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Prompt Re-examination of Value of Family Doctors
Re: "Top
10 Questions," an interview with Dr. Ruth Wilson
July 30 issue of the Medical Post.
Unfortunately,
despite the Medical Post's attempt to clear the air,
the Coalition of Family Physicians of Ontario remains deeply
concerned about family health networks (FHNs).
Dr. Wilson
starts by saying we "just need some incentives and practice
supports and improvements to 24/7 access." We're glad
Dr. Wilson agrees with us, but her answer is a new bureaucracy;
the COFP wishes improvement of our existing system.
Dr. Wilson
defined the FHN payment scheme as a "blended approach
(that) allows FHN physicians to receive a sustainable increase
in remuneration if they provide broad-based comprehensive
care." The payment scheme consists of the base capitated
rate and incentives and bonuses to encourage comprehensive
care.
The capitated
figure of $96.85 is based on OHIP billings for work done by
family physicians. This figure is then used to provide the
basis for FHN remuneration, which is supposed to encourage
comprehensive care.
If FHNs were to be set up to fairly pay for comprehensive
care, then the billing analysis should have been of practices
that are deemed to provide comprehensive care, not of the
OHIP billing submissions in general. By Dr. Wilson's "definition,"
FHNs are to encourage delivery of comprehensive care, which
implies the care generally provided is not comprehensive.
Yet, the OHIP billings for all care have been used to determine
the value of FHN comprehensive care!
Is Dr. Wilson
stating that the extra ("bonus") fees FHN physicians
are eligible for are the only things that separate current
care from the more desirable comprehensive care? If so, there
are simpler solutions than creating an entire new bureaucracy
that requires a 71-page legal contract.
It is our
understanding that physicians who sign an FHN contract agree
that:
The care they provide their 2,401st patient is worth less
than any prior patient.
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They
accept the concept of a limitation on their practice.
What if the roster size is reduced in the future? What
if you are not permitted to discharge enrolled patients?
The Ministry of Health and Longterm Care (MOHLTC) gets
full care for half price!
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They
should be financially penalized if a patient seeks care
outside the FHN, even if they made themselves available—no
patient accountability.
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They
accept additional legal liability not covered by the CMPA.
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They
will provide the ministry with their practice profile
in exchange for an additional 10% in fees ("shadow
billing"), a potential legal nightmare.
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They
will even assist economic development in Ontario!
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The preamble
states: "And whereas the parties wish to encourage the
establishment of family health networks in order to assist
economic development in Ontario through the provision of more
comprehensive care in areas where this is needed" (emphasis
added).
In personal
communication, Jim Simpson, OMA general counsel, acknowledged
this "is an unusual provision," which, in his opinion,
"does not impose any obligation," in that the preamble
is not binding but is used to interpret clauses in the agreement
if they are ambiguous. With all due respect, this clause is
in the contract. Why, Dr. Wilson? How will government lawyers
use this clause in the event of any dispute?
Dr. Wilson
agrees the base rate of $96.85 is about 25 cents a day. She
goes on to say this represents "what is being paid now."
Is this her justification for perpetuating poor pay?
I was at
the special OMA council meeting where I heard many concerned
physicians ask questions that were not answered. I personally
asked about legal liability. My line of questioning was terminated,
ostensibly in the interest of time.
More questions:
What does the CMPA think about FHNs? Why does the April 2002
CMPA "Info Letter" include a focus on indemnification
clauses? Mere coincidence, as I was told in a personal communication?
That Info Letter warns clearly that the CMPA will not consider
itself bound by one-sided indemnification clauses in contracts
signed by doctors. Write the CMPA and ask for a copy of the
letter sent to Dr. Elliott Halparin Nov. 6, 2001. The major
issue is breach of contract. Does the CMPA cover you?
What does
the OMA legal department think about FHNs? Write the OMA and
ask specifically about the Nov. 5, 2001 OMA Legal Department
Memorandum, along with any other questions you may have. (You
should have many!)
That memo
documents legal concern about circumstances in which FHN physicians
could be bound "even after the Agreement is terminated
and payment thereunder ends." By the way, the memorandum
points out there exists a situation that could "limit
the rights of physicians to withdraw from their FHN agreement."
In an open
letter to Ontario family physicians, found in the Ontario
Medical Review December 2001 issue, Dr. Ruth Wilson wrote,
"This new template goes a long way toward addressing
our need for fair compensation. We'll be paid properly for
the care we've always given. . . ."
Was Dr.
Wilson saying we have been providing comprehensive care, just
not getting proper pay? In the same month, Enbridge offered
365 days of coverage for my furnace for $99.95. This figure
does not include the equivalent of a "general checkup,"
which brings the cost up to $174.95 for the year!
So where
does this place the value of a family physician in the eyes
of the architects of the FHN program?
—Dr.
Allan Studniberg, vice-president of the Coalition of Family
Physicians of Ontario.
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