approval.

2. At the time of this bulletin, the OMA has not made available to its membership a legal analysis of the FHG contract.  (Does one exist, or was one available at the time the contract was signed by the board?)  No one should sign this contract without a PROPER legal analysis.

3. With regard to FHGs, the OMA Section on General and Family Practice, in its newsletter, has recently advised its membership; “This is insufficient funding to sustain existing comprehensive family practice care or to attract medical students into family medicine”.

4. The OMA Council was not given the opportunity to vote on the Re-opener terms.

5. FHGs are a dramatic change in the doctor patient relationship and Family doctors were never asked to ratify or approve this new funding model and the associated legal contract.  FHNs were similarly introduced without the approval of family doctors.

6. FHGs will be operating under the auspices of another government bureaucracy, the Ontario Family Health Network (OFHN) that currently manages and promotes Family Health Networks (FHNs).

Introductory summary

The re-opener: only provides for an insulting increase for family physicians in FFS; totally inadequate recognition for comprehensive patient care in FHGs or FFS; opens the door for MRC audits on FHG doctors; and provides no basic contractual necessities such as an objective dispute resolution and renegotiation conditions.  Read on…

The Good:

1. There is recognition that family doctors who provide continuing comprehensive care should be compensated more appropriately for their increasingly demanding and complex work. There are a modest 10% add-on to the most frequently billed family practice codes and another 10% for office billings from 5 to 8 pm and weekends. These bonuses apply only to rostered patients.

2. Bonuses are offered for patient sign-up and for achieving target numbers of vulnerable patients suffering from a few significant clinical conditions.

3. Bonuses are available in return for mandatory on-call duties.

The Bad:

1. All the good is actually bad.  The value of the recognition for comprehensive care is a token; the bonuses for sign-up and vulnerable patients are meager; and the after-hours bonuses fall flat in comparison to industry standards of 50% for after-hours work.  There is precedence in the Schedule of Benefits of a 45% premium for surgical assists and anesthesia during evenings and weekends; with no increased overhead costs involved.  FHG after-hours clinics will have an increased overhead cost: yet the premium is only 10%.

2. There is no specific targeted funding of the family physician’s work of co-coordinating care and managing the patient’s master medical record.  Such funding was an essential and central defining feature of both the SGFP and COFP models, and would have been instituted with an appropriate monthly comprehensive care/case fee.

3. There is no provision for a dedicated Comprehensive Care Code or for pensions.

4. Each FHG doctor must sign a medical services contract with the MOHLTC and the OMA.  In the SGFP and COFP model, all that was required was that patients sign a simple declarative statement identifying the family doctor to whom the funding for comprehensive care would flow.

5. Such penalties that might be imposed by the MOHLTC on FHG doctors for perceived contractual breach are not specified.

6. The FHG doctor may refer any disputes only to the co-signatories of the FHG contract; namely the OMA and MOHLTC who make up the Physician’s Services Committee; the same people that the contract is signed with.  There is no objective process for a physician to contest a dispute.

7. The FHG contract can be changed by the PSC (OMA/MOHLTC) with 30 days notice. There are no constraints as to what may be amended.  Your only options are to accept the amendment, or try and exit the FHG with 90 days notice.  Exiting a FHG may not be possible without legal consequences.  Return to traditional FFS is not the Minister of Health’s “expectation” (see below).

8. FHGs give the illusion of offering an additional 10% on gross, which could flow to net income.  Careful consideration of the variables demonstrates that this increase may not be attainable because there will be increased administrative and management costs associated to operate a FHG.  There will be costs associated to keep track of rostered patients and the billings on them.  Furthermore, any increase is only generated on rostered patients; the patients who are not rostered will not generate an increase; so, only a proportion of the gross will be getting the 10% addition.

9. Any FHG financial benefit will also be variably offset by an insufficiently compensated overhead cost associated with both rostering of patients, and providing after-hours services.  The FHG contract mandates your provision of after-hours services; and you will likely be required to keep your office open longer hours than you do now, with an associated increase in overhead costs.  

10. Small FHGs are particularly vulnerable to being unable to meet contractual commitments.  There are no provisions for reduced After-Hours coverage, as a result of physicians’ being unable to work because of, vacation, maternity/paternity leave, personal, or unexpected health reasons.

The Ugly:

1. Once a contract (such as for a FHG) is signed, then you are obliged to honour each and every term of the contract.  The signed contract sets the standard for future contracts.  Only minor improvements may be possible in future negotiations.  If you sign it, then this is what you are stuck with.

2. The FHG doctor has accepted a specific job description with contractually defined service provision; guaranteeing an extensive array of clinical services, as well as 24/7 availability; without proper safeguards, resources, benefits and remuneration.  One signs away their autonomy for a pittance to enter a seriously flawed contract.

3. The FHG contract runs until 2007 before there is any renegotiation.  Any aspect of this contract can be unilaterally amended by the PSC with a 30-day notice.  This is unheard of in contract law.

4. The variability of possible interpretations for fulfillment of FHG contracts easily opens the door to a potentially very worrisome MRC type audit.  Recall that the contract obligates you to provide a specified level of care, which could be unattainable under certain interpretations.

5. The FHG doctor will now report to yet another bureaucracy, the Ontario Family Health Network.  This is the same bureaucracy that manages and promotes FHNs and has been oblivious to the concerns of grassroots physicians.

6. Reverting back to an increasingly under-funded FFS may not be a viable option in the years to come.  It is important to recall Health Minister Tony Clement’s words to the April 2003 OMA Council “…the bad news is this—if you sign on for a FHG (Family Health Group), there is an expectation that in the future you will be voluntarily moving to a FHN (Family Health Network)…”

THE KILLING PILL-THE REST OF THE RE-OPENER

A) The 2003/4 increase in FFS above the mandated 2% is an insulting 0.5%.  The purpose of the Re-opener was to apply any increase economically mandated above the stipulated 2% that the master agreement already provided.  The PSC only allocated one significant increase to FFS physicians who do not enter into FHGs or FHNs: a 4.4% increase to A007 on August 1^st.  Adjusting for this partial year, and that A007s are only a portion of an FP’s billings, the increase works out very closely to 0.5% over the mandated 2%  (i.e. 4.4% X 2/3 yr X estimated 85% billings = 2.5%).  

B) What does this mean?

o Given the huge net income disparity between FPs and specialists and;

o in light of the greater proportional increase for FFS given to specialists and;

o increases are minimal for both FHGs and traditional FFS comprehensive care:

That although the OMA indicated support, and obtained at least minimal recognition for FFS comprehensive care, the PSC negotiated a contract for us with the government that; will make FFS comprehensive care unsustainable and; attempts to beguile traditional FFS comprehensive care family physicians into signing a seriously flawed contract.  Unfortunately for FFS family physicians: the OMA Board chose to accept this contract; without proper consultation with the Section of General and Family Practice and, without requiring that it be voted on in council or ratified by the membership; and there is no proper legal analysis available for the membership.

THE COFP RECOMMENDS THAT YOU DO NOT SIGN A FHG CONTRACT

Douglas Mark MD, President Allan Studniberg MD CCFP & Christopher Pinto MD, Vice presidents

and the

Executive Committee of the Coalition of Family Physicians of Ontario