REVIEWING MODELS FOR PHYSICIAN COMPENSATION CANADA AND ABROAD

1. 1 REVIEWING MODELS FOR PHYSICIAN COMPENSATION CANADA AND ABROAD WILLIAM L. OROVAN CAROLYN TUOHY

2. 2 METHODS OF PHYSICIAN COMPENSATION FEE FOR SERVICE CAPITATION SALARY MIXED MODELS AFP/APP�S

3. 3 ISSUES ARISING PRIMARY VERSUS SPECIALTY CARE MD PREFERENCES (AGE,GENDER, SPECIALTY) FUNDER PERSPECTIVES (BUDGETS, OUTCOMES) INCENTIVES/ETHICS/CLINICAL JUDGEMENT

4. 4 FEE FOR SERVICE:THE DEBATE MD PERSPECTIVE PHYSICIAN AUTONOMY VOLUME DRIVEN TARGET INCOMES INCENTIVE FOR COMPLETENESS OF CARE FREEDOM OF MOVEMENT FOR PATIENTS

5. 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

6. 6 CAPITATIONMD PERSPECTIVE LESS AUTONOMY BURDENSOME (ROSTERING) INCREASED RISK (COMORBIDITY) NEED LARGE(R) PATIENT POPULATIONS OUTCOMES VERSUS EFFORT BASED

7. 7 CAPITATIONFUNDER PERSPECTIVE ENCOURAGES EFFICIENCY (N.P�s) INCENTIVE TO LIMIT SERVICES (LAB, HOSP) �SKIMMING� IN ROSTERING BUDGET CERTAINTY IMPROVED CARVEOUTS/BONUSES AS NEEDED

8. 8 SALARYMD PERSPECTIVE REDUCED AUTONOMY REDUCED CLINICAL/PROFESSIONAL SCOPE NO PRODUCTIVITY INCENTIVE NET LOSS OF INCOME NO INCENTIVE TO CONTINUITY OF CARE

9. 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

10. 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)

11. 11 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)

12. 12 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)

13. 13 ALTERNATE PAYMENT(ONTARIO) NUMBER OF CONTRACTS 315 NUMBER OF PHYSICIANS 4508 VALUE $637.6 mm

14. 14 CANADIAN NON FFS BY PROVINCE (2002)

15. 15 TOTAL NON FFS ONTARIONOVEMBER 2004 (G.P.�s) FHN FHN/FHG FHG PCN SEAMON(FHN) HSO TOTAL 374 48 2610 161 17 150 3360

16. 16 AFP (AHSC)

17. 17 FHNONTARIO

18. 18 FHGONTARIO

19. 19 PCNONTARIO

20. 20 UNITED KINGDOM I SPECIALISTS (NHS) -SALARIED (BY SESSIONS) -UP TO 10% ADDITIONAL FFS -�MERIT� BONUSES -�REVIEW BODY ON DOCTORS REMUNERATION� -PRIVATE OPTION AVAILABLE

21. 21 UNITED KINGDOM II GP�s - 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

22. 22 UNITED STATES FFS (MODIFIED BY RBRVS) CAPITATION MODALITIES DECLINING EMPHASIS ON ADAPTING FFS

23. 23 AUSTRALIA HOSPITAL/SPECIALISTS SALARY FFS SESSIONAL GP�S FFS -BULK BILLNG (80%) -BILL DIRECT (20%)

24. 24 NEW ZEALAND HOSPITAL/SPECIALISTS - MAJORITY SALARIED GP�S -FFS 85% OF MD�S -CAPITATION 15% OF MD�S

25. 25 SWEDEN GP�S - 86% SALARIED - 12% FFS - 7% PRIVATE

26. 26 CONCLUSIONS REVIEW CURSORY/COMPLEX SITUATION DYNAMICS OBSCURE/FFS VS OTHER REFORM OF FFS REMAINS POSSIBLE GRADUALISM/VOLUNTEERISM