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Alternate Funding Plan for Focused Practice General Practitioners in Care of the Elderly

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Title: Alternate Funding Plan for Focused Practice General Practitioners in Care of the Elderly


1
Alternate Funding Plan for Focused Practice
General Practitioners in Care of the Elderly
  • Information Session
  • March 8, 2012

2
Agenda
  1. Introductions
  2. Overview of the Care of the Elderly Alternate
    Funding Plan
  3. Common Elements
  4. Model 1 (In-Home Care of the Elderly Model)
  5. Model 2 (Medical Consultation Services Model)
  6. Next Steps

3
Purpose of this Information Session
  • The Ministry of Health and Long-Term Care
    (ministry) and the Ontario Medical Association
    (OMA) wish to introduce the main elements of the
    new Care of the Elderly (COE) Alternate Funding
    Plan (AFP) model.
  • The information contained in these slides
    provides only a general overview of the COE AFP
    model.
  • This Information Session will assist physicians
    to determine whether
  • The COE AFP model is suitable for his/her
    practice and
  • A physician wishes to formally submit an COE AFP
    Application for review and evaluation.
  • If approved to participate in the model, the
    terms of funding for the COE AFP model would be
    subject to the COE AFP Agreement, which would be
    entered into by the ministry, approved
    physician(s), and the OMA.
  • Physicians are encouraged to consult with the OMA
    Legal Department or their own legal counsel to
    review all of the terms and conditions associated
    with this funding prior to signing the COE AFP
    Agreement.

4
What is the COE AFP?
  • The AFP model for GPs who focus their practice in
    COE was developed jointly by the ministry and
    OMA.
  • The duration of the COE AFP Agreement will be 3
    years, with potential renewal periods of 3 years.
  • There is limited funding allocated for the COE
    AFP. This funding is only available to a limited
    number of positions as was previously approved
    for the development and implementation of
    alternative funding programs for Focused Practice
    GPs in Palliative Care and HIV.
  • The COE AFP model includes 2 Models of Service
    provision In-Home Care of the Elderly Model and
    Medical Consultation Services Model.
  • The COE AFP model is designed to compensate
    physicians who have practices with predominantly
    Frail Elderly patients. Please see the
    definition of Frail Elderly for each Model of
    Service provision on the following slides
  • Model 1 (In-Home Care of the Elderly Model)
    Slide 19
  • Model 2 (Medical Consultation Services Model)
    Slide 27
  • Physicians can participate as a solo physician or
    as one of a Group of physicians under the COE AFP
    model.

5
Who can participate in the COE AFP Model?
  • Model 1
  • A physician who is a party to a Patient Enrolment
    Model (PEM) Agreement and is approved to
    participate in the In-Home Care of the Elderly
    Model cannot continue to be affiliated with, and
    be a party to, the PEM Agreement.
  • If a physician joins the In-Home Care of the
    Elderly Model by signing the COE AFP Agreement,
    and then decides to become a party to another PEM
    Agreement, the COE AFP Agreement would
    automatically terminate.
  • Model 2
  • A physician who is a party to a PEM Agreement and
    is then approved to participate in the Medical
    Consultation Services Model can be affiliated
    with, and be a party to, both the PEM Agreement
    and the COE AFP Agreement. The physician is
    required to meet the terms and conditions of both
    agreements.

6
Common Elements
7
Governance
  • A written governance agreement must be
    established and maintained during the entire
    term, including any renewals, of the COE AFP
    Agreement by the Group Physicians. The OMA can
    provide advice for the development of your
    governance agreement.
  • A Group will have two elected officers a Lead
    Physician and an Associate Physician.
  • The governance requirements do not apply to a
    single Group Physician who is not a Medicine
    Professional Corporation.

8
Funding
  • Funding per 1.0 FTE for the provision of Group
    Services by a Group Physician is as follows
  • 259,705 annual base rate (continuing medical
    education included)
  • 30,000 annually for administrative services
  • The base rate and funding for administrative
    services will be adjusted proportionately based
    on the Part-Time Group Physicians approved FTE
    designation
  • Incentive payment of 5 of the fees on submitted
    claims shadow billed for services for which valid
    claims are submitted
  • The FTE Designation (and hours of Group
    Services per week) are further defined for each
    Model of Service provision on the following
    slides
  • Model 1 (In-Home Care of the Elderly Model)
    Slide 21
  • Model 2 (Medical Consultation Services Model)
    Slide 29

9
Fee-For-Service Payments and Cap
  • A Group Physician may bill the Ontario Health
    Insurance Plan (the Plan) for fee-for-service
    (FFS) payment for services that are specified in
    the COE AFP Agreement, subject to a funding
    maximum set out in the Agreement (the FFS Cap).
  • The permissible FFS Cap is 15,000 per year per
    1.0 FTE Group Physician for valid claims billed
    to the Plan, in accordance with the Health
    Insurance Act, for the services specified in the
    COE AFP Agreement.
  • The permitted FFS Cap is prorated to correspond
    to a Part-Time Group Physicians approved FTE
    designation, as set out in the table below

FTE Permissible Fee-For-Service Cap
0.5 FTE 137,500
0.6 FTE 113,000
0.7 FTE 88,500
0.8 FTE 64,000
0.9 FTE 39,500
10
Fee-For-Service Payments and Cap
  • The services for which a Group Physician may bill
    the Plan include
  • Services that are not funded by alternate payment
    under the COE AFP Agreement
  • Any service provided during Evening and Weekend
    Hours
  • Obstetrical deliveries and
  • Emergency services.
  • As stated in the previous slide, services for
    which a Group Physician is paid FFS is subject to
    the applicable FFS Cap. However, certain
    services, or levels of services, are exempt from
    the FFS Cap.
  • The services that will not count towards a Group
    Physicians FFS Cap include
  • Services provided during Evening and Weekend
    Hours up to a maximum of 19,500 in billings per
    year
  • Obstetrical deliveries and
  • Emergency services provided in the emergency
    department of a public hospital.
  • Services that are funded by alternate payment
    are described in Slides 15 and 16 (Model 1) and
    Slide 25 (Model 2) and pay an incentive payment
    of 5 of the fees on submitted claims shadow
    billed for services for which valid claims are
    submitted. Services funded by alternate payment
    cannot be billed to the Plan.

11
Vacation
  • Each Group Physician who provides Group Services
    at 1.0 FTE is eligible for a maximum of 4 weeks
    of paid vacation leave per year.
  • Vacation time will be prorated for Group
    Physicians with 0.5 FTE to 0.9 FTE designation.
  • Locum Vacation Coverage For Groups of less than
    3.0 FTEs, funding is available for locum
    physicians only for direct patient services.

12
Information Technology
  • Physicians may be eligible for information
    technology funding according to the terms and
    conditions of OntarioMDs EMR Adoption Program
    and are advised to contact OntarioMD for further
    information at 1-866-744-8668 or
    emrfunding_at_ontariomd.com.

13
Reporting Requirements
  • Group Physicians will submit
  • Shadow Billing Reports setting out the details of
    the Group Services rendered in a manner similar
    to billing the Plan on a FFS basis.
  • Time Diary Reports for each Model of Service a
    Group Physician is approved to participate in.
    Time Diary Reports detail the consultations,
    direct services and indirect services provided by
    each Group Physician.
  • Quarterly Financial Reports to provide details of
    the allocation and expenditure of the Group
    Physicians base rate payment and the
    administrative payments.
  • Other reports the ministry may reasonably require
    from time to time.

14
Model 1 (In-Home Care of the Elderly Model)
15
Model 1 (In-Home Care of the Elderly Model)
  • Group Physicians approved to participate in Model
    1 would provide the following Group Services
  • Direct Patient Services, which is defined to
    include
  • Comprehensive Care
  • Care of the Elderly Focused Services
  • Services during Evening and Weekend Hours and
  • Medical Consultation Services and
  • Indirect Services.

16
Model 1 (In-Home Care of the Elderly Model)
  • Examples of Comprehensive Care includes
  • Health assessments, diagnosis and treatment,
    primary mental health care, primary palliative
    care, support for hospital, home and Long-Term
    Care Homes and services co-ordination and
    referral services.
  • Examples of Care of the Elderly Focused Services
    include
  • Comprehensive geriatric care assessments,
    including on-going care and follow-up visits, the
    management of older persons with multiple health
    problems, advocacy for the patient and
    facilitating the transition between various
    settings (i.e. hospital to home).
  • Examples of Medical Consultation Services
    include
  • An assessment of a patient following a referral
    from another health care provider for the purpose
    of treating the patients acute and chronic
    health conditions due to age-related illness.
  • Examples of Indirect Services include
  • Interdisciplinary team conferences, telephone
    consultations, travel time and administrative
    activities.

17
Model 1 Evening and Weekend Hours
  • Group Physicians approved to participate in Model
    1 shall provide Group Services during Evening and
    Weekend Hours. The number of these after-hours
    sessions is determined by the collective FTE of
    the Group.
  • For example, if the Group consists of between 0.5
    and 1.0 FTE, the Group is responsible for
    providing one 3 hour session on one of the
    following occasions Monday to Thursday night
    (from 500 p.m. to 800 p.m.) or for a 3 hour
    session on the weekend.
  • Group Physicians who provide Groups Services
    during Evening and Weekend Hours bill the Plan
    for FFS payment for the services rendered in
    accordance with the Health Insurance Act and
    subject to the funding maximum set out in the COE
    AFP Agreement (the FFS Cap).
  • The first 19,500 of billings per year for Group
    Services provided during Evening and Weekend
    Hours is exempt from the FFS Cap. Once this
    threshold has been reached, the value of any
    additional billings to the Plan for Group
    Services provided during Evening and Weekend
    Hours will contribute to the FFS Cap.
  • In addition, Group Physicians who provide
    services during Evening and Weekend Hours are
    eligible to receive an after-hours premium of 20
    of the value of the fee codes specified in the
    COE AFP Agreement, provided the claim is valid
    and the applicable service is provided to an
    Enrolled Patient.

18
Patients Served by Model 1 (In-Home Care of the
Elderly Model) Group Physicians
  • Group Physicians approved to participate in Model
    1 are funded by the ministry to provide Group
    Services to the following patients
  • An Enrolled Patient who meets the criteria for
    Frail Elderly
  • An Enrolled Patient who does not meet the
    criteria for Frail Elderly and
  • A person who is not enrolled but who meets the
    criteria for Frail Elderly.
  • An Enrolled Patient is an insured person who has
    been enrolled by a Group Physician under the COE
    AFP Agreement (further information on enrolment
    is found on Slide 23).

19
Patients Served by Model 1 (In-Home Care of the
Elderly Model) Group Physicians
  • For the purposes of Model 1, a Frail Elderly
    patient is defined as follows
  • 65 years or older with one or more of the
    following age-related illness(es), condition(s)
    or presentation(s)
  • Complex management needs
  • Polypharmacy
  • Cognitive impairment (e.g. dementia or delirium)
  • Age-related reduced mobility or falls and/or
  • Unexplained functional decline not otherwise
    specified
  • and
  • resides in a home that includes
  • patients home
  • assisted living or retirement residence (but does
    not include a long-term care home) or
  • a hospital under only the following conditions
  • the patient is residing in the hospital on a
    time-limited basis and
  • the physician provides only Direct Patient
    Services to the patient
  • and
  • meets one or more of the following criteria

19
20
Service Locations for Model 1 (In-Home Care of
the Elderly Model)
  • Group Physicians approved to participate in Model
    1 are to provide Direct Patient Services at the
    following locations
  • The patients primary residence (excludes
    long-term care homes) or
  • The physicians office where he or she regularly
    provides patient services, as long as the minimum
    level of service at a patients primary residence
    has been provided.
  • Group Physicians must provide at least 50 of
    total Direct Patient Services in the patients
    primary residence.

21
Hours and FTE Designation
  • Physicians may apply for ministry funding at any
    one of the permitted FTE levels of funding, as
    set out in the table below. As approved by the
    ministry, Group Physicians are funded at a
    minimum of 20 hours per week of Group Services.
    Group Physicians will provide the minimum number
    of hours according to their approved FTE
    Designation.
  • Note, the provision of Group Services during
    Evening and Weekend Hours does not count towards
    the Group Physicians fulfillment of the hours of
    service that correspond to his/her approved FTE
    designation.

FTE Designation Hours of Group Services Per Week Inclusive of travel time required to provide Group Services
1.0 FTE 40 Hours
0.9 FTE 36 39 Hours
0.8 FTE 32 35 Hours
0.7 FTE 28 31 Hours
0.6 FTE 24 27 Hours
0.5 FTE 20 23 Hours
22
Performance Measures and Standards
  • Group Physicians in Model 1 must meet the annual
    performance measures that correspond to the
    applicable approved FTE designation, as set out
    in the table below.
  • Each visit must be a direct patient encounter for
    the benefit of a Frail Elderly patient to count
    toward the Group Physicians fulfillment of the
    performance measures.

FTE Designation Minimum Annual Visits Frail Elderly Enrolled Patients Minimum Caseload Frail Elderly Enrolled Patients
1.0 FTE 1600 120 150
0.9 FTE 1440 108 119
0.8 FTE 1280 96 107
0.7 FTE 1120 84 95
0.6 FTE 960 72 83
0.5 FTE 800 60 - 71
22
23
Enrolment
  • Within twelve months of the effective date of the
    COE AFP Agreement, Group Physicians shall invite
    each patient in each of their practices to enrol
    if the person is at the time of enrolment
  • An Insured Person
  • Seeking Direct Patient Services
  • Not incarcerated in a provincial or federal
    institution and
  • Not enrolled in another AFP.
  • The ministry will provide an incentive of 5 on a
    per patient basis for the initial enrolment of
    patients for 12 months commencing on the
    effective date of the COE AFP Agreement, provided
    that similar payments were not received by the
    Group Physician pursuant to another PEM
    Agreement.
  • Patients will be enrolled to the individual Group
    Physician. However, there is an option for group
    enrolment. If the Group selects this option, the
    enrolling Group Physician is designated as most
    responsible for providing, coordinating or
    overseeing, as appropriate, Group Services for
    that patient.

24
Model 2 (Medical Consultation Services Model)
25
Model 2 (Medical Consultation Services Model)
  • Group Physicians approved to participate in Model
    2 are to provide the following Group Services
  • Medical Consultation Services with a minimum of
    50 of the approved FTE designation spent on the
    provision of Medical Consultation Services in the
    community (i.e. a non-hospital setting) and
  • Indirect Services.
  • Medical Consultation Services are defined in the
    COE AFP Agreement as an assessment whereby
  • The assessment is conducted following a written
    request from a referring physician or Health
    Profession Member who has requested the opinion
  • The physician is competent to give advice in
    respect of acute and chronic health conditions
    due to age-related illnesses
  • The assessment is for the purpose of treating a
    patients acute and chronic health conditions due
    to age-related illnesses and
  • The assessment is requested because of the
    complexity, seriousness or obscurity of the case
    or because another opinion is requested by the
    patient or the patients representative.
  • In the first year of the COE AFP
    Agreement, Group Physicians will make best
    efforts to achieve this threshold. In the second
    and third years of the Agreement, the Group
    Physicians shall be required to achieve the 50
    threshold.

26
Patients Served by Model 2 (Medical Consultation
Services Model) Group Physicians
  • Group Physicians approved to participate in Model
    2 are funded by the ministry to provide Medical
    Consultation Services to the following patients
  • An Insured Person for whom a Group Physician
  • Is not the most responsible physician and
  • Has received a written request to provide Medical
    Consultation Services for a patient from another
    physician or Health Profession Member.

27
Patients Served by Model 2 (Medical Consultation
Services Model) Group Physicians
  • Group Physicians are asked to acknowledge in the
    COE AFP Agreement that the purpose of the COE AFP
    model is primarily to enhance the provision of
    services to the elderly and Frail Elderly.
  • For the purposes of Model 2, a Frail Elderly
    patient is defined as
  • 65 years or older with one or more of the
    following age-related illness(es), condition(s)
    or presentation(s)
  • Complex management needs
  • Polypharmacy
  • Cognitive impairment (e.g. dementia or delirium)
  • Age-related reduced mobility or falls and/or
  • Unexplained functional decline not otherwise
    specified
  • and
  • Resides in home, which includes a community
    residence, an assisted living residence,
    retirement residence, long-term care home or
    in-hospital
  • and
  • Is frail and vulnerable and will be seen by
    referral from another physician or health
    profession member.

28
Service Locations for Model 2 (Medical
Consultation Services Model)
  • Group Physicians approved to participate in Model
    2 are to provide Medical Consultation Service at
    the following locations
  • Office of another physician/ Health Profession
    Member or the office where the physician normally
    provides services
  • Patients home includes community resident,
    assisted living residence, retirement residence,
    or long-term care home
  • Outpatient or therapeutic clinic including
    hospital outpatient settings or
  • Hospital if
  • The service is for the benefit of the Frail
    Elderly patient
  • The Frail Elderly patients residence in the
    hospital is on a time-limited basis and
  • The service provided is only direct care to the
    Frail Elderly patient.
  • Please note, some of the important differences
    between Model 1 and Model 2 include the
    definitions of a patient, a patients home
    and Frail Elderly, as well as the rules
    regarding the provision of services in a hospital
    setting.

29
Hours and FTE Designation
  • Physicians may apply for ministry funding at any
    one of the permitted FTE levels of funding, as
    set out in the table below. As approved by the
    ministry, Group Physicians are funded at a
    minimum of 20 hours per week of Group Services.
    Group Physicians will provide the minimum number
    of hours according to their approved FTE
    Designation.
  • A Group Physician must provide a minimum of 50
    of his/her approved FTE Designation on the
    provision of Medical Consultation Services in the
    community i.e. not in a hospital (see previous
    Slide 25 for further details).

FTE Designation Hours of Group Services Per Week Inclusive of travel time required to provide Group Services
1.0 FTE 40 Hours
0.9 FTE 36 39 Hours
0.8 FTE 32 35 Hours
0.7 FTE 28 31 Hours
0.6 FTE 24 27 Hours
0.5 FTE 20 23 Hours
30
Performance Measures and Standards
  • Group Physicians in Model 2 must meet the annual
    performance measures that correspond to the
    applicable approved FTE designation, as set out
    in the table below.
  • Each new consultation or follow-up visit must be
    directly for the benefit of a Frail Elderly
    patient to count toward the Group Physicians
    fulfillment of the performance measures.

FTE Designation Blended Number of Annual New Consultations and Follow-up Visits Frail Elderly Patients
1.0 FTE 990
0.9 FTE 891
0.8 FTE 792
0.7 FTE 693
0.6 FTE 594
0.5 FTE 495
31
Evaluation
  • The COE AFP model will be evaluated after the
    first 12 months of the effective date of each COE
    AFP Agreement.
  • The ministry and the OMA will review the Time
    Diary Reports as part of the evaluation of the
    model. Any element of the model may be subject
    to review, including
  • Indirect services
  • Travel time
  • Administrative activities
  • Other activities and
  • Direct services.
  • The ministry and the OMA will also review the
    performance measures and standards (starting 6
    months following the effective date of each COE
    AFP Agreement) for the Medical Consultation
    Services Model.
  • For the purpose of these reviews, the ministry
    will provide the OMA with copies of the Time
    Diary Reports submitted by the Groups, after
    first removing any information that identifies an
    individual from the Reports.

32
Summary of the Two Models
COE AFP Element In-Home MRP Model Consultative Model
Enrolment Yes No
FTE Range 0.5 1.0 0.5 1.0
Required Hours Per Week per 1.0 FTE 40 (plus a 3 After-Hours Block Coverage per minimum 0.5-1.0 FTE) 40
Minimum Performance Measures and Standards per 1.0 FTE. Under the COE Agreement, physicians will provide Group Services to all patients and not only those who meet the definition of Frail Elderly. 120 enrolled Frail Elderly patients 1600 Annual Visits to Frail Elderly Enrolled Patients 990 Blended Number of Annual New Consultations and Follow-up Visits for Frail Elderly Patients
32
33
Summary of the Two Models
COE AFP Element In-Home MRP Model Consultative Model
Long Distance Travel Yes Travel Time Included in Required Hours per Week Yes Travel Time Included in Required Hours per Week
After Hours Obligation Yes No
Enrolment Fees Yes 5.00 Per Patient Rostering Fee No
Base Rate Salary 259,705 for 1.0 FTE Part-time Physician salaries pro-rated 259,705 for 1.0 FTE Part-time Physician salaries pro-rated
34
Summary of the Two Models
COE AFP Element In-Home MRP Model Consultative Model
Administrative Overhead 30,000 for 1.0 FTE Part-time Administrative Payment pro-rated 30,000 for 1.0 FTE Part-time Administrative Payment pro-rated
Shadow Billing Yes 5 Yes 5
Fee for Service Cap Yes - 15,000 per 1.0 FTE Yes - 15,000 per 1.0 FTE
After Hours Cap Yes - 19,500 Yes - 19,500
Information Technology (IT) Physicians may be eligible for IT funding through OntarioMDs EMR Adoption Program and will contact the OMA for further information. Physicians may be eligible for IT funding through OntarioMDs EMR Adoption Program and will contact the OMA for further information.
Continuing Medical Education Included in the Base Salary Included in the Base Salary
Vacation Yes (Full time GPs 4 weeks Part time GPs - pro-rated) Yes (Full time GPs 4 weeks Part time GPs - pro-rated)
Locum Coverage (during vacation time) Yes Yes
34
35
Next Steps
  • Physicians who have expressed interest in the COE
    AFP model and would like to pursue further will
    need to first request the COE Application package
    from the ministry by emailing to
    COEApplications_at_ontario.ca.
  • Completed Applications must be submitted to the
    ministry by May 18, 2012 by mail or e-mail.
  • As part of the application submission
  • Physicians will need a minimum of 2 Letters of
    Support (one from the LHIN and a minimum of one
    from an organization).
  • A minimum of 1 other letter of support from an
    organization in your proposed geographical area
    of service may be from
  • Community Care Access Centre (CCAC)
  • Hospital/ or Regional Health Centre, or
  • Regional Geriatric Program (RGP).
  • The letters of support must address the
    information submitted in your Application and
    support, with a clear rationale, the need for the
    proposed Care of the Elderly services in your
    proposed geographic area of service. The letters
    also need to provide explicit commitment to any
    proposed partnership or collaboration
    arrangements as detailed in the Application.

35
36
Application Review
  • The ministry will review and evaluate all
    Applications and
  • Advise successful physicians or physician groups
    in writing that their application has been
    selected, and will ask them to confirm their
    continued interest and
  • Request documentation from successful physicians
    or physician groups to complete the COE AFP
    Agreement.
  • Any approvals provided by the ministry in respect
    of COE AFP model Applications will be subject to
    the successful physicians, ministry and OMA
    entering into the approved COE AFP Agreement.

36
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