Let’s Talk TPSA – Guest Post

Editor’s Note: Dr. Nadia Alam shares an extensive and balanced PRO-CON diagnosis for each plank of the Tentative Physician Services Agreement, 2016. 

Dr. Darren Cargill offered input, too. You will remember him from his “9 Steps to Deciding on the Doctors’ New Deal” guest post. 

Please find contact info for Nadia and Darren at the end. [CONs went out vetted by OMA to D5 earlier.]

Enjoy! 

Funding Utilization

PRO: The TPSA will provide set funding that increases by 2.5% per year for four years. Any overage in 2016 is forgiven; any overage in the other three years must be reconciled. As long as growth stays below 3%, physicians will likely not see a significant reconciliation. There is a possibility that there will be no shortfall; there may even be a surplus. The most recent ICES data suggests that growth is 1.9% per year. Anything higher is attributed to physicians as drivers of utilization — which can be controlled.

CON: In the TPSA, funding for utilization is capped at 2.5%. However, utilization fluctuates unpredictably from lows of 0.6% to highs of 4.9%. The lows correlate with government-imposed clawbacks and hard caps; the highs correlate with healthcare transformation. Taking the two extremes out, the average sits around 3.5% according to the OMA Economics chart (attached). Given this, there is a very real probability that an annual increase of 2.5% will not match actual patient need for physician services. Reconciliation of any and all differences will fall to physicians to shoulder. Since utilization is unpredictable, reconciliation will also be unpredictable, making it difficult for physicians trying to manage the business end of their medical practices.

The ICES average is a descriptive analysis looking back at the past 15 years. It only looks at fee-for-service payments, ignoring the impact of alternate funding arrangements including patient-enrolled family medicine models. Alternate funding models make up 30-40% of physician remuneration (according to CIHI) so there is a big chunk of data missing from the ICES figure of 1.9% utilization. Moreover, utilization increases in recent years reflect more physicians in the system not changes in individual billing practices — none of this is reflected in the TPSA calculations.

One-time Payments

PRO: As long as growth in physician services remains at or below 2.5%, physicians will receive bonus payments each year to use as they wish above and beyond the budget of:

$50M in 2016-17

$100M in 2017-18

$120 M in 2018-19

$100M in 2019-20

Should utilization exceed 2.5%, these one-time payments will offset this overage first before reconciliation. Any remaining will be distributed based on appropriateness, relativity and value for money. Funding for new or Ministry-driven initiatives will be provided separately (example, IVF program).

CON: The annual one-time payments are awarded to physicians only if they constrain costs within the hard cap. Given the probability that the hard cap will not match reality, many physicians wonder if they will have to limit patient services to earn the one-time lump sump payments? Many worry about the ethics of accepting bonus payments for rationing care.

If instead the lump sum payments are meant as a cushion in case of overage, then it is obvious that the MOH knows that 2.5% clearly cannot match future patient need.

Co-Management

PRO: The government has recognized that physicians can and should help manage the physician services budget. This will be done in a bilateral manner to achieve the goals of the PSA.

“With great power comes great responsibility” – Uncle Ben

It is no longer acceptable for physicians to feel that they are not part of the solution for sustainable healthcare. This solution involves, physicians, government and patients. As front-line physicians, we see waste, redundancy and ineffective practices on a regular basis. Bringing our experience to bear on this issue of sustainability is crucial. Allowing government to continue its unilateral management of the healthcare system has proven disastrous in just a short period of time.

CON: Bilateral management of physician services was awarded to physicians years ago. It is called the Physician Services Committee. It is unclear what additional benefit a redundant process will offer physicians even if it is under a different name. Furthermore, there has been no analysis into the outcome/ success/ failure of previous efforts at co-management; so it is unclear whether bilateral management has ever achieved its goals. What we do know is that despite all previous attempts, physicians were subject to unilateral actions in 2015-2016, so the power imbalance between physician and government remains despite having a seat at the table.

The OMA has warned that rejecting the TPSA means further unilateral actions. If this is true, then the TPSA is little more than another ultimatum and the government is not engaging in good-faith negotiations. This erodes the assumption that co-management can exist much less succeed between physicians and government without binding arbitration to level the playing field.

Modernizing the Schedule of Benefits & Other Payments

PRO: The Schedule of Benefits is out-dated with many services that are redundant or unnecessary. Currently there are over 7000+ fee codes. Technology has changed the speed and ease with which we deliver healthcare, one example being cataract surgery and diagnostic imaging (it is worth noting these specialties have already been subjected to unilateral cuts). Modernization will remove $100million in fee codes and other payments in 2016-17, and another $100million in fee codes and payments in 2019-20. This will be off-set, in whole or in part, by the one-time payments (as long as growth is below 2.5%). This process will occur bilaterally with a binding facilitator available in case of disagreements.

CON: As part of the 2012 PSA, physicians found $850 million in modernization/ cost-savings from the Schedule of Benefits. There is no information on whether such previous modernizations achieved their intended goal of streamlining physician services. There has been no analysis done to see if an additional elimination of $200 million is even possible. There has been no information made available to see where these cuts will occur and which specific codes will be impacted. There is no information on if and how non-FFS payments will be affected. This creates significant unpredictability for physicians trying to manage the business end of their medical practices.

Progressive Cuts to Group Practices

PRO: Co-management will consider group practices that generate billings of over $1 million a year to identify value, appropriateness and relativity. High billers are also significant service providers. This “soft cap” may provide opportunities for new graduates as the work previously done by one physician could be redistributed to multiple physicians. Proper use of individual billing codes or application for a group billing number can mitigate concerns.

CON: Many community-based radiology, cardiology, ophthalmology, and gastroenterology clinics operate on a group-billing model that bills over $1M per year; many of these have significant overhead costs in the range of 50-75% of billings. The TPSA will cut the clinics that bill over $1million dollars. Many of these clinics already saw severe reductions in funding for services because of the unilateral actions and revocation of IHF funding; as a result, many reduced staff, hours or service. More cuts will worsen this scenario, meaning that as more community clinics close, local hospitals will be forced to take on more patient care. Given that hospitals themselves are chronically under-funded, the reality will be that patients will see longer waitlists, compromising timely access to care. One example is the Barrie Endoscopy Clinic that is closing next year. All endoscopy and GI services will be funnelled to the hospital and undoubtedly, waitlists will balloon.

2015 Unilateral Actions

PRO: Given the acrimonious relationship between government and physician in 2015, the TPSA provides a framework that lets government and physician move towards a trusting relationship. Trusting, collaborative relationships like this produce successful healthcare reform ventures like the primary care enrolment models. The TPSA prevents the government from enforcing further unilateral actions until the Charter Challenge has received its first decision.

CON: The cuts and policy changes imposed by the government in 2015 will have ongoing repercussions. This cannot be ignored. Many clinics have had to cut services — including on-site labs, hours of service, staffing, and flu shot clinics. Many clinics have closed. The TPSA ignores the past at its peril. The codes that were cut in 2015 affected patient care in countless ways. For example, cutting the E078, the chronic disease fee, undermined doctors providing care for diabetes, IBD, liver disease, and kidney failure.

New Family Medicine Graduates

PRO: The Managed Entry Program restrictions will be lifted so that 40 new family doctors can enter FHO arrangements per month, as it was in 2012. This is better than the restriction of 20 per month in 2015. This will help address access issue that nearly 1 million Ontarians have who are without a family doctor.

CON: Since their introduction in 2004, FHO-based practices are the primary way new family physicians are trained during residency. Prior to 2012, there were no restrictions on the number of family physicians wishing to set up FHO practices. 2012 saw the introduction of the Managed Entry Program that limited FHO applicants to 40 per month. 2015 saw further restriction to 20 per month. The TPSA lifts that restriction back to 40. However, it does not eliminate it, nor does it eliminate the impractical New Graduate Entry Program.

Worse, the TPSA does not restore income stabilization or rostering fees — programs cut in 2015 that are considered crucial to meeting the overhead expenses of the first year of community family practice.

Binding Facilitation

PRO: There will be a neutral Third-Party Facilitator who will help physicians and government achieve the goals of the PSA. This person will be jointly recruited and vetted. Their decisions will be binding on both parties. This will help bridge the gap between what we have now (no dispute resolution) and binding arbitration (reliable dispute resolution). Aside from stability, this may also address concerns that OMA no longer has ability to advocate against cuts its membership feels are improper.

CON: 2012 saw introduction of the Facilitation-Conciliation process; this process was supposed to improve the power imbalance between physician and government so that further unilateral actions could be avoided. Regardless, 2015 saw unilateral actions. Binding Facilitation is expected to be a bridge to Binding Arbitration. However, the details of this process are not defined. The Facilitator will rule on how the conditions of the TPSA are met. So, they don’t rule on how much of a cut is acceptable, just where it must occur.

Moreover, the first quarter of the year is over, deadlines are looming and consequences are firm; yet there have been no steps taken to recruit or vet the Facilitator. It is unclear how disputes will be managed if it takes longer than expected to find a Facilitator.

Health Human Resources

PRO: It is unfair to license physicians when we cannot guarantee jobs for them. Medical training is a costly investment requiring years of sacrifice. That sacrifice is justified if physicians can reliably find gainful employment upon graduation. That is not in keeping with current conditions. Many physicians right now graduate and find that they have unpredictable employment consisting of locums and mainly on-call work. This can be assessed through broad consultation and co-management of health human resources.

CON: Much has been made of how the current number of 950 net new physicians entering the system is “unsustainable”. The reality is that many new graduates struggle to find a job. The reality is also that waitlists for specialist services are out of control. There is a mismatch between available funded healthcare resources and actual patient need.

Many specialists in fact no longer accept elective referrals because their waitlists are too long. It is short-sighted to say that the solution is to limit the number of physicians entering the system to an arbitrary number that “should be” funded (approximately 700). The TPSA does not address the larger issue of chronic under-funding of the healthcare system. In fact, the risk of insufficient funding of physician services budget in and of itself will exacerbate this issue.

Patient Accountability

PRO: At the moment, many patients will draw on limited healthcare resources for reasons that are not medically necessary. This is the first ever PSA where government is willing to acknowledge patient accountability and its impact on the healthcare system.

CON: The words “patient accountability” are in the TPSA, however detail is lacking. There has been no analysis done of the financial impact of patients requesting and obtaining services that are not medically indicated. So it is unclear whether patient accountability will yield expected savings. It is also unclear how patient accountability will be established. What is clear is that there is no extra funding for the added cost to cover the resources, education and publicity required for this to be successful.

Primary Care Improvements

PRO: There are 1 million Ontarians without access to primary care. Only 40% of patients are able to access same-day/ next-day visits with their primary care providers. These metrics will be assessed and corrected via the TPSA, with the expectation that it will improve patient care. Most physicians in patient-enrolled models are living up to the their contracts; some are not. Currently the only option available to government is a stern letter and termination of the contract. There needs to be intermediary steps to ensure physicians are living up to their contractual obligations.

CON: Physicians are expected to improve primary care access metrics: namely, access to primary care for unattached patients, access to after-hours and weekend care, access to urgent appointments, as well as reporting on physician resources and availability. There is no extra funding to cover the additional cost of the administrative and clinical requirements; it will have to come out of the capped physician services budget. There is no analysis available of the short-term and long-term impact these changes will have on one of the largest sections in the OMA.

What’s more, many patients rate their access acceptable — even if it doesn’t fit the performance standards that the MOH has chosen as a goal. Many physicians find that even when they do have same-day/ next-day availability, the timing does not work for the patient; so the data that the MOH is basing its baseline statistics on is suspect.

The changes to Bill 210 are contingent on meeting these requirements.

Bill 210, The Patients First Act

PRO: The OMA has been advocating against Bill 210, the Patients First Act, for over a year now. Despite that, it has passed its first and second readings in Legislature. After the third reading, the Bill will likely pass into law. The TPSA allows the OMA to change some of the objectionable parts of the Bill (specifically Section 29 and 38).

CON: Removing Sections 29 and 38 allows the OMA to retain its representational rights. However, these modifications will only be recommended by the government if and only if physicians meet the conditions set out in Primary Care Improvements.

What’s more, the more objectionable parts of Bill 210 remain unaddressed. There is no discussion of the added bureaucracy of 80 new sub-LHINs will burden a strained healthcare system. There is no discussion of how MOH-appointed investigators will be able to access patient medical records without patient permission. Bill 210 remains a concern that is only somewhat mitigated by the TPSA.

Appropriateness of Billing Practices

PRO: There are many physicians who bill inappropriately and who “game” the system. At a time when healthcare resources are scarce, as responsible fiscal stewards, physicians need to find every efficiency and root out every bit of waste they can.

CON: Many physicians fear the form such billing audits will take; many worry that this will be similar in consequence to CPSO’s Medical Review Committees. On a practical level, the MOH already has a billing audit department, so it is unclear why the task is being replicated on the OMA side. It is unclear where funding for the added administrative costs will come from. It is unclear how billing profiles will be analyzed and deemed appropriate or inappropriate. It is unclear how among the thousands of physicians, the OMA will drill down on just the ones who are indeed “gaming” the system without collateral damage — which is what happened with the CPSO’s MRC.

Value for Money

PRO: As fiscal stewards, physicians should not provide medically unnecessary or low-value services. If we expect the government to clean up the waste on their end, we must do the same on ours. We must balance standard of care with fiscal responsibility.

CON: In 2012, physicians undertook projects to reduce unnecessary or low-value services, like annual physicals and routine pre-operative testing. While the goal is laudable and should be continued from year to year, it’s unclear how much of a financial benefit will be derived from reducing more of these so-called “unnecessary” physician services — especially since other providers can now obtain those services for patients including nurse practitioners.

Charter Challenge

PRO: The TPSA allows the Charter Challenge to continue uncontested. Likely, a first decision will be made by 2018-19. Likely, the decision will be in our favour. However, if Ontario’s court system awards physicians Binding Arbitration, the government can apply for a Stay — in which case, physicians will not get to enjoy the security of BA until the Stay has been appealed and overruled. This could delay an effective BA for up to a decade. The government has offered to give up its right to a Stay if the TPSA is ratified.

CON: The Charter Challenge for binding arbitration will continue. However concern has been raised by various lawyers that absolving the government of all responsibility for the damages caused by the unilateral actions weakens the Challenge. What is also worrying is that there is added language in the TPSA about injunctions on further government unilateral actions. The necessity of adding this in raises the possibility that despite the TPSA, government can still impose unfair UA on physicians. This contract does not fix the power imbalance already present between government and physician.

Relativity

PRO: The OMA has been attempting to address relativity for decades, with varying amounts of success and failure. The OMA has been using a process known as CANDI to provide an objective approach. As you can imagine, however,  this has been a source of fierce debate and met with great resistance. There remain fee codes that are over-valued and fee codes that are under-valued leading to great revenue and income disparity between the various specialties. The co-management process will allow physicians to address this issue of relativity. In fact, if growth remains below 2.5%, the one-time lump-sum payments can be used to address some of the relative inequities between specialties.

CON: For decades, the OMA has unsuccessfully tried to address relativity. This TPSA is defined by an impractical hard cap, unpredictable reconciliation and obvious demands for more services; it is unclear how it will improve equity between low-billing and high-billing specialties.

Ontario already has the lowest fee-for-service payments for all specialties. Given the probability of inadequate funding for physician services, it’s unclear how low-billing specialties will be built up. The flip-side — cutting high-billing specialties — was tried back in 2012. Further cuts to high-billers will not improve the lot of low-billers. It will however drive many of these high-billing specialists out of the province meaning less access to care and longer waitlists.

Vote!

The TPSA is an exercise in weighing risk and benefit. It is an imperfect deal. Regardless of what you vote, please read the TPSA itself and vote with your conscience!

Nadia Alam Family Doctor & Anesthesiologist Georgetown   Blog: Huff Post Nadia Alam Twitter: @DocSchmadia

with contributions from:   Dr. Darren Cargill Palliative Care, Windsor Twitter: @ReasonableWlvrn