REVIEWING MODELS FOR PHYSICIAN COMPENSATION CANADA AND ABROAD

1. REVIEWING MODELS FOR PHYSICIAN COMPENSATION CANADA AND ABROAD WILLIAM L. OROVAN CAROLYN TUOHY

2. METHODS OF PHYSICIAN COMPENSATION • FEE FOR SERVICE • CAPITATION • SALARY • MIXED MODELS • AFP/APP’S

3. ISSUES ARISING • PRIMARY VERSUS SPECIALTY CARE • MD PREFERENCES (AGE,GENDER, SPECIALTY) • FUNDER PERSPECTIVES (BUDGETS, OUTCOMES) • INCENTIVES/ETHICS/CLINICAL JUDGEMENT

4. FEE FOR SERVICE:THE DEBATE MD PERSPECTIVE • PHYSICIAN AUTONOMY • VOLUME DRIVEN • TARGET INCOMES • INCENTIVE FOR COMPLETENESS OF CARE • FREEDOM OF MOVEMENT FOR PATIENTS

5. FEE FOR SERVICE:THE DEBATE FUNDER PERSPECTIVE • INCENTIVES TO OVER SERVICING • UNPREDICTABLE BUDGET • IMPEDES ACADEMIC OUTPUT • ‘AVERAGE’ ACUITY REMUNERATED • RELATIVITY AN ISSUE • ACADEMIC DISAPPROBATION

6. CAPITATIONMD PERSPECTIVE • LESS AUTONOMY • BURDENSOME (ROSTERING) • INCREASED RISK (COMORBIDITY) • NEED LARGE(R) PATIENT POPULATIONS • OUTCOMES VERSUS EFFORT BASED

7. CAPITATIONFUNDER PERSPECTIVE • ENCOURAGES EFFICIENCY (N.P’s) • INCENTIVE TO LIMIT SERVICES (LAB, HOSP) • ‘SKIMMING’ IN ROSTERING • BUDGET CERTAINTY IMPROVED • CARVEOUTS/BONUSES AS NEEDED

8. SALARYMD PERSPECTIVE • REDUCED AUTONOMY • REDUCED CLINICAL/PROFESSIONAL SCOPE • NO PRODUCTIVITY INCENTIVE • NET LOSS OF INCOME • NO INCENTIVE TO CONTINUITY OF CARE

9. SALARY FUNDER PERSPECTIVE • INCREASED BUDGET CERTAINTY • NO INCENTIVE TO OVER SERVICING • ADMINISTRATIVELY SIMPLE • ENCOURAGES CME & PREVENTION • TEAM BASED CARE • REWARD SENIORITY, EFFICIENCY • UNDERSERVICED AREAS ATTRACTIVE

10. MIXED MODELS • IN ONTARIO FHN, FHG, HSO’s • DECADE LONG EFFORT TO MOVE MD’s • APP’s (RURAL, E.R.,GERIATRICS) • AFP’s (AHSC’s)

11. PATIENT ATTITUDES TOWARD PHYSICIAN REMUNERATION • ALL METHODS LEAD TO SOME CONCERN • ADULT SURVEY STUDY - Salary 16% - FFS 25% - Capitation 53% • HIGHEST IN ‘BEST EDUCATED’ GROUP (Pereira et al Arch Int Med ’01)

12. IMPACT OF PAYMENT METHODS ON DECISIONS • PHYSICIAN SURVEY/CLINICAL SCENARIOS • CAPITATION VS FFS FFS CAPITATION DRUG 75.9% 55% TEST 46.7% 33.1% REFERRAL 77.5% 66.6% TRANSPLANT 91.6% 92.0% • “BOTHER” INDEX HIGHER FOR CAPITATION (SHEN ET AL MEDICAL CARE 2004)

13. ALTERNATE PAYMENT(ONTARIO) • NUMBER OF CONTRACTS 315 • NUMBER OF PHYSICIANS 4508 • VALUE $637.6 mm

14. CANADIAN NON FFS BY PROVINCE (2002)

15. FHN FHN/FHG FHG PCN SEAMON(FHN) HSO TOTAL 374 48 2610 161 17 150 3360 TOTAL NON FFS ONTARIONOVEMBER 2004 (G.P.’s)

16. AFP (AHSC)

17. FHNONTARIO

18. FHGONTARIO

19. PCNONTARIO

20. UNITED KINGDOM I • SPECIALISTS (NHS) -SALARIED (BY SESSIONS) -UP TO 10% ADDITIONAL FFS -“MERIT” BONUSES -“REVIEW BODY ON DOCTORS REMUNERATION” -PRIVATE OPTION AVAILABLE

21. UNITED KINGDOM II • GP’s - PRIMARY CARE TRUSTS - TERMS OF SERVICE CONTRACTS - 1800 PTS/MD (declining/negotiated) - ‘MIXED’ REMUNERATION -FFS 15% OF INCOME -CAPITATION 40% -SALARY 30% -CAPITAL 15% - INCENTIVE/QUALITY INDICATORS/POINT SYSTEM

22. UNITED STATES • FFS (MODIFIED BY RBRVS) • CAPITATION MODALITIES DECLINING • EMPHASIS ON ADAPTING FFS

23. AUSTRALIA • HOSPITAL/SPECIALISTS SALARY FFS SESSIONAL • GP’S FFS -BULK BILLNG (80%) -BILL DIRECT (20%)

24. NEW ZEALAND • HOSPITAL/SPECIALISTS - MAJORITY SALARIED • GP’S -FFS 85% OF MD’S -CAPITATION 15% OF MD’S

25. SWEDEN • GP’S - 86% SALARIED - 12% FFS - 7% PRIVATE

26. CONCLUSIONS • REVIEW CURSORY/COMPLEX SITUATION • DYNAMICS OBSCURE/FFS VS OTHER • REFORM OF FFS REMAINS POSSIBLE • GRADUALISM/VOLUNTEERISM