In-Patient Care Models – Non-Profit Model – Group Contract Model

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In-Patient Care Models

Communities - click each heading to view details.

Mission – Dr. Peter Barnsdale and Dr. Manju Bhatt

Community: Mission – Mission Memorial Hospital

Hospital size and services: 30 inpatients (overcapacity 34), 20 Patient Assessment and Transition Home (PATH) beds. Inpatients come from the emergency room and transfers from Abbotsford when they are less acute. Hospital has a visiting internal medicine service and X-ray, and will soon have CT on site.

Previous model: Community family physicians looking after own and any unattached patients. Call groups from mainly two clinics. Doctor of the Day/Night. However, many MRPs dropped off or became hospitalists. By January 2022, there were only six family physicians providing care for own patients left and the rest of care was provided by hospitalists.

New model: Full hospitalist model. Hospitalists 1 and 2 work days, 9-11.5 hours | PATH unit line works 4 days, 5 hours, other days and times covered by Hospitalist | Hospitalist 3 works evening (5-11 pm), 6 hours / Night doctor (Hospitalist 1 and 2 alternate nights), 11pm-8am by phone and go in if needed, 9 hours. Hospitalists cover Residential Care. Require minimum of six hospitalists for this model. Hospitalist schedule is set for entire year and is provided mainly by out-of-area hospitalists. None of the hospitalists have a family practice. Emergency Room physicians do admissions, can be consulted, and respond to codes or critically ill patients, but hospitalists remains MRP. Issues: Recruitment and retention of hospitalists and PATH physicians.

Funding model: Hospitalists have a contract with Fraser Health and Fraser Health provides funding for Night doctor (on call). Receive regular volume surge payments.

Penticton – Dr. Tiffany Bursey and Julie Young from South Okanagan Similkameen Division of Family Practice

Community: Penticton and surrounding communities – Penticton Regional Hospital

Hospital size and services: 155-bed regional hospital.

Previous model: Longitudinal family physicians looking after own patients and Doctor of the Day. Many doctors retired, and the program was under threat as of 2017. The number of FPs with privileges at the hospital declined from 50 in 2018 to 16 in 2022.

New model: Mixed model. There are three arms in this model. Arm 1: community family physicians and nurse practitioners who still want to do inpatient work cover their patients 0700-1700 weekdays and 0700-1200 weekends. Arm 2: team of 20 Community Inpatient Service (CIS) physicians at various FTEs cover unassigned patients 0700-1700 every day. CIS physicians are also required to work in primary care in the community – usually as locums for their colleagues in longitudinal practice. CIS currently has four lines. Additional two come in January 2023: Line 1 works 0700-1500, does admissions and assigns patients so they are evenly split; Line 2 works 0900-1700 and covers all calls in the last two hours, Lines 3 and 4 work 0800-1600 and review lab results. Arm 3: Doctor of the Day. MRP for assigned and residential care 1200-1700 weekends. MRP for all 1700-0700 weekdays. DoD is responsible for admissions overnight.

Funding model: Managed by SOSDoFP, who takes care of group billing. The model is funded mainly by FPSC programs, including Unassigned Network Incentive, LTC Initiative After Hours Call, Assigned Inpatient Network Incentive, Bridge Funding, and MSP billings. Pay for CIS, Doctor of the Day, Assign Inpatient Network incentives, physician leads and team meetings, PM, admin. MSP billing covers 80% of the CIS physician compensation. FPSC incentives and bridge funding cover the remaining 20% and 100% of the DoD cost. However, the CIS physicians are not compensated comparably to hospitalists and community FPs expect to be compensated on par with CIS. SOSDoFP is considering funding these top-ups out of their contingency funds but this is not a sustainable solution.

Saanich – Dr. Andrew Kwasnica

Community: Saanich – Saanich Peninsula Hospital

Hospital size and services: 65 acute care beds, always running 40% overcapacity. 14-bed emergency room, always running 19 patients at a time. 12 bed palliative care unit. Attached long term care facility.

Previous model: n/a

New model: Doctor of the Day program, has been running for a long time. The program was failing in 2016 but has been revitalized by aggressive recruitment and retention. Currently, during weekdays only 10-15% of the beds are covered by family physicians caring for their own patients. Rest of patients and weekends are covered by the DoD program, which is divided into four groups, each containing between 5 and 7 community physicians augmented by locums. The group is now 42 physicians. Half are locums, and 19 have their own longitudinal practices and cover own patients or defer them to DoD group. Shifts are 7 days long and 1:6 or 1:8. DoD physicians available on site from 0700 – 2300. Overnight covered by ER physicians for acute issues. The locums are incentivized to do community work; those who agree to work in the community for a physician attached to the hospital are prioritized for extra shifts on the DoD schedule. Workload varies between 12-22 patients. Model is closely linked to Shoreline Medical Society, a non-profit society. Physicians working for Shoreline are required to provide some shifts in the hospital, during which they don’t pay overhead, and other physicians cover their clinic. DoD do admissions for non-assigned patients and during weekend, rotating between four groups.

Funding model: MSP billings (not pooled) and FPSC funding and bridge funding (till March 2024). Admissions and discharges are topped up by FPSC funding. ER physicians receive some FPSC stipends. The Saanich Peninsula Hospital Foundation also provides funding to Shoreline Medical Society and provides locum retention bonuses for two-year contracts. The program would have collapsed without their financial involvement. However, funding is the constant threat to the program.

Sechelt – Dr. Annette McCall and Dr. Karin Forgie

Community: Lower Sunshine Coast Community – Sechelt Hospital

Hospital size and services: 40-50 inpatients, 11-bed emergency room. Also has a CCU, inpatient psychiatric ward, obstetrics, surgical services, internal medicine, and an imaging department including a CT scanner.

Previous model: Almost all family physicians were full-service family physicians practicing in both the hospital and the community. Almost all family physicians who had a longitudinal practice were required to contribute to hospital-based care: obstetrics, anesthesia, emergency, or in-patient rounding. Some family physicians had fulfilled more than one role in hospital (e.g. obstetrics and ER). There were exceptions based on individual needs that continued to be "grandfathered;" some physicians were not required to contribute, yet others who wished for the same were denied that option and gave up their longitudinal practice in order to provide focused care. The perception of this model for newcomers was confusing and had the appearance of lack of fairness. Remuneration was poor, as many physicians were also asked to pay up to 30% of the MSP payments, which were inadequate, to their respective clinics, bringing an hourly wage for weekend and evening work to less than $100/hr with no compensation for being on call.

New model: The new model is as above but compensation has increased significantly due to the inpatient bridge funding. Currently less than one quarter of the available physicians do in-patient rounding, between 10 and 12. The currently small number of inpatient rounding physicians poses a risk for the viability of inpatient rounding by this group: physicians may drop out due to retirement, leaving the coast or simply resigning their hospital privileges (one physician so far has done that). Unattached inpatients make up about 25% of all inpatients and are attached one by one to family physicians with hospital privileges (approx. 27 physicians) who can bill a one-time fee for serving this patient in addition to the regular MSP billing. The range of inpatients per family physician is between 0 and 10 inpatients. More than five inpatients make it very challenging to sustain a fully booked family practice and continue to be available for the inpatients during the day. Currently the ER physicians admit patients, which is becoming unsustainable for the ER physicians.

Funding model: The current model is funded jointly by FPSC bridge funding and MSP billings, as well as some funding from the long-term care initiative funding and some sessional funding for psychiatric inpatient care. Some physicians are in this group because they’re not trained in or comfortable providing emergency medicine, obstetrics or anesthesia, some do it because it is the right thing for the community, not because they love the work, and some do it because they love hospital medicine and want to contribute in a fair and equitable way to the running of the community hospital. The team is looking for solutions to decrease the pay disparity and thus make it more attractive to compete with emergency work. Work is also underway to clearly and fairly state expectations of all family physicians with longitudinal practices and hospital privileges to participate in hospital work, thus eliminating the previous unfairness and "grandfathering of special needs." Request has been put forward to VCH for sessional funding for the weekends on-par with the Lion's Gate Hospital hospitalist payment model.

Cowichan – Dr. Graham Blackburn and colleague, and Rory Allen from Island Health

Community: Duncan – Cowichan District Hospital

Hospital size and services: 148 in-patient beds (with 160-170 patients in the building at any time).

Previous model: Family physicians cared for their patients (approximately 60%) with unattached patients attached to the Doctor of the Day, a rotation where an unattached inpatient is attached to the next doctor on the list. The number of doctors on the list has been dwindling in addition to an increase in unattached patients. They added a program called UNIT – Unattached Inpatient Team. The UNIT members are in hospital for a week and take a full load of patients. Some continue to see their own attached inpatients during this week. Unattached patients’ assignments now alternates between DoD and UNIT. There have been challenges getting physicians to sign up for either Doctor of the Day or UNIT shifts.

New model: The Cowichan Valley Division of Family Practice with Island Health and the local Medical Staff Association completed a comprehensive review of inpatient care models. The report from this project recommended moving to a group coverage model with physicians on call. Physicians/clinics will align into shared coverage groups and nominate physicians for shifts to cover inpatients who are attached to their group, as well as a certain number of unattached patients, based on the number of attached patients currently in hospital. Each group will cover a maximum of 15 patients. Model includes daily stipend (8 hours) for physician for admission of unattached patients and assignment to coverage group. Will also include physician for after-hours call coverage from 1600-0800 (evening rounding, be on call, and go in if needed). Further engagement is underway to determine the feasibility of this model in the Cowichan Valley

Funding model: The model is currently funded by MSP billings. Billings are pooled for unattached patients. The return on billings is 90%, but it can take three to six months to receive. There is a possibility of accessing COVID funding to top up physician compensation.

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Non-Profit Model

Presentation by Christine Matuschewski (CEO) and Dr. Tracey Smillie (Physician), Supporting Team Excellence with Patients Society (STEPS); and Karen Morgan (Executive Director) and Dr. Christopher Dowler (Physician), Shoreline Medical Society (slide deck available here)

FAQ - click each heading to view the answer.

What is your general operating and funding model?

Physicians work fee-for-service or under the new-to-practice contract with a split between 28% and 35%. Both organizations pursue other funding avenues as well, including grants and charitable donations. STEPS is a not-for-profit and relies on grants, while Shoreline is a charity and receives capital and operational funding from different foundations and private citizens. Both indicate that operating funding challenges are frequent and regular. BC Health is not yet set up to fund the community health centre model, however, the BC Association of Community Health Centres is advocating for better funding models.

What is it about the model that makes it successful?

The not-for-profit structure pulls the administration work of a clinic to specialized staff members, allowing physicians to focus on their practice instead. It promotes a supportive, collegial environment, and allows physicians to focus on the community. It also encourages community participation in developing a robust longitudinal care system in the community, either through participation in the non-profit board and work on projects, or through donations and fundraising. Shoreline also includes physicians in its governance model, which allows them to have input on decisions that may affect operations. Because Shoreline is a charity and receives donations, they are able to make decisions as to the best use of those funds, whereas STEPS, which does not have a charitable status, relies on grants, which can only be used for certain specific items or activities.

What kind or community support (financial, in kind, other) do you receive, if any?

Both organizations receive a great deal of community support, both financial and otherwise. Both organizations have key community members on their boards of directors. STEPS deliberately did not pursue charitable status, but partners with other organizations to achieve the same goals. This takes the form of using community capacity as in-kind donations, expertise, fundraising, etc. Shoreline, conversely, receives both capital and operational funding from the Saanich Peninsula Hospital and Healthcare Foundation, and is able to organize community fundraisers due to their charitable status.

Who where the people driving the development?

In both cases, physicians and some engaged community members drove the model forward. In STEPS’ case, the physician lead at the Thompson Division of Family Practice realized that the multi-physician business plan that had come out of GP4Me work in their region would never go forward unless she did something with it. For Shoreline, it was the chief of staff at the Saanich Peninsula Hospital, which was facing collapse due to a physician shortage; despite being located so close to Victoria operates on the rural model, where the bulk of in-patient care is provided by family physicians. In both cases, finding passionate community members with additional skills (legal, accounting, fundraising, etc.) was a key factor in successfully moving forward with the non-profit model.

What supports are available for physicians?

Physicians have access to specialized staff to can help maximize their billing and assist with administration and clinic management. External funding and grants support with overhead costs. Allied health professionals are available to support team-based care and the multi-physician format, especially when the clinic is not owned by one of those physicians, and encourages a culture of mentorship, collegiality, and collaboration.

How much autonomy, flexibility and freedom do physicians have?

Physicians have clinical autonomy under this model, but workflows and operational decisions require compromise and communication. For example, physicians must fill out the EMR system for their patients within a set timeline and with a certain standard of information as all other physicians in the clinic, so as to make both coverage and billing more efficient. STEPS has a focus on “what is fair,” for the society, the physicians and the team as a whole. This focus helps steer the needed compromise in a successful way.

What makes this work environment so satisfying?

Both physicians indicated that the collegiality of physicians, transparency of finances, and community engagement in the health centre were key factors in their satisfaction with the model. Dr. Smillie had worked in a family practice run by another physician, at a community health centre, and had her own private practice before joining STEPS. The first had a distinct lack of transparency around clinic finances, the second required giving up a lot of autonomy, and the third was enjoyable but quite lonely with minimal access to allied health providers. Dr. Dowler had completed his residency in rural Manitoba in a community that supported their local medical clinic, and was surprised to discover that was not the norm but rather the exception in British Columbia. He locumed at about 20 different clinics looking for a similar environment before learning about Shoreline, and likely would have left BC had he not joined them.

How are patients attached?

Patients are attached to individual physicians, or pairs of physicians if those physicians are sharing a practice.

How do you arrange for practice coverage and in-practice care?

Both organizations use cross coverage and recruit locums. Physicians work in the hospital one week every two months to provide in-patient care. To encourage locums to sign on, Shoreline created a return-of-service expectation. If a locum works in the hospital for one week (which they have been able to make financially lucrative) they also have to do locum coverage at a clinic that supports the hospital. At first locums found this frustrating, but many have come to enjoy it.

How do physicians get compensated?

Physicians have autonomous practices under the umbrella of the organization. Physicians bill fee-for-service for their work (unless they are under a new-to-practice contract), with the organization taking a cut to fund administration and capital costs. STEPS started with a base rate of pay but moved to a 70/30 split in order to not destabilize the health care system in the region by pulling locums and physicians from other clinics. Shoreline offers a four-step graduated split (between 35% for monthly billings up to $8,000 and 28% for monthly billings of $12,000+), and also retains a billing specialist on staff to maximize physicians’ income within the publicly funded system. Note: Physicians are required to pay overhead if the organization is a charity; this is a requirement of the Canada Revenue Agency.

How many patients are seen per physician?

While it depends on physician preference, most physicians see 25 to 30 patients in a full office day. STEPS now has five clinics and serves approximately 17,000 patients. Shoreline has two clinics with 25 physicians.

What is your team set up (e.g. multi-disciplinary, how are you working together)?

STEPS hires allied health professionals to work in the clinics, while most Shoreline’s AHPs are funded through the primary care network. Both run a team-based care model.

How do you treat physicians with a special focus?

While all physicians have regular longitudinal practices, those that have specialties find different supports under this model. As one example, STEPS has a family physician who also does transgender and gender-affirming care. STEPS looks for grants to top up this specialist to a sessional rate to make it financially viable under the FFS model. Shoreline uses an internal referral system, where physicians will refer patients to their colleagues with a special focus.

What is your ability to retain and recruit physicians?

Both organizations have been successful in retaining and recruiting physicians. They are both heavily involved in the medical education system. All STEPS’ physicians are preceptors with UBC, and Shoreline is very involved with the local residency program. They find that physicians who train at their clinics are more likely to come back to practice or locum, and their model is such that it minimizes the barriers to physicians beginning their practice. Shoreline has developed a good and efficient onboarding system and has a simple EMR, both of which contribute to their reputation as one of the easiest places to work.

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Group Contract Model

Presentation by Elisabeth White (Senior Regional Advisor and Advocate, Doctors of BC - slide deck available here) and Drs. Erin Hasinoff and Lisa Gaede (North Shore Medical Group - slide deck available here)

FAQ - click each heading to view the answer.

What was the key reason for moving to the group contract model?

There were several reasons doctors gave, including dissatisfaction with the instability of income in the fee-for-service (FFS) model, interest in more financial stability month-to-month for budgeting purposes, and interest in working better with the primary care network (PCN).

What were doctors’ experiences moving from fee-for-service to a group contract?

For early adopters of the group contract model, there was a lot of frustrating paperwork and very little assistance available. The latter has changed somewhat now that more group contracts have been put in place, although the paperwork associated with a group contract remains high.

Following adoption of a group contract, physicians account for their time worked in fifteen-minute increments, which are recorded in a spreadsheet and submitted to the Health Authority on a quarterly basis. Physicians do find this a bit onerous, but quicky get used to it.

Encounter codes (categorizing the work done) and shift codes (essentially clocking in and out of work) are entered into the EMR, and as there are only 21 encounter codes, the recording process is easier than FFS. For example, there is only one code for immunization – it does not matter what type of immunization was performed or how old the patient was.

Physicians still use ICD-9 codes, but unlike FFS, they can use multiple ICD-9 codes for one patient encounter. Recording this in the EMR factors into the complexity calculation the government uses to determine the payment bracket for the group in subsequent years.

The ratio of time spent between administration and direct patient care has remained the same for physicians under the group contract. However, they are now compensated for indirect patient care, which they are not under FFS.

What process was followed to enter into a group contract?

The first steps are to get a group of at least three physicians together who work on the same EMR (required) and then submit an expression of interest to the Ministry of Health. The expression of interest is fairly simple, and includes each physician’s MSP billing number. The ministry will then examine the physicians’ previous year’s billing, and will come back to the group with an offer of what they will pay the group for a year. There is very little room for negotiation on this offer. Staff members at Doctors of BC will also review the contract at this point to ensure that it is fair and compliant with the Physician Master Agreement (PMA).

Next, the physicians must enter in to a Group Governance Agreement (GGA), which should be drafted by a lawyer, possibly with advice from an accountant. The GGA lays out remuneration of each member, responsibilities for start-up costs and operating expenses, responsibilities and decision-making, steps for conflict management, scheduling, and terms of agreement and termination. It is vital to have this agreement in place to govern the working relationships of the group.

Prior to shifting to the group contract, the group must open a new bank account and get a new group payee number assigned. As well, the EMR vendor must be contacted and given time to update the software with the new codes. Note that some physician work, including WCB, ICBC, LTC, and maternity, is still billed as FFS.

How long was the transition to the group contract, and what went well or not well?

The early adopters first applied in November 2020 and switched to the group contract in August 2021, a total of nine months. That timeframe may be shortened now that more group contracts have been implemented province-wide.

The physicians found that it took between two and three months to get used to the new way of working. The day-to-day became easier with fewer billing codes, but because reports are submitted quarterly, they did not get feedback on whether or not they were submitting correctly for several months. By the end of six months, things were going more smoothly and they knew they were on track.

Because there is no contact at the Ministry of Health for group contract physicians, all communication must go through the Health Authority, and that can be frustrating and cause delays in answers to questions.

What are the benefits and challenges of working in a group contract payment model?

Benefits include:

• Indirect patient care and administration now count as part of the physician’s hours of work, which more fairly values the actual work performed by a family physician. The contract allows physicians to be compensated for the time they spend working, not just for the services they perform.
• It separates patient care from remuneration, and allows physicians to adjust their time and bookings for patients with complex medical issues or those traveling from further away who may want to discuss multiple issues in one appointment.
• It allows physicians to still bill FFS for uninsured services, as the contract just covers in-office family practice time and work.
• PCN administration can be covered as part of the contract.
• Locums can bill under FFS or under the contract, whichever works better for the physician and the locum. Some locums prefer to bill under the contract.
• It provides a stable income, which is good for overhead and budgeting.
• MSP rejections are minimized. There are hardly any reconciliations billed back unless the physician has coded something incorrectly.
• Physicians in the contract found they were able to take more time off (based on the availability of locums or other coverage) because of the stability of funding and the working hours provisions within the contract (maximum 90 hours in a two-week period).

Challenges include:

• Shifting primary contacts from the Ministry of Health to the Health Authority, and then changing staff members as primary contact within the Health Authority, made it challenging to get questions answered, though that appears to be stabilizing.
• EMR vendors have little motivation to make changes to their software for small groups, so some processes are managed by doing workarounds rather than software changes.
• QI and the attachment process can be a bit bulky.
• The contract estimates 1,680 hours per year as a full-time equivalent (FTE) for a family physician, which is low.
• The reporting requirements are onerous, but also allow for data analysis to see where the physician is spending their time.
• There is uncertainty about future payments in the second and following years of the contract.
• Physicians cannot decide to unilaterally do patient panel changes or group changes without consulting with the Ministry of Health. For example, a part-time physician cannot decide to work an extra day per week or a new physician cannot be added to the group without Ministry approval. This constitutes a slight loss of autonomy.
• With a new compensation model coming out in 2023 through the PMA, there may be less reason to move to a group contract than there was two years ago. There is a lot of up-front work and expense involved in moving to a group contract, so it may be worthwhile to wait and see what the new compensation model looks like.

What should physicians consider before exploring a group contract?

First and foremost, physicians in the group need to trust each other. The compensation comes in a lump sum for the entire group, and each physician has authority on the bank account. As well, what one physician does can affect the whole group. This is why a good GGA is essential prior to moving to a group contract.

Physicians should also be aware that there is quite a bit of administration involved in moving to a group contract. The stable funding and compensation are nice, but there is quite a bit of paperwork involved, and physicians should be aware of that. That said, part-time physicians feel as though they are doing a lot of work, but are fairly compensated for it.

As well, the group is sharing patients (sort of). The group contract covers the patient panels of each individual doctor, and if the group is working in the same office as physicians not in the group, those patients should not see physicians outside of the group, as those physicians cannot bill FFS for those patients, essentially asking them to do unpaid work.

How much autonomy, flexibility, and freedom do physicians have within the group contract model?

Changes to hours of work or the composition of the group must go through the Ministry of Health, as the contract is a legal agreement and would need to be officially altered between the two signing parties. This constitutes a small loss of autonomy.

The FTE of the contract equates to 48 weeks of 35 hours/week for the year. While the group commits to patients having access to medical care from the group for certain hours per day and certain days per year, this allows for time off, which physicians within the group work out themselves either by having the group providing cross coverage, or by a locum.

One additional restriction is that the physicians cannot mix FFS (WCB, ICBC, LTC, in-patient, maternity, walk-in) work and contract work for patients within their patient panel without billing that time differently. For example, a physician could see one of their patients for a 15-minute appointment for a WCB case, and then must exclude those 15 minutes from their shift code and time tracking spreadsheet for the day.

Physicians under the group contract are required to meet the hours requirement of the contract, but that feedback does not happen until well after the end of the first year. However, quarterly data is available more quickly now that both the Ministry and the Health Authority are getting more practiced at administering group contracts.

How are patients attached?

Patients are attached by submitting a billing code via teleplan. This links them to both the physician and the group. Physicians must have a conversation with patients about their attachment on a yearly basis, and some patients find that confusing.

Who takes care of forms/legal letters/etc. for patients under this model?

The physician to whom the patient is attached continues to do this work for them as indirect patient care.

How do you arrange for practice coverage within this model?

Practice coverage is the same as under FFS, with the additional possibility of locums being paid under the contract rather than FFS. Physicians within the group can cover for each other, bring in locums as FFS, or pay locums out of the contract, whichever they prefer.

How does physician income compare to the FFS model?

Physicians who have moved to a group contract have generally found their income has increased. There are some physicians that bill well under FFS and some that struggle with it. For the latter, a group contract makes more sense financially.

What influences patient intensity pay?

While the initial contract amount is determined by previous MSP billing, physicians continue to use ICD-9 codes, sometimes multiple, for each patient encounter. Recording this in the EMR factors into the complexity calculation the government uses to determine the payment bracket for the group in subsequent years.

How are AHPs compensated?

AHPs are compensated through the PCN (if one exists).

How many patients are seen per physician?

Physicians under a group contract generally find that their practice size has stayed stable. However, they report that their capacity has increased, as they are able to delegate more and also do not have to find time for patient appointments for simple matters in order to be compensated for that time. For example, a physician under a group contract can fax off a prescription refill for a patient or go over lab results and will be compensated for that time without seeing the patient in the office, which frees up that time for another patient who does need to be seen.

Are you able to recruit new physicians/locums?

Physicians under group contract have found it easier to recruit locums because they can generally offer them a better split, or offer them an hourly rate instead of straight FFS.

What kind of community support (financial, in kind, other) do you receive?

None.

What is the minimum time commitment?

There was a minimum of 0.5 FTE for each physician applying under the group contract (this requirement may have changed). Therefore, part-time physicians are allowed as part of the group. The group as a whole is assigned an FTE amount that is shared among all the physicians.