After 10-12 years of university, medical residents master survival skills under incredible pressure. Marching towards the end of training feels like walking to the deep end of a swimming pool. It gets really hard. You drown in debt. But you know the end promises a rapid rise to the surface.
At least it used to. The Ontario government cancelled multiple programs for new graduates. It rationed entry into capitated practice models essentially eliminating them for most grads. ‘New patient’ enrolment fees and 1st year income stabilization were axed (the only source of income in capitated models). See Scott Wooder’s blog for more.
We all hope that some of our best students will sacrifice their youths in training to become physicians. Thoughtlessly slamming the door on any meaningful hope of using your training in Ontario for the next few years is callous and cruel. And it destroys a vital resource that compromises the care of those who need it most.
Listen to what residents and medical students have said on this blog and in email:
Mike says:
“I’m a soon to be family medicine grad and I’m just so upset with the changes our government is proposing. New grads doing family medicine who hoped for income stabilization during their first year will likely lose anywhere from 30-60% of what they would have earned. Like most people I have a new mortgage and bills. Unlike most people I have $200,000 of debt and have made numerous financial sacrifices to get to where I am with no pension, vacation pay, benefits or paid vacation in my future. My income needs to account for these.
Unfortunately, this policy has consequence that will fall on patients. I won’t be able to go out and start a family health team and roster patients. This won’t allow me to balance my books – there’s no incentive now to be a good family doctor. Instead I’ll have to do rushed fee for service walk-in and ask patients to only bring up one concern per visit. This is not what I got into medicine for.
Additionally, our most vulnerable patients who are so complex are having their attached health care dollars taken away. I worry that they will have a harder time getting care. Taking away any incentives to do after hours and weekends is going to push everyone into the emergency rooms where it costs 10-20x as much to treat them there. These policies are short sighted….
It’s a bad time for new family med grads and I hope our future is brighter and family doctors, and physicians in general, can really be part of the solution for optimizing care and reducing money in the system without impacting patient care.”
Matt says:
“As a R2 in family medicine I feel exactly the same as Mike. The recent changes that the Ontario government is imposing on physicians demonstrates how little respect they have for our profession. Unfortunately the coverage I have seen has not brought up the changes that are going to affect predominantly new grads.
As far as I understand, the income stabilization program has been removed and new grads are no longer allowed to join FHTs/FHOs and roster patients (other than in remote regions). This forces new grads to work in a fee-for-service model.
Income stabilization is incredibly helpful for a new grad. If a new grad is building a new practice (or joining a practice) and building a patient roster, they will need several patients before they have a positive cash flow. The income stabilization program ensured that physicians could build up a practice and still have enough take home to eat and pay off interest.
Fee-for-service has its benefits and drawbacks, most of which have been mentioned above. Overall complex patients tend to be overlooked in a fee-for-service model and physicians are essentially forced to either push through simple visits (ie. refills each month to have quick and easy appointments to bill) or to find other sources of income (block fees, non-OHIP covered services) if they want to make money and take care of complex patients.
Furthermore, a quick comparison of the OHIP SOMB and other provinces SOMBs (in particular Alberta’s SOMB) will demonstrate that several common billing codes pay significantly less in Ontario. Previously this didn’t matter as much in a patient rostered type model, however, with new grads being forced into fee-for-service models this makes a huge difference in realized income.
I feel very fortunate that I have the opportunity to “vote” on the policy by simply leaving the province. As a new grad I would prefer to serve a province that respects the work and value that I bring to my community. Unfortunately, several of my colleagues are stuck in Ontario due to family and mortgages.
The Ontario government has essentially balanced their healthcare budget by picking on the group of physicians (brand new family medicine grads, usually with > $150k student loans) who can afford it the least. This is akin to the bully in the playground preying on the kid who can’t defend himself.”
Stephen said:
“The concerns I’ve heard from fellow family medicine residents and those new in practice are largely centred around the changes that restrict their ability to practice patient-centred family medicine. Many have trained in family health teams and a significant amount wish to practice in a similar model. Unfortunately, the new changes restrict enrolment in these models to high-need areas (for which there is no clear definition!). Having being attracted to family medicine for the opportunity to practice team based care, there is a feeling that the rug is being pulled out from under them. Given the significant medical debt that residents carry coupled with the fact many have already starting setting up a life and family where they trained, relocating becomes very difficult. Many new and upcoming graduates are now taking a serious look at walk-in clinics given the restricted rostering options, loss of income stabilization for new graduates, and the various financial pressures facing them.”
And again, Matt says:
“…The government is balancing the budget by refusing new graduates the ability to roster patients…
…Again, this is not the entitled generation whining for more pay. This is a generation of new doctors who are being forced to work in a factory style family practice or move provinces. Both of these will end up affecting how you receive primary care in the future.”
Kevin said:
“I am also a PGY2 in family medicine. Some of my colleagues have already outlined my situation quite accurately above, and I wholeheartedly agree with them. My three points to add to the conversation are:
1)Directly due to the manner in which the cuts will affect new graduates in family medicine many are in the process of cancelling their plans to start a family practice in Ontario. The one alternative discussed above is to move to another province, but for many this is not ideal as we have partners/children/family to consider. The second solution that I am seeing is that we are opting to do only non-office based family medicine such ER, hospitalist, palliative care etc. Personally I had planned to start my office based practice July 1st, but this has been put on hold, and I am exploring hospital based work only. Common sense tells me this will not be a savings to OHIP as patients who would have been rostered to a new physician July 1st will now continue to access expensive ER services.
2)Although I understand the sentiment, the expression “Many of us would do this job for free” is very unhelpful and furthers the divide between new graduates and established physicians. I am not ashamed of saying that I will not do this job for free, I will not even do it for the vastly reduced compensation that is now being offered. Quite simply I can’t. I have $260,000 debt from medical school, 0% of my mortgage paid off, 0% of my retirement funded, and all the same household expenses as everyone else. I love the work I do, but I am governed by the same fiscal realities as everyone else.
3)The Ministry should make public what they feel is fair compensation for a family physician. Take into account debt load, overhead costs, a hypothetical 40hr work week and standard billing codes such as A007. Show new physicians and the public how many patients I need to see each week to achieve this “fair compensation”. How many minutes does this leave for each patient? I think the results of this would be very revealing.”
Brian said:
“As a medical student in clerkship, in the process of deciding my career path, I can say that the cuts to family medicine are a significant new deterrent to choosing Family over almost any other specialty. In my experience so far, FFS practice all-to-frequently leads to burned-out, cynical docs who resent their patients for being the tiniest bit complex. The cuts will not change this for the better, and I do not want that future for myself.
I find this all very sad, because I truly believe that family medicine is the most important – and potentially most personally rewarding – kind of medicine. But financial realism creeps in, and now I find myself having to “sell out” and consider which specialties/ practice model will allow me to enjoy a reasonable lifestyle and retire before 70, rather than choosing based on what I WANT to do. As was mentioned earlier by one of the very perceptive residents, this is not what we signed up for when we decided to become doctors. This was supposed to be a vocation, not a job; a life dedicated to patients, not to paying off our bottom line just to keep food on the table….”
If you know a medical student or resident, be especially nice to them right now. Even better, talk about this with your friends, write a letter to the editor or speak with your MPP. Taxpayers shouldn’t tolerate the government playing havoc with your healthcare.
photo credit: wsj.com
In addition to residents, many graduates from the last few years will be negatively impacted. I know several new family physicians doing locums, checking out practice opportunities, starting off with a focused practice or on parental leave. Without any warning their plans to join practices have been shattered. Those now in practice that are counting on their assistance to revitalize our teams, care for our patients and for US are dismayed.
Be kind to these physicians- Ontario is looking very grim.
Of course! I totally missed that important group. Thanks so much for taking time to share you comment! It can take years to find a suitable match in a new graduate to replace a retiring MD or to join a group. I can’t imagine searching, waiting and recruiting only to have all that go to waste. Everyone loses: patients, new physician, and the group they hoped to join.
Very grim indeed.
Thanks again,
Shawn
I’ve noticed an increase in the number of retirement notices since mid-January. It seems like the physicians that have been sacrificing their retirement to provide care to their community while awaiting new grads, no longer feel that their sacrifice is appreciated.
It might be the start of a tidal wave. Politicians don’t seem to understand how much doctors value respect, autonomy, true partnership… After getting out of student debt, many doctors value the intangibles of practice far more than income. To wit, many doctors pay very little attention to what they bill or earn despite media spin to the contrary.
Thanks so much for sharing that, Ryan! With all the retirements, there’ll be no new grads to pick up the slack because there’re not allowed into practice groups.
Shawn
I and a couple other PGY2 Family Medicine residents who are doing our residency in Ontario who are from other provinces were strongly considering staying, but currently no longer. We love Ontario and the people here, but forcing us into fee for service when we all assumed the long term plan in Ontario was to reduce FFS as much as possible, is very confusing.
I suppose if the plan is to reduce capitation opportunities and also to eventually reduce our opportunities for fee for service, then are you not then just eliminating our ability to practice in Ontario as new graduates? Eliminating care for patients? I am sure the 1 million people without family physicians in this province will be in appreciation of this general non-direction of healthcare.
Lastly, one of the most concerning things about this all is that the mis-information being released to the general public to defend these policy decisions is by someone who made the same hippocratic oath as I and other intensly dedicated, and ethical, learners. This is surely not what Hippocrates had in mind.
Frank, I only hope readers take time to look down through these comments! You articulate exactly what we’ve been saying. Ontario will not be a destination of choice for physicians at all. I echo your thoughts about misinformation and slander…from a fellow physician no less. We all take an oath and strive towards honesty. When we make mistakes, we correct our errors. It tarnishes us all.
I don’t blame you for looking elsewhere. You’re one of the few who, hopefully, have a relatively painless option to pursue outside Ontario.
Thanks again for reading and adding your comment!
Shawn
the problem is people who have inappropriately billed over the past decade, additionally family physicians are working less days, working less hard because they are paid based on roster size and not how many people you can see in one day.
they have been getting more money and efficiency has not improved, frankly I feel it has decreased
solution : work harder folks
its tough times for people in all job markets, it sucks but lets face facts
Interesting comment, Craig. Let’s see if I follow you. Lots of bad docs billed lots and lots of inappropriate fees and worked less and less. Now Ontario has no money. I assume you imply the bad docs and Ontario running out of money are connected? So now all the good and bad docs have to work harder. Did I get it right?
I just have to ask, do you receive a government salary?
Seriously, I must not understand your comment. You can’t possibly imply that there are so many ‘inappropriate billers’ that they bankrupt the system? I would want to see some convincing evidence of the fraud you allege. Even if your theory was true, how does “work harder folks” for lower fees, a growing population, and increased medical needs fix the problem of 900,000 patients without a family doctor?
The whole issue must centre on patient needs and access to quality care. As we’ve discussed in the last 6 posts, slashing fees causes reduces services to those who need it most. It’s got nothing to do with doctors or incomes. We will always be busy. It’s about decreased service for patients who need it.
Maybe your comment was not meant to be taken seriously. I may have missed the irony entirely.
Thanks for sharing regardless.
Regards,
Shawn
Sorry, my wife is a family doctor and works very hard. If she saw more patients in a day her 15 min appointment with you would turn into a ten min appointment or less. For every day she sees patients she has a half to 3/4 day worth of paper work, calling patients to follow up, and reviewing results. She already works five days a week (3 seeing patients, other two to make sure you get the best cafe possible by following up on everything) + weekend clinics + evening clinics (usually one of those every couple of weeks). So…how much harder would you like her to work?! We also have two young children, a mortgage and $300 K of debt.
Seems like the Liberal propaganda machine has been successful. Kudos to them for successfully misinforming Ontarians.
Excellent note, Mml. The best way to resist the “propaganda machine” is to share stories like yours. Doctors feel deeply offended/wounded/irritated by the mis-information and maltreatment. Patients will feel a different sort of distress as these cuts start to bleed.
Thank so much for sharing!
Shawn
I agree that we need to take a look at what some specialists are billing the government (ie cataracts). If it used to take 2 hours and now it takes 15 minutes, there needs to be an adjustment.
There are calculations based on the number of appt’s per day that determines what an appropriate roster size should be. The OMA also has a recommended number of hours of service per week based on roster size (1300 = 40). A problem is that many of the older FFS positions with large rosters (>3000) joined FHO/FHT – if there is a max # of patients a physician can have then thousands of people, especially in small communities, would be without a physician.
Also, in a blended model, once you meet your recommended # hours/week there is no incentive to work more hours in the office (shadow billing at 4 patients/hour is ~$14). I have a small practice (~500 patients) and I work part-time in the ER. Based on the numbers it’s recommended I work about 16 hours/week in the office (I work about 20 or an extra half day to keep wait times for routines < 2 weeks). If I am going to work more, I want to be paid for my time which means I will do ER, surgical assist, etc, rather than seeing my rostered patients.
Thanks, Ryan, for sharing your personal stats! This helps tremendously.
I offer a gentle push-back about mentioning fees that other physicians bill. Just like we bristle at comments made by those who don’t fully understand our business, we need to be cautious when we comment on other docs fees. The fee schedule has some very strange anomalies that hang on for decades. It definitely needs updating.
Again, your personal information cannot be assailed. Awesome; thanks so much for commenting!!
Best
Shawn
As the wife of a PGY1 Family medicine resident, I’m very disappointed in Ontario’s decision to force a FFS model on new grads. Having a combined household debt of over 200k (with his med school and my grad school) and a second baby on the way in June, we struggled with whether to sign the “return for service” incentive that the province offers (to help reduce debt load). However, we ultimately decided to opt out, as we wanted to ensure flexibility of job prospects. Given this most recent blantent disregard for the financial and overall well being of new family docs by our home province, I’m glad we have the flexibility to leave Ontario upon completion of his residency training.
Thanks so much for sharing this, Amanda! Stories like you just shared can change history. Seriously. This is really powerful. Please encourage everyone you know to tell their story – not ranting or arguing – but just telling their personal experience like you did now.
My heart aches reading your comment. I hope others get the chance to hear it, too. The Medical Post just asked to put this blog on their site. I’d encourage you to comment there, too, when it goes live. The more people that hear your experience, the better chance we have to see change.
Thanks again. I hope you guys find a spot to live and practice that values your service.
Kind regards,
Shawn
The elimination of Income Stabilization (IS), the decision to not allow new FHT/FHO’s to be formed in urban areas, and the elimination of the New Grad/New Patient (Q033A) roster fee all disproportionally affect new grads. The Q033A fee alone can amount to between $30,000 and $40,000 for new grads in their first year.
What is not mentioned, is that these same changes may in fact disproportionally benefit retiring physicians. With IS as an option for new grads, retiring physicians were not in a position to sell their practice, as new grads had a means to earn a decent income in their first while building their practice. Now that option is no longer there, so a retiring physician who is currently part of a FHO now has a very valuable asset that can be sold for a significant price.
It remains to be seen whether the MOHLTC will put a limit on how many new physicians can join an existing FHO, but that decision will have a very significant impact on how the changes will affect physicians currently in a FHO, and those wishing to join one.
Good point, Martha! The cuts suddenly put a huge value on rostered practices. Yet another blow to new grads. Thanks for sharing this! Shawn
although I somewhat agree with most of these posts that are essentially throwing family medicine grads, residents and locus “under the bus” I have observed that there are doctors that have taken advantage of the capitation system and certainly are not “putting in their hours” on a weekly basis seeing their patients. Most doctors I know take atleast a day off a week, and they can because of capitation. Some doctors have also derostered their patients if they are being seen too frequently because any more than 4 times a year is perceived by some doctors as them losing money. There is no doubt some degree of greed out there, most family doctors will make more than a full time community based specialist depending on the specialist. i.e. neuro, psych,
Why should the government fund their CME, no other specialist group gets this.
I do think its been quite an issue that these capitation models were put in place to make family medicine attractive and to take on patients in the province that didn’t at the time or currently have a family doctor but now the grads will leave and who can blame them with how the government is treating the established and yet to be independent practicing doctors in the province. I feel compelled to add that if the teachers think they are in for a raise, they should think again and expect cut backs in pay just like the docs.
Thank you, Sue. You raise good points!
Many healthcare observers focus on inputs, as you did. For example, “How many hours did doctors work?” “How many patients did they see?”
I suggest we focus on outputs. A major aim in capitation is to get more done for patients at each visit and to have fewer visits overall. Furthermore, primary care reform encourages telephone and email consults, quality audits of practice patterns, and a number of other activities that do not look like a traditional healthcare input. We need to find out: do patients appreciate capitation? Do they receive ‘better’ care (if we can agree on quality measures)?
Finally, governments like rostered patient models because it gives them far greater control and audit over everything physicians do. That comes at a premium. In other countries, governments have attracted physicians into capitated models then cut the funding once they got them all in.
Thanks again,
Shawn
Thanks Shawn.
I also don’t see where there has been any discussion for “patient accountability”. They will continue to book appointments for frivolous issues that perhaps didn’t warrant a visit to their doctor or to the ER for that matter. Some of the health care costs are also related to patient’s behaviour and expectations that I don’t think has been really addressed nor will this really change when the patients can ask and get what they want since they don’t pay out of pocket for services, like co-pays in the states.
So today I woke up realizing my services will be worth 2.65% less, but more importantly I feel demoralized and unappreciated by a government that got into this fiscal mess by their own mismanagement of Orange, e-health, cancelled gas plants, etc. , the list goes on !! I feel we have no control nor are we strong enough like what the teachers have with their union to get a fair deal.
You really packed in a string of great comments into one paragraph, Sue. Patient accountability, behavioural change, patient control of spending (either out of pocket or directing tax dollars), co-pays, fee cuts’ impact on MD morale, the Liberal governments string of spending imbroglios, and physician powerlessness compared with unionized bargaining process. Wow. You’ve offered enough material for 10 blog posts! All excellent comments.
For what it’s worth, the things you mention resonate with almost every physician I hear from. We can be sure of this: the combination of 2012, and the legislation this spring, will cause irreversible change to healthcare in Ontario. Our discussions here will echo and escalate over the next few years. Patients need to know. It will change things for them most of all.
Thanks so much for taking time to read and comment!
Shawn
This discussion is very informative. Thank you all.
Shawn or any commenters, are you aware of any FHO spots being sold? If so, any thought on what the going rate is? Any insights would be greatly appreciated.
Thanks.
Hello Peter,
Thanks for asking. I’ve heard rumours but have not seen evidence. I wouldn’t jump to purchase spots just yet. The whole market could change in a few months (hopefully!). As you know, most new doctors bought practices in the old days. It was a business decision: start income flowing ASAP to pay for debts. No one questioned whether it was necessary. That ended in the mid to late 1990s.
While some cry ‘foul’ at the idea returning, I do not follow the logic. A medical practice is a small business. It takes years to establish a good one. Buying a productive practice filled with satisfied patients who blend well with the physician seems to make good sense. I am still in the building phase of my small rural practice and can see why people used to buy them in the past.
Having said that, I’m too cheap to buy what I can build myself….even if it takes longer and ends up costing more!! (Stupid, I know).
Thanks again for writing. I wish you the best in these dark days. You are smart and resourceful. I’m certain that you will make a great living. It just might not be in the standard family practice setting you expected. Ontario’s loss; your gain.
Best regards,
Shawn
It is reasonable to expect that a FHO practice would be worth at least 6 months of capitation payments. When a physician transfers their roster, the other physician will receive the monthly capitation payments for the first 6 months, whether or not they see the patients. After 6 months, they will only continue to receive capitation payments for the patients who have been officially rostered to the new physician. Capitation payments typically only represent about 75% of a FHO physician’s total monthly income, and tend to be about $20K a month for an average roster size.
Thanks for this, Martha! Great comment. Residents will want to know this. s
As I have read many of the comments going back and forth I felt compelled to provide some insight. I work for a management consulting firm in midtown Toronto, Cirrus Consulting Group, that specializes in everything being discussed here. We work with individuals and groups, both in FHG’s/FHO’s/FHT’s and FFS to ensure that their practice is running efficiently and effectively. We often find that family physician in Ontario are not paying close enough attention to their ‘business’. We work closely with the physicians and their staff to make sure that they are being paid appropriately for the care they are providing. As a boutique firm, we are able to provide hands on attention to all our clients with in person meetings and access to our team of experts at all times.
I would encourage all of you that are practicing family medicine in Ontario, regardless of your payment model, to check out our website and get in touch with either myself or another member of our team to speak about your situation and ways in which Cirrus can assist you.
To get into a little more detail about the topics above – we are currently seeing a significant amount of interest for the purchase and sale of family practices in Ontario. As it was mentioned, there is value now for a roster of patients and a spot in a FHO, whereas before, anyone could join so it didn’t make any sense to purchase. As for value, purchasing physicians are guaranteed income for the first 6 months after taking over and in our experience, this relates to the average sale price of about $150-200K, even though I would expect the sale price to be higher with such demand.
Overall, Cirrus can help with all aspects of your practice from the start of your career with income projections and setup, to the end of your career with practice valuations and retirement. I look forward to speaking with many of you and your colleagues about your individual situations and how Cirrus can help optimize your practice.
Please check out – http://www.cirrusconsultinggroup.com and my direct email is jsteinberg@cirrusconsultinggroup.com
Thanks so much for sharing your very helpful comments, Josh! I will share this around social media sites, too.
Cheers
Shawn