Title: Alternate Funding Plan for Focused Practice General Practitioners in Care of the Elderly
1Alternate Funding Plan for Focused Practice
General Practitioners in Care of the Elderly
- Information Session
- March 8, 2012
2Agenda
- Introductions
- Overview of the Care of the Elderly Alternate
Funding Plan - Common Elements
- Model 1 (In-Home Care of the Elderly Model)
- Model 2 (Medical Consultation Services Model)
- Next Steps
3Purpose 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.
4What 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.
5Who 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.
6Common Elements
7Governance
- 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.
8Funding
- 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
9Fee-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
10Fee-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.
11Vacation
- 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.
12Information 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.
13Reporting 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.
14Model 1 (In-Home Care of the Elderly Model)
15Model 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.
16Model 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.
17Model 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. -
18Patients 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).
19Patients 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
20Service 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.
21Hours 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
22Performance 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
23Enrolment
- 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.
24Model 2 (Medical Consultation Services Model)
25Model 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.
26Patients 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.
27Patients 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.
28Service 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.
29Hours 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
30Performance 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
31Evaluation
- 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.
32Summary 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
33Summary 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
34Summary 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
35Next 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
36Application 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
37Questions and Answers