Victoria PCN Combined VDFP/SIDFP Neighbourhood Meeting Q&A (March 2022 - Group Contracts)
Last updated on: May 11, 2022
This webpage includes the questions and answers discussed during the March 24, 2022, Combined VDFP/SIDFP PCN webinar on Practicing Family Physician Group Contracts (PFPGCs), and is intended to supplement the webinar recording. The Ministry of Health provided additional information on some answers after the webinar. These additions are highlighted as ‘Ministry clarification’.
Note: During the webinar, questions were answered by Drs Anna Mason and Vanessa Young based on their personal experience working on a Practicing Family Physician Group Contract.
Group contracts are in constant development for improvement. Please use the information below to support you as you prepare for a contract discussion, taking into account that the information provided may have changed.
Looking for more information on PFPGCs? Visit our living library of resources, forms, contacts, and more here.
Table of Contents
Please click the topics below to view the related Q&As:
- Attachment
- Benefits and uptake
- Billing and coding
- Contract adjustments
- Contract evaluation and evolution
- Eligibility
- Reporting hours worked
- Clinical hours requirement
- Locums and time off
- Ministry oversight
- New-to-practice physicians
- Panel complexity
- Patients, bookings, and visits
- Payments and payment rates
- The physician experience
- Quality Improvement (QI)
- Teaching
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Attachment
I am a maternity provider. A group of my colleagues were able to get a contract where they can attach referred and unattached patients for the duration of their maternity care. I started on a contact in January 2022. Am I able to attach maternity patients in this fashion?
- The Ministry of Health will consider this on an exception basis. If the Ministry approves, they will provide the group with an exception approval to the contract.
Please talk to your ministry contacts.
Are physicians required to have attachment conversations with patients they have had for years?
- 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.
If all doctors in BC were on salary, would attachment improve with allowable hours?
- 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.
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Benefits and uptake
Do contracted physicians still get benefits through the BCMA, CME, Disability Insurance, CPRSP, etc.?
- Yes. The only benefit not included is the Community Longitudinal Family Practice bonus (quarterly payment), although work is taking place to review this.
What is the uptake of these contracts in the Health Authority at large?
- 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.
Have any of these contracts been awarded to large groups?
- 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.
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Billing and coding
Do you bill 502’s on everyone once a year that you previously billed any of the complex care fees to?
- Dr. Vanessa Young reports she bills 502s often (e.g., prescription refills, info communicated by staff, etc.)
Can we bill time for education activities?
- 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.
How do ICBC and WCB billings work?
- Physicians bill these as they normally would.
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Contract adjustments
If a physician is accepted for a contract and is estimated to, for example, have a panel and hours currently around 0.7 FTE but wishes to increase their panel and hours to 1.0 FTE in the first year, is this possible? Or do physicians need to have their panel fully established prior to accepting the contract?
- 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.
If someone signed at 0.8 FTE and then finds out they are really 1.0 FTE, can the contract be adjusted easily and quickly?
- 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.
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Contract evaluation and evolution
Are there mechanisms in place to ensure the contracts are formally re-evaluated to address major concerns?
- 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.
Has a Gender-based Analysis Plus (GBA+) been done on the group contracts or new-to-practice contracts? 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
Has the Ministry considered including the option of a parental leave in these contracts? There is a significant amount of need and interest (see links above). Longitudinal family practice is one of the few career choices for family doctors (other than hospitalist or other episodic care) where lack of maternity leave is a real barrier for women to participate. If a reasonable parental leave were included in these contracts, it could attract many more female physicians back to longitudinal family practice.
- 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.
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Eligibility
Do the doctors under contract have to be physically located at the same location?
- 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).
How likely is it that this will ever be available to a solo practitioner?
- 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.
We have a group of seven but 1-2 of our physicians are certain that they don’t want to join the contract. Does that mean that the rest of us cannot sign on?
- 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.
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Reporting hours worked
How are after-hours and on-call services addressed in these contacts?
- 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.
What are shift codes?
- 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.
Is it cumbersome to track your hours (e.g., having to determine how much time was spent on an ICBC visit, etc.)?
- 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.
How do you ensure you work your minimum hours but not much over, and plan ahead to reduce if you can tell you will overshoot?
- 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.
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Clinical hours requirement
Is the 1680 hours/FTE/year a hard cap?
- 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.
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Locums and time off
How are locums paid when covering a physician on the contract?
- 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.
Dr. Mason mentioned she secured a locum for $100/hour working under her contracted hours; how is that attractive when sessional is $160?
- 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.
1.0 FTE at 35 hours a week works out to 48 weeks a year. Are you allowed to take this as a month off as long as you have locum coverage? And are you allowed to take more weeks off than the 4 weeks if you have someone covering your contract hours?
- 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.
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Ministry oversight
What is the Ministry's goal with these contracts? Are they wanting 50 per cent of all family doctors on these contracts, or all of them?
- There is no target regarding uptake. The intent is to provide an alternative to fee-for-service.
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New-to-practice physicians
Is it possible to accept a new physician without a patient panel into a group contract?
- 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.
Does a new-to-the-area doctor have to "kick-start" their panel in a fee-for-service clinic before migrating to a contracted clinic?
- 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.
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Panel complexity
Do we get to see the Ministry calculator?
- 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.
My panel has a large proportion of elderly and complex patients; does this affect panel size for group and new-to-practice contracts?
- Yes it does. If a panel is very complex, your panel size can be smaller than 1250.
If complexity weight is based on an average and physicians start coding problems much better, would we have more difficulty exceeding the average and therefore not get the complexity bonus?
- 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.
Can you discuss the factors that determine patient complexity?
- 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.
Is snomed coding accepted for defining complexity?
- No snomed coding is not accepted to define complexity.
What site is best for ICD9 codes?
- Dr. Vanessa Young considers Google to be the best for searching ICD9 codes - note that one must use ICD9 and not ICD10.
Ministry clarification: https://www2.gov.bc.ca/gov/content/health/practitioner-professional-res…;
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Patients, bookings, and visits
Can you address multiple problems at a time with patients?
- Yes you can.
How do bookings look now that patient issues are not limited to one per visit?
- Dr. Vanessa Young's booking is the same as pre-contract. She always addressed more than one issue per visit.
Does the contract make it harder to manage patients that require more time?
- 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.
It sounds like patient visits per hour is not a consideration. Is that true?
- 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.
If you're paid the same amount under contract no matter how many patients you see in a day, how do you facilitate bookings if you are uncertain of the time you will spend with each patient?
- Dr. Vanessa Young still books 15-minute appointments for most, and 30 minutes for paps, excisions, counseling, dementia, etc.
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Payments and payment rates
Is it possible to have group contract payments made to individuals rather than the group?
- 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.
How are contract band rates determined, individually or as a group?
- 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.
Is there any funding to pay physicians for the time spent re-organizing their clinics in consideration of this contract BEFORE actual contract implementation?
- No, there is currently no dedicated funding.
What is the hourly rate, for 1.0 FTE post overhead, including non-MSP?
- 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.
Is the Physician Master Agreement (PMA) working on getting the hourly rate to go up to $173/hr after overhead?
- The hope is that this will happen, but it is not on the horizon just yet.
Is there any agreement with the Ministry as to annual increases to keep up with rising overhead costs and inflation?
- 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.
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The physician experience
Has being on contract changed how Drs. Young and Mason practice?
- 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).
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Quality Improvement (QI)
Can you explain what the QI requirement is?
- 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.
Is the $20,400 for the QI component different from the 1 hour of QI per week?
- 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.
Is the QI portion mandatory, or could I decide to not do QI and simply not get the associated bonus?
- 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.
Do you bill the QI per hour?
- 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.
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Teaching
How does teaching residents factor into the contracts? Do FPs need to work side-by-side with the resident?
- 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.