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AFHTO congratulates the Ministry of Health and Long-Term Care and Ontario Medical Association on reaching a Tentative 2012 Physician Services Agreement.  AFHTO’s Executive Committee has reviewed the agreement to assess what it may mean for family health teams. Overall, the tentative agreement contains a number of provisions that are aligned with the vision for FHTs to deliver accessible, comprehensive, high-quality, patient-centred primary care. These include measures to improve care for vulnerable populations, support evidence-based care, incorporate technology into the process of care, ease the ability of FHTs to bring in new doctors, and include FHT physicians in FHT quality improvement plans. The Tentative Agreement also contains a number of fee reductions and revisions. The amounts are varied, and in the OMA’s words, “… have been negotiated to be as fair and reasonable as possible, reflecting a balance of the government’s fiscal priorities, and the proposed evidence-based changes and program revisions set out in the Tentative Agreement.” There are a number of details to be worked through. The tentative agreement includes establishment of a Primary Care Policy Committee to imple­ment primary care initiatives and address policy issues identified in this agreement.  AFHTO will monitor the issue of staffing pressures on FHTs related to the increase in after hours requirements and the expansion of access to interdisciplinary services to non-FHT physicians, to ensure that FHTs are supported to improve and deliver optimal care. Further details on these topics are presented below for information. AFHTO encourages all FHT physicians to review the documents available to them through the OMA website (www.oma.org) and vote in the OMA referendum – November 28 to December 5.  Informed by the referendum results, OMA Council will meet on December 9 to vote on ratification. …………………………………………………………………………………………………………………………………………………………… Provisions in the Tentative 2012 Physician Services Agreement that could affect Family Health Teams Supporting care for vulnerable populations:

• Existing bonuses for house calls will be enhanced.
• A one-time acuity modifier is proposed and will be developed by the Primary Care Policy Committee (see below), until an acuity-adjusted capitation model is developed and implemented.  Forty million dollars is set aside for this initiative and the funding will come from other cuts.
• To develop proposals for medically complex patients, both post-discharge and ongoing, demonstration projects will be established to measure results, which will be evaluated after one year.
• Fee codes for group appointments will be introduced for chronic diseases and some mental health issues. These diseases include diabetes, congestive heart failure, asthma, chronic obstructive pulmonary disease (COPD), hypercholesterolemia, and fibromyalgia.

Supporting evidence-based care:

• Annual health exam will be replaced by personalized health review for ages 18 to 64.
• The lab requisition will be modified to remove ferritin, TSH, Chloride, CK and B12 but these tests may still be ordered.
• Only ALT (but not AST) may be ordered by non-specialists in community labs.
• Only red cell folate may be ordered by non-specialists.
• Thyroid scans should only be ordered for hyperthyroidism, congenital hypothyroidism, and masses in neck or mediastinum.
• Follow up colonoscopies will be at intervals of 5 or 10 years based on indicators.
• Paps will be every three years from age 21 to 70.
• The following tests will no longer be billable to OHIP:  annual stress tests for asymptomatic patients at low risk for CAD; preoperative cardiac testing for low/moderate risk patients; routine chest films.
• A working group will be established to review evidence to minimize overuse, misuse and underuse of best practice.

Incorporating technology in patient care:

• The Northern Health Travel Grant will be modified to encourage virtual visits where appropriate.
• A working group will evaluate existing pilots and use the data to recommend a model for better communication between hospitals and primary care.
• An evaluation will be developed to examine patient-initiated to provider eConsultations.
• eReferral fee codes will be developed for specialist referral with dermatology and ophthalmology as the initial trial specialties.
• An OTN Working Group will evaluate Personal Video Conferencing (PVC) deployment progress, utili­zation, volume and workflow trends to reduce the need for full telemedicine premiums and a new premium for northern and non-northern telemedicine consultations will be developed.

Increasing the opportunity for physicians to enter FHO and FHN models:

• Current stream of 25 entries into FHNs and FHOs will be expanded to 40 physicians per month beginning April 1 2013— 20 in a prioritized stream based on local need; and the remainder on a first come, first serve basis. Unfilled spots can be shifted to either stream or into subsequent months.  (There will be unrestricted entry to FHGs for all physicians.)

After hours requirements:

• New enhanced after hours requirements will apply to groups with 10 or more physicians:
  • 10-19 physicians – 7 blocks (2 additional)
  • 20-29 physicians – 8 blocks (3 additional)
  • 30-74 physicians – 10 blocks (5 additional)
  • 75-100 physicians – 15 blocks (10 additional)
  • 100-199 physicians – 20 blocks (15 additional)
  • 200+ physicians – 25 blocks (20 additional)
• Existing exemptions continue for ED coverage and obstetrics. If the FHN/FHO contract requires that 50% of FPs are required to have hospital privileges, then the group is exempt from the additional requirement.
• Some FHTs may be challenged to support additional after hours clinics with the necessary administrative and IHP staff.  AFHTO will monitor staffing pressures and advocate for the resources needed to meet requirements.

Annual quality improvement plans:

• Following from the Excellent Care for All Act, all interprofessional models of primary care (FHTs, CHCs, AHACs, and NPLCs) will be required to submit annual qual­ity improvement plans to Health Quality Ontario as of April 1, 2013. The tentative agreement expands participation to include phy­sicians practicing in these models.

Fee reductions and revisions:

• Diabetes management fee will be reduced from $75 to $60.
• Preventive care management fees ($6.86) will be discontinued but the annual preventive care bonuses will continue.
• Access Bonus rebate will be discontinued.  The Access Bonus itself is not changed.
• Two special bonuses that had been rarely accessed (In Office Service and Out of Office Care) will be discontinued.
• Physician payments for Telephone Health Advisory Service will be discontinued. Physicians will not be required to provide on call to THAS, however physician groups may continue to do so on a voluntary basis. Physician groups will still be required to report after hours clinic schedules. PEM groups will continue to receive a report when enrolled patients use Telehealth Ontario.
• Individual PEM physicians with more than 2,400 patients will receive the full value of the CCM fee for the first 2,400 rostered patients. For each subsequent patient, the fee will be reduced by 50%.
• Global payment discount of 0.5% will apply to all physician payments regardless of model.

Access to interdisciplinary services:

• Patient access to interdisciplinary primary health-care services will be expanded by allocating IHP resources to non-FHT affiliated phy­sician groups of three physicians or more, including Family Health Groups, Family Health Networks, Family Health Organizations and RNPGAs.  An implementation plan will need to be developed. What this could mean for the future direction of interdisciplinary primary care and the role FHTs could potentially play in implementation is unknown.

Once again, AFHTO encourages all FHT physicians to review the information available to them through the OMA and vote in the referendum.