REVIEWING MODELS FOR PHYSICIAN COMPENSATION CANADA AND ABROAD

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REVIEWING MODELS FOR PHYSICIAN COMPENSATION
CANADA AND ABROAD

• WILLIAM L. OROVAN
• CAROLYN TUOHY

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METHODS OF PHYSICIAN COMPENSATION

• FEE FOR SERVICE
• CAPITATION
• SALARY
• MIXED MODELS
• AFP/APPS

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ISSUES ARISING

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

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FEE FOR SERVICETHE DEBATE

• MD PERSPECTIVE
• PHYSICIAN AUTONOMY
• VOLUME DRIVEN
• TARGET INCOMES
• INCENTIVE FOR COMPLETENESS OF CARE
• FREEDOM OF MOVEMENT FOR PATIENTS

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FEE FOR SERVICETHE DEBATE

• FUNDER PERSPECTIVE
• INCENTIVES TO OVER SERVICING
• UNPREDICTABLE BUDGET
• IMPEDES ACADEMIC OUTPUT
• AVERAGE ACUITY REMUNERATED
• RELATIVITY AN ISSUE
• ACADEMIC DISAPPROBATION

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CAPITATIONMD PERSPECTIVE

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

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CAPITATIONFUNDER PERSPECTIVE

• ENCOURAGES EFFICIENCY (N.Ps)
• INCENTIVE TO LIMIT SERVICES (LAB, HOSP)
• SKIMMING IN ROSTERING
• BUDGET CERTAINTY IMPROVED
• CARVEOUTS/BONUSES AS NEEDED

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SALARYMD PERSPECTIVE

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

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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

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MIXED MODELS

• IN ONTARIO FHN, FHG, HSOs
• DECADE LONG EFFORT TO MOVE MDs
• APPs (RURAL, E.R.,GERIATRICS)
• AFPs (AHSCs)

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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)

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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)

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ALTERNATE PAYMENT(ONTARIO)

• NUMBER OF CONTRACTS 315
• NUMBER OF PHYSICIANS 4508
• VALUE 637.6 mm

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CANADIAN NON FFS BY PROVINCE (2002)
s
PEI 57 30
QUEBEC 7896 54
SASK 260 16
ALBERTA 227 4.4
ONTARIO 3013 14
BC 2337 28
N.S. 1287 64
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TOTAL NON FFS ONTARIONOVEMBER 2004 (G.P.s)

• FHN
• FHN/FHG
• FHG
• PCN
• SEAMON(FHN)
• HSO
• TOTAL

• 374
• 48
• 2610
• 161
• 17
• 150
• 3360

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AFP (AHSC)
LOCATION ACTIVE PHYSCIANS
TORONTO 1409
HAMILTON 492
KINGSTON 138
OTTAWA 570
LONDON 436
TOTAL 3045
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FHNONTARIO
MONTH SITES DOCS PATIENTS
JAN 04 16 235 123,645
APRIL 04 27 245 255,966
AUG O4 38 331 373,855
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FHGONTARIO
MONTH SITES DOCS PATIENTS
JAN 04 152 1742 222,092
APRIL 04 176 1995 767,653
AUG O4 916 2307 1,043,834
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PCNONTARIO
MONTH SITES DOCS PATIENTS
JAN 04 12 157 275,604
APRIL 04 12 158 275,437
AUG O4 12 162 276,163
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UNITED KINGDOM I

• SPECIALISTS (NHS)
• -SALARIED (BY SESSIONS)
• -UP TO 10 ADDITIONAL FFS
• -MERIT BONUSES
• -REVIEW BODY ON DOCTORS REMUNERATION
• -PRIVATE OPTION AVAILABLE

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UNITED KINGDOM II

• GPs
• - 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

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UNITED STATES

• FFS (MODIFIED BY RBRVS)
• CAPITATION MODALITIES DECLINING
• EMPHASIS ON ADAPTING FFS

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AUSTRALIA

• HOSPITAL/SPECIALISTS
• SALARY
• FFS
• SESSIONAL
• GPS
• FFS -BULK BILLNG (80)
• -BILL DIRECT (20)

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NEW ZEALAND

• HOSPITAL/SPECIALISTS
• - MAJORITY SALARIED
• GPS
• -FFS 85 OF MDS
• -CAPITATION 15 OF MDS

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SWEDEN

• GPS
• - 86 SALARIED
• - 12 FFS
• - 7 PRIVATE

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CONCLUSIONS

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