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The Coalition of Family Physicians will be periodically issuing to all Ontario family physicians, a Family Practice Advisory, which will assist them to take into account and plan for the current and anticipated community family practice environment. The creation of such an advisory is necessary at this time to give our colleagues direction as to the adequacy of resources required to provide for comprehensive continuing family practice in these confusing and stressful times.

During the past year, both the OMA Section of General and Family Practice (SGFP) and the COFP independently developed solutions to the Family Medicine crisis – new payment models that would recognize and reward the provision of comprehensive care. The intention of both the SGFP and the COFP was to make available a new comprehensive care funding formula as an expansion of traditional FFS and also as an alternative to FHNs (the government’s primarily capitation-based funding mechanism). It was not surprising that the COFP’s model was remarkably similar to the SGFP model; both are solutions based on fee-for-service, simply understood, quickly deployable, robust, sustainable and likely to find widespread favour with grassroots family physicians. The OMA Board presented the SGFP model to the Physicians Services Committee (PSC), a committee of OMA and MOHLTC representatives, for consideration during the 2003 “reopener” negotiations for the final year of our contract. The negotiations resulted in a new completely different PSC version funding formula that has been released as Family Health Groups (FHGs).

Inexplicably, the OMA Board signed the 2003 “reopener” Memorandum of Agreement with the Ontario Government just days before Council was due to meet. The OMA Economics Department provided the Board with an analysis of the agreement, but the Board prohibited prior release of this document. Council had no meaningful opportunity to discuss this entirely new model. FHGs and FHNs represent the most significant change in our practice environment in the last 35 years. Incredibly, as with FHNs, there was no ratification by family doctors and there was no approval from Council.

Specific issues and concerns with FHGs

1. The PSC negotiation resulted in the cherry-picking of the SGFP model. There are critical omissions including the essential items that define the model. Most notable is the absence of monthly Comprehensive Care Management code that is adjusted based on patient age and gender.

3. The main attraction of the FHG is the 10% bonus to a number of fee codes for rostered patients. Further increases for the duration of the contract will only mirror increases in FFS. There is no provision for renegotiation until 2007.

4. On-call payment works out to $2.00/hr per FHG group ($4.00/hr groups of 10 or more).

5. Telephone Health Advisory Service (THAS) 24/7 response mandates “access to a Group Physician.” The nature of this coverage can be changed with a 30 day notice - see below.

6. FHG physicians enter into an agreement with the OMA and the MOHLTC. The dispute mechanism is such that any problems will be referred back to the PSC, which of course includes the MOHLTC and the OMA itself, an obviously nonsensical arrangement. The prospect of referring a dispute back to the parties with whom you have an agreement, with no binding arbitration and no consequence to the other side, is alien to all known contract law.

8. The FHG doctor has a contractual obligation to “provide or arrange to provide” an extensive array of services. The FHG doctor must ensure he or she has the staff and infrastructure and stamina to guarantee all of the contractual obligations. FHG doctors take on more, entirely new, legal and service obligations at continued deeply discounted prices.

9. To truly restore an appropriate funding level, the COFP maintains at least a 40% increase is required in family physician funding.

"Hey, I do this stuff and they're offering me more money; so, why not sign up?"

The obvious question for those many family doctors who provide comprehensive care services is; “Why refuse any additional money that might be offered?” The COFP recognizes that many physicians are in no position to refuse any financial inducements. A starving person will eat moldy bread at the risk of getting sick. It is critical to carefully consider exactly what you are trading away for a nominal increase in income. You are trading your professional autonomy and acquiring legal risk.

OMA officials tell us that the average comprehensive care FFS doctor will realize about $17,000 or so with FHGs. An average practice may well be about 1700 patients; so, a ballpark estimate is that a FHG family doctor will see an increase in income in the area of about $10 per patient per year over FFS (assuming no increased overhead being accrued).

Under the SGFP/COFP models, there are no legal contracts for doctors to sign. The only piece of paper to sign would be a simple declaration by patients confirming the names of their family doctor. These doctors would provide these patients continuous comprehensive care and receive appropriate remuneration. If the patient were to become dissatisfied with the care provided, then the patient would have every right to leave that practice and seek care elsewhere. This type of arrangement allows for healthy competition and encourages quality care.

In contrast, the FHG doctors enter into a contract with the OMA and MOHLTC that is binding on the physicians, but can be unilaterally amended with only a 30-day notice. The FHG contract requires a commitment to a detailed and extensive list of service expectations. These expectations are still open to interpretation. Remember, the very same people who created the contract will arbitrate any dispute you may have.

2. Create a FHN: the FHG doctor may feel compelled to listen to the Minister of Health Tony Clement who recently spoke to OMA Council stating, “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). Once you assess your role in FHG you have a choice of moving off that back to the pre-FHG world or you have an option to move forward to a FHN. I’m not here to sugarcoat it. I’m not here to perhaps say to you what you want. I’m here to tell you the straight goods. So when I say stepping-stone, I mean that you have voluntarily made a commitment that you would either move up or out when you are in a FHG.”

It is for these reasons that the COFP feels it necessary to advise family physicians that the stability of the comprehensive care environment is now so severely compromised that prudence dictates that each physician consider minimum protective measures be undertaken as outlined in the Family Practice Advisory.

Family Health Groups allow family physicians to obtain limited additional funding from the MOHLTC. Clearly, FHGs do not adequately compensate continuing comprehensive family medical care. FHGs have shortcomings as described above. To go beyond the meager FFS increase, the reopener singles out family medicine as the only specialty required to sign a legal contract. The reopener provides marginal incentive for established FFS practitioners to continue providing continuing comprehensive care. It will not reverse the profound lack of interest in family medicine by medical students. Lastly, it will not assist the majority of the 900,000 Ontario citizens currently searching for a family physician.

We are deeply dismayed that the OMA/MOHLTC negotiating team did not properly incorporate the grassroots solutions made available to them by the OMA Section of General and Family Practice and by the Coalition of Family Physicians. The Family Medicine crisis continues.

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