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Published byAlicia Gatewood Modified over 9 years ago
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1 REVIEWING MODELS FOR PHYSICIAN COMPENSATION CANADA AND ABROAD WILLIAM L. OROVAN CAROLYN TUOHY
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2 METHODS OF PHYSICIAN COMPENSATION FEE FOR SERVICE CAPITATION SALARY MIXED MODELS AFP/APP’S
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3 ISSUES ARISING PRIMARY VERSUS SPECIALTY CARE MD PREFERENCES (AGE,GENDER, SPECIALTY) FUNDER PERSPECTIVES (BUDGETS, OUTCOMES) INCENTIVES/ETHICS/CLINICAL JUDGEMENT
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4 FEE FOR SERVICE: THE DEBATE MD PERSPECTIVE PHYSICIAN AUTONOMY VOLUME DRIVEN TARGET INCOMES INCENTIVE FOR COMPLETENESS OF CARE FREEDOM OF MOVEMENT FOR PATIENTS
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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
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6 CAPITATION MD PERSPECTIVE LESS AUTONOMY BURDENSOME (ROSTERING) INCREASED RISK (COMORBIDITY) NEED LARGE(R) PATIENT POPULATIONS OUTCOMES VERSUS EFFORT BASED
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7 CAPITATION FUNDER PERSPECTIVE ENCOURAGES EFFICIENCY (N.P’s) INCENTIVE TO LIMIT SERVICES (LAB, HOSP) ‘SKIMMING’ IN ROSTERING BUDGET CERTAINTY IMPROVED CARVEOUTS/BONUSES AS NEEDED
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8 SALARY MD PERSPECTIVE REDUCED AUTONOMY REDUCED CLINICAL/PROFESSIONAL SCOPE NO PRODUCTIVITY INCENTIVE NET LOSS OF INCOME NO INCENTIVE TO CONTINUITY OF CARE
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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
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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)
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11 PATIENT ATTITUDES TOWARD PHYSICIAN REMUNERATION ALL METHODS LEAD TO SOME CONCERN ADULT SURVEY STUDY - Salary 16% - FFS25% - Capitation53% HIGHEST IN ‘BEST EDUCATED’ GROUP (Pereira et al Arch Int Med ’01)
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12 IMPACT OF PAYMENT METHODS ON DECISIONS PHYSICIAN SURVEY/CLINICAL SCENARIOS CAPITATION VS FFS FFSCAPITATION DRUG75.9%55% TEST46.7%33.1% REFERRAL77.5%66.6% TRANSPLANT91.6%92.0% “BOTHER” INDEX HIGHER FOR CAPITATION (SHEN ET AL MEDICAL CARE 2004)
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13 ALTERNATE PAYMENT (ONTARIO) NUMBER OF CONTRACTS315 NUMBER OF PHYSICIANS4508 VALUE$637.6 mm
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14 CANADIAN NON FFS BY PROVINCE (2002) #’s% PEI5730% QUEBEC789654% SASK26016% ALBERTA2274.4% ONTARIO301314% BC233728% N.S.128764%
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15 TOTAL NON FFS ONTARIO NOVEMBER 2004 (G.P.’s) FHN FHN/FHG FHG PCN SEAMON(FHN) HSO TOTAL 374 48 2610 161 17 150 3360
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16 AFP (AHSC) LOCATION# ACTIVE PHYSCIANS TORONTO 1409 HAMILTON492 KINGSTON138 OTTAWA570 LONDON436 TOTAL3045
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17 FHN ONTARIO MONTHSITESDOCSPATIENTS JAN 0416235123,645 APRIL 0427245255,966 AUG O438331373,855
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18 FHG ONTARIO MONTHSITESDOCSPATIENT S JAN 041521742222,092 APRIL 041761995767,653 AUG O491623071,043,83 4
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19 PCN ONTARIO MONTHSITESDOCSPATIENT S JAN 0412157275,604 APRIL 0412158275,437 AUG O412162276,163
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20 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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21 UNITED KINGDOM II GP’s -PRIMARY CARE TRUSTS -TERMS OF SERVICE CONTRACTS -1800 PTS/MD (declining/negotiated) -‘MIXED’ REMUNERATION -FFS15% OF INCOME -CAPITATION40% -SALARY30% -CAPITAL15% -INCENTIVE/QUALITY INDICATORS/POINT SYSTEM
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22 UNITED STATES FFS (MODIFIED BY RBRVS) CAPITATION MODALITIES DECLINING EMPHASIS ON ADAPTING FFS
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23 AUSTRALIA HOSPITAL/SPECIALISTS SALARY FFS SESSIONAL GP’S FFS -BULK BILLNG (80%) -BILL DIRECT (20%)
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24 NEW ZEALAND HOSPITAL/SPECIALISTS - MAJORITY SALARIED GP’S -FFS 85% OF MD’S -CAPITATION 15% OF MD’S
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25 SWEDEN GP’S - 86% SALARIED - 12% FFS - 7% PRIVATE
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26 CONCLUSIONS REVIEW CURSORY/COMPLEX SITUATION DYNAMICS OBSCURE/FFS VS OTHER REFORM OF FFS REMAINS POSSIBLE GRADUALISM/VOLUNTEERISM
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