Yes, the current expectation is to have an attachment conversation with, and provide written confirmation for, every patient. It is something that physicians currently on contract are pushing back on because they feel that patients can be confused by the conversation, it is time-intensive, and isn’t always feasible within the constraints of work.

Perhaps attachment would improve if all doctors were on salary, however, there are some physicians for whom fee-for-service works well and who have no interest in moving away from fee-for-service.

Yes. The only benefit not included is the Community Longitudinal Family Practice bonus (quarterly payment), although work is taking place to review this.

As of March, 2022, there were eight clinics on group contracts in the Vancouver Island Health Authority, with several more in the works and set to begin.

The largest group on the Island to be approved to-date is six physicians, although Island Health is looking at onboarding others that are larger.

Dr. Vanessa Young reports she bills 502s often (e.g., prescription refills, info communicated by staff, etc.)

If the education is related to managing a patient (e.g., Up-To-Date), physicians can bill the time. They cannot bill for time spend reading journals, attending Continuing Medical Education (CME), etc.

Ministry clarification: Some educational activities are billable under QI reporting (52 hours per year). Please refer to QI requirements or contact PSP for further details.

Physicians bill these as they normally would.

An increase in panel size and hours could be possible. The group’s situation would need to be explored further to determine if the group as a whole could fulfill contract requirements at current state, prior to the increase in panel size and hours.

If during the contract period the group wants to expand its practice (e.g., a part-time physician expanding to full-time or an established physician newly joining), they can submit a request for reconsideration to the Ministry.

It is best to go into negotiations with an accurate estimate of FTE. Contracts can be amended, however this can be cumbersome.

Ministry clarification: Hours will be reconciled within 120 days of the end of first year of the Term.

There are no formal review mechanisms currently in place. However, Island Health and the Ministry are keen to learn and evolve with physicians’ needs, and are receiving ongoing feedback from existing contracted physicians. Dr. Young has initiated discussions with Doctors of BC around the need for formal feedback channels.

Question continues:

It appears that the inability of a family physician to work less than 0.5 FTE creates a barrier for many female physicians who tend to assume more household/childcare burden and often work 0.5 FTE or less (see reference here). Considering female physicians make up 75% of family doctors nowadays**, this would be important to remove barriers preventing them from practicing longitudinal practice. Especially when those working less than 0.5FTE have the highest interest in alternative payment models like contracts (see reference here).

**Overall, the number of female physicians is still less than parity (CMA quotes 43% female, 57% male). But if you look at NEW grads, numbers are quite different. CMA quotes nearly 2/3 (64%) of female physicians under age 35 are female (see reference here) Looking closer to home, 89% of the UBC Victoria site family medicine residents in 2019/2020 were female, for example. It is roughly estimated that 75% of the latest family medicine graduates are female.

Ministry responses pending

It is understandable that physicians will take leave for a variety of reasons including maternity leave. The Practicing Family Physician Group Contract contains considerable flexibility in how the hours are allocated amongst the physician group. The physicians on the group contract can cover for each other, as capacity allows. Additionally, the contract allows for the use of locums and subcontractors for longer-term leaves.

Doctors can be in different sites (i.e., multi-site clinics) but they must be part of the same Primary Care Network (PCN) and be prepared to work together to provide the services under the contract. They must also be able to access each other’s EMR. This requires a high level of trust and transparency around disbursement of income, practice patterns, hours expectations, etc. There is a group on contract in Victoria with three doctors in one clinic and two in another.

Ministry clarification: Multi-site clinics should identify their scenario to MoH went submitting their EOI. If a clinic is in close proximity but crosses a PCN border, please also notify MoH when submitting the EOI (as this will require special approval).

This contract is a work in progress. It isn’t available to solo practitioners now. However, there is the option to virtually co-locate, and some physicians are currently doing this (see question above). Additionally, as physicians on the new-to-practice contracts reach the end of their two-year terms, the Ministry may introduce a new solo contract option.

Unfortunately, yes. As of now, all physicians in a clinic must participate. However, this is another area that will hopefully change in the future.

Ministry clarification: As the mixed modality policy is currently under development, clinics without mixed modalities are being prioritized; however, all clinics are encouraged to submit an EOI in order to understand their mixed modality situation.

Physicians track time spent dealing with specific calls/cases and count as hours under the contract. This also includes time spent with patients outside of the physician’s panel while on call as a member of a broader community call group.

Shift codes are a way of reporting to MSP on how many hours one works each day under the contract. It is easy once you’ve been demonstrated to do it.

It can be, but you are still paid for your time to do so. Some physicians use an app to track, write it down on paper, or even reference their EMRs.

The hours-tracking spreadsheet is coded to flag (in red) when physicians are forecasted to exceed the maximum of 90 hours during a biweekly period, which allows physicians to map out their hours and plan accordingly. For example, Dr Anna Mason was able to see that she was on track to reach her hours quota in November and planned for a fall locum who would work on fee-for-service while she took vacation. As with most locum considerations, there is planning and awareness required to schedule coverage.

There is actually a range on hours (1680-2100), which is derived from the Physician Master Agreement (PMA). However, physicians are fully paid out at 1680 hrs. There is no need to work more than 1680 if not desired.

Locums can be paid either under contract or by fee-for-service, depending on how each physician would like to fulfill their contract hour requirements. For example, Dr. Anna Mason has offered a flat hourly rate ($100, no cap) for a locum working under her contract, which she and the locum found to be simple and hassle free, and the locum got paid faster. On the other hand, Dr Young’s locums have worked fee-for-service under an attractive 90/10% billing split.

Ministry clarification: Locums can be paid either Fee-for-Service or report hours under the contract. Locum payment is determined by the clinic or physician the locum is covering for.

AOP form assigning payment to the clinic payee is preferred for both locums billing FFS or reporting hours under the contract. This provides the most comprehensive quarterly reporting for the PFP physician group.

It all depends on what’s attractive to each doctor. In Dr. Mason’s situation, the locum preferred to not deal with management processes and liked that they got paid quickly.

As long as the group’s contracted hours requirements are met each physician can take as much time off as you want. For example, Dr. Vanessa Young has taken ten weeks off this year, all covered by locums.

There is no target regarding uptake. The intent is to provide an alternative to fee-for-service.

A requirement for the group contract is that each physician have an established panel. A physician without an established panel can take over a retiring or departing family physician’s patient panel up to 6 months after the physician departs. If the new physician joins after 6 months, the new physician would need to start a new-to-practice contract. Then, once a panel is established, they could transition to a group contract.

Yes, they would need to build a panel, but fee-for-service isn’t the only option. They could also join a new-to-practice contract, which would allow them to build a panel over two years (800 by end of year 1, 1,250 by end of year 2). Then, once a panel is established, they could transition to a group contract.

Physicians don’t get to see the Ministry calculator, but they can get a good sense of it through their Community Longitudinal Family Practice (CLFP) payment data.

Yes it does. If a panel is very complex, your panel size can be smaller than 1250.

The average is compared provincially (not per individual), so a change is not likely. However, as more people come on board, the overall complexity average might be impacted.

Ministry clarification: We anticipate the changes to the complexity average will be negligible.

Patient complexity is determined based on a Ministry scoring system (the John Hopkins Adjusted Clinical Groups (ACG) model) that considers, healthcare system costs corresponding to specific diagnoses. This means that each physician’s diagnostic coding (i.e., the 4–5-digit ICD9 codes) plays a large role in how panel complexity is rated. The more different diagnostic codes there are per patient, the more complexity is received per panel. Each quarter, contracted groups will receive a Ministry report that includes complexity, attachment numbers and encounters.

In general, the scoring system is difficult to understand. Increased transparency around the process is anticipated as more physicians become curious about the contracts and want to know more.

No snomed coding is not accepted to define complexity.

Dr. Vanessa Young considers Google to be the best for searching ICD9 codes – note that one must use ICD9 and not ICD10.

Ministry clarification

Yes you can.

Dr. Vanessa Young’s booking is the same as pre-contract. She always addressed more than one issue per visit.

Dr. Vanessa Young stated that this is not her experience. In fact, she feels these patients have been easier to manage. Without the time pressures of fee-for-service, there is flexibility to spend more time with the patients that need it.

In theory, patient visits per hour is not a consideration. There is no minimum-patients-per-hour requirement on the contract. The number of patients per hour is up to each physician and how they want to service their panel. However, booking pressures always exist when managing a full panel.

Dr. Vanessa Young still books 15-minute appointments for most, and 30 minutes for paps, excisions, counseling, dementia, etc.

The Health Authority makes payments to the clinic, so the clinic retains flexibility with how it is dispersed to individual physicians (e.g., when one physician is covering for another or if there is a premium for working less-desirable hours). However, if there is interest from a clinic to disperse payments to individuals this can be explored.

Ministry clarification: The clinic’s governance or practice agreement should be used to determine the individual practitioner payment.

Contract band rates are determined by comparing the practice’s combined panel size and complexity (i.e., complexity weight) to expected provincial averages. Contract band rates are achieved when the clinic exceeds panel size expectation as a group. Complexity weights are reported for the group and per physician, so everyone can see where they stand against provincial averages.

Ministry clarification: Panel size expectation is adjusted based on the panel complexity and the impact of clinical teaching. Please see Appendix 3 of the Contract for further details.

No, there is currently no dedicated funding.

The hourly rate for Band 1 is $175 (assuming 1680 hours annually for 1.0 FTE). However, post-overhead calculations depend on each clinic’s overhead and third-party billing practices. For example, prior to signing the contract, Dr. Anna Mason’s clinic overhead was 35-38%, and under the contract it is just less than 20 per cent.

The hope is that this will happen, but it is not on the horizon just yet.

There is no formal agreement on annual increases, and this would depend on PMA negotiations.

Ministry clarification: As stated in Appendix 3 of the Contract, Contract Band rates are for the 2021-22 Fiscal Year. As of April 1, 2022 Contract Band rates will increase as part of Physician Master Agreement negotiations.

Yes, it has changed their practice. They are spending more time with patients, taking more holidays, and getting paid for everything they do. Another benefit is that, because physicians are paid regardless of how many patients they see in a day, there is flexibility to spend more time with their patients that really need it (e.g., those with complex or mental health issues).

The QI requirement is a significant undertaking to be aware of (up to 52 hours/year per FTE can be reported under the contract), which includes panel management and use of the Patient Experience Tool. Physicians who complete the required QI activities over the course of a year qualify for a payment of $20,400 per full-time physician, prorated for part-time.

No, they are the same. Physicians can claim up to 52 hours per year under the contract (or up to 1 hour per week). To receive the $20,400/year QI bonus, each physician must complete the QI contract requirements as determined by PSP.

In theory, you could choose not to do QI and not receive the bonus, however, the general intent is for physicians to engage in QI. Although this situation has not yet been encountered during contract negotiations, the contracts are still relatively new and there is an interest in learning and adjusting over time.

Ministry clarification: Quality improvement (QI) is an expectation of the contract.

Yes, the contract spreadsheet, where physicians track your hours, there is a section for QI. The intention is to spread the hours out over the duration of the contract. Physicians can report up to 52 hours of QI per year per FTE (e.g., per 1680 hours of clinical work), which works out to be one hour per week. The best advice is to keep QI simple and be reasonable about what you can complete.

The contract does include teaching residents. It is not a contract requirement to work side-by-side. All hours spent clinical teaching is billable under the services under the PFP Group Contract.