Hospital On-Call Coverage program

Overview

The Hospital on-Call Coverage (HOCC) program was developed to:

• enhance and stabilize the delivery of hospital on-call services to Ontario patients
• provide stability and predictability in physician on-call coverage across Ontario

The program:

• recognizes the additional burden placed on physicians for providing on-call services beyond their normal workday
• provides funding for hospital on-call coverage to offset coverage expenditures previously borne by hospital operating budgets

Currently, there are approximately 16,000 physicians participating in the program at 170 hospitals.

HOCC background

The HOCC program was first established under the 2000 Framework Agreement between the Ministry of Health (MOH) and the Ontario Medical Association (OMA) to provide funding for direct physician payment for hospital on-call coverage or to offset existing payments for hospitals on-call coverage borne by hospital operating budgets.

Part of the agreement provided for a HOCC committee, made up of representatives from both MOH and OMA to oversee the establishment and coordination of the program. Since its inception in 2000 the HOCC program has been updated to include:

• enhanced funding program
• funding for additional on-call rotation scheduled (rotas)
• intra-sectional allocations
• regional on-call arrangements

MOH is currently responsible for policy, operations and financial components of the HOCC program. Under the 2021 Physician Services Agreement (PSA) a fundamental re-design of the HOCC program into a burden-based funding model is to be undertaken by the ministry and the OMA with an anticipated implementation date of April 1, 2025.

Principles of Hospital On-Call Coverage registration

1. A physician may be registered for HOCC in only 1 specialty/service at only 1 hospital/site.
   • The hospital or Medical Advisory Committee (MAC) determines the services for which on-call is required at the hospital. A physician must choose in which 1 specialty he/she wishes to register for HOCC funding.
   • A physician may actually participate in more than 1 service rotation/call group but can only be registered for HOCC funding under 1 stipend.
2. A physician will normally be paid from the stipend under which he/she is registered.
   • Although a physician may cover 2 different services/sites on the same shift, only 1 payment may be made for that shift. This payment will normally be made from the 1 stipend in which the physician is registered for HOCC.
3. Notwithstanding Principle 2, the distribution of HOCC funding among the physicians who actually provide the call is a local matter to be administered at the hospital level with the agreement of the registered physicians.
   • For example: The hospital may pay a Vascular Surgeon from the General Surgery stipend on a night where the Vascular Surgeon provides coverage for General Surgery if all of the following criteria are met:
     • on a night when he/she is not on call for Vascular Surgery
     • if minimum coverage is maintained in both Vascular Surgery and General Surgery services
     • if the physicians registered in General Surgery agree among themselves
   • However, in conformity with Principle 1, the Vascular Surgeon may not register for HOCC in General Surgery, nor count toward the number of registered General Surgeons.
4. To qualify for full HOCC funding, minimum call coverage must be provided for each specialty as follows:
   • General Practitioners (GPs) and Level II Specialists 
     • 5 or more physicians must provide 100% after-hours call coverage
     • 4 physicians must provide 91% after-hours call coverage
     • 3 physicians must provide 80% after-hours call coverage
     • 2 physicians must provide 80% after-hours call coverage
     • 1 physician must provide 60% after-hours call coverage
   • Level III Specialists
     • 5 or more physicians must provide 100% after-hours call coverage
     • 4 physicians must provide 95% after-hours call coverage
     • 3 physicians must provide 91% after-hours call coverage
     • 2 physicians must provide 81% after-hours call coverage
     • 1 physician must provide 54% after-hours call coverage
   • Minimum required coverage is calculated over the course of a year to account for reasonable variability in coverage over the course of the year and to accommodate vacations, illness, continuing medical education, etc.
   • If the minimum required coverage cannot or will not be provided, the HOCC Program must be notified via the form Appendix “D” and the HOCC funding will be pro-rated accordingly on approval by the HOCC administration.
   • The hospital is responsible for managing the minimum coverage requirements and recovering or not distributing funds for those night(s)/weekend(s) when this has not been provided.

5. In specialties where 2 concurrent rotations may be funded by HOCC (only Family Medicine, Internal Medicine, Anesthesia, Obstetrics/Gynecology and Pediatrics/NICU), the department must have at least 10 members and the rotations must operate separately and concurrently with no cross-coverage to provide seamless call. That is, 2 physicians (1 from each rotation/call group) must be first on-call at all times.

General guidelines

1. Funding from the HOCC initiative shall be made on the basis that a physician can only be registered for HOCC at 1 hospital or 1 hospital site, and only for 1 specialty.
2. A first-call after-hours on-call rota must currently exist and continue to function for the specialist group seeking HOCC coverage. Specific funding for back-up coverage, such as second call, is not provided.
3. A physician can only receive 1 HOCC payment per on-call shift, even if multiple sites or specialties are being covered concurrently. HOCC funding is provided for on-call availability, which does not change under these circumstances.
4. Locums, physicians on alternate funding arrangements or physicians being compensated through a contract with provisions for on-call are not eligible for HOCC funding.
5. The Level IV specialist payments are for special visits for the provision of non-elective/emergency assessments and procedures in the evenings, nights, on weekends or holidays. The specialist is limited to 2 call-in fees per calendar day.
6. This agreement is not intended to affect the traditional patterns of hospital on-call coverage currently being provided by the physicians.
7. Hospital on-call is defined as being available to provide timely access to medical care to hospital patients after-hours. After-hours is defined as Monday to Friday 5 p.m. to 7 a.m. (17:00 to 07:00 hours) and Saturday, Sunday and holidays all day as outlined in the Schedule of Benefits.
8. Funding for Critical Care Medicine is limited to intensivists providing coverage to closed critical care units (ICU), who are not part of an alternate funding arrangement and who are not listed for HOCC for another specialty.
9. For medical sub-specialties such as Endocrinology, Nephrology, Critical Care and Geriatric Medicine, after-hours on-call rotas seeking HOCC funding must be first on-call, completely separate from the Internal Medicine and/or any other on-call schedule.
10. HOCC funding for General and Family physicians is limited to those physicians providing on-call to the hospital. Examples of General and Family practice on-call services provided may include, but are not limited to, surgical assistants, broad based obstetrical coverage and admission and care of unassigned patients.
11. Physicians may not limit their on-call availability strictly for their own patients or for those in their own group or practice.

Eligibility criteria for second Hospital On-Call Coverage stipends in approved specialties

The departments of General and Family Medicine, Anesthesia, Obstetrics and Gynecology, General Internal Medicine and Pediatrics (Neonatal Intensive Care units only) may be eligible for a second stipend so long as they meet all of the following criteria:

• The department seeking the second stipend must have at least 10 active members providing after-hours hospital on-call coverage (there do not need to be 10 physicians on each of the 2 call schedules).
• The rotation seeking the second HOCC stipend must be first on-call (in other words, 2 physicians must be providing first on-call after-hours coverage to the hospital at all times). Funding for second call, such as back-up coverage, is not provided.
• The 2 rotas must operate concurrently and separately from one another with no cross-coverage. When applying for the second stipend, copies of both on-call rotation schedules must be submitted to clearly demonstrate that the 2 physician groups operate separately.
• Seamless call must be provided by both rotations.

Eligibility criteria for Level II Interim Enhanced Emergency Department Backup On-Call funding

• Emergency department (ED) groups must be in hospitals designated for 24-hour on-site ED physician coverage.
• The emergency department must have a distinct published physician backup on-call roster and protocol with 24 hours a day, 7 days a week, 365 days a year coverage with no gaps. The backup on-call roster must be provided to the Ministry and HOCC Committee on request.
• Eligibility for funding for ED backup coverage assumes that there be no gaps in scheduled ED coverage:
  1. gaps in scheduled ED coverage will result in reductions (pro-rating) of HOCC - ED Backup On-Call funding appropriate to circumstance
  2. frequent gaps in scheduled ED coverage will result in withdrawal of HOCC - ED Backup On-Call funding
  3. new groups (such as those not currently registered for Interim Enhanced HOCC) must commit to the Interim Enhanced HOCC Program prior to pursuing an application for Level II ED Backup On-Call funding
  4. a set of criteria that establishes when to call in the ED backup physician, approved by the Chief of Emergency Medicine and accounting for local variations in circumstance, must be in place at each hospital and be available to the Ministry and HOCC Committee on request
  5. the backup on-call onsite response time must be 30 to 60 minutes as local circumstances dictate

Eligibility criteria for Level II Intra-Sectional Allocations of Hospital On-Call Coverage funding for Cardiology, Neurology, Ophthalmology and Otolaryngology

Eligibility criteria for Level II Intra-Sectional Variability of HOCC funding for Cardiology/Neurology

The department seeking the change from Level III HOCC funding to Level II HOCC funding must have at least 4 active members providing after-hours on-call coverage.

Note: In very specialized circumstances, groups of less than 4 may be considered for Level II funding on a case-by-case basis.

The group must provide direct first call after-hours to the Emergency Department (meaning not backup to the Internist on-call). Groups wishing to apply for an intra-sectional allocation (ISA) must directly answer to the emergency room (ER) physician, general practitioner (GP) or other appropriate designated staff (such as the Charge Nurse when the Cardiologist/Neurologist is the most responsible physician), and come in to the hospital when clinically indicated to be considered for Level II funding. Members of the call group must directly answer pages to the emergency department and in-patient areas for problems in their specialty. Calls cannot be "filtered" by the General Internist.

The department must provide letters of support from the Department Chief and the Chief of Emergency Medicine or the MAC Chair to confirm that the particular group provides direct first call independent of the General Internal Medicine call schedule.

The department must provide call schedules for a 3-month period for both General Internal Medicine and the sub-specialty group seeking the change in HOCC Level (such as Cardiology or Neurology) to demonstrate that there is no overlap and no cross-coverage. Physicians’ names may not appear on both schedules. A physician may only be registered for HOCC at 1 hospital, and for only 1 service.

Physicians applying for consideration to be moved to Level II HOCC funding must agree to participate as a group, not as individuals.

Groups not wishing to participate at Level II will remain at Level III with their existing call/practice arrangements. Groups that have the Internist on call dealing with all after-hours issues and only provide a response to the Internist may continue this practice without any change in their HOCC status.

Eligibility criteria for Level II intra-sectional variability of Hospital On-Call Coverage funding for Ophthalmology/Otolaryngology

To be eligible for Level II funding 1 of the following 3 criteria (A or B or C) must be met:

1. Hospitals that are geographically capable of forming regional call groups must agree to do so and should be prepared to include 3 or more hospitals with 5 or more members of their specialty
2. Tertiary hospitals that have 4 or more specialists and currently do not share call with another hospital (in other words, are not in a regional group) will be eligible
3. The hospital is geographically isolated and cannot form a regional call group

In addition:

• All regional groups or hospitals receiving Level II funding should expect referrals from hospitals close to their region that do not have specialty coverage.
• Calls to the regional call group must be responded to in a timely fashion. Patient referrals from the region expedited through CritiCall will be managed using a “best efforts” approach for patient care within the region or, failing availability of resources, providing advice to aid in patient transfer out of the region.
• The surgeons involved may only be registered for HOCC funding at 1 hospital and for 1 service. The hospitals involved in the regional call arrangement must together designate 1 hospital and 1 contact to be responsible for submitting the application and distributing the HOCC funding. For purposes of HOCC funding, physically or geographically separate buildings will constitute separate hospital sites.
• Each regional group will be entitled to one Level II stipend that may be divided through local or regional arrangements, however the group decides, as long as there is someone on call for all hospitals in the group for any given shift.
  • For example: A regional group of 3 hospitals with 3 specialists in each hospital would receive one Level II HOCC stipend for 5+ physicians to be divided among the 9. There could be regional coverage for the entire week or there could be an arrangement where each hospital has local coverage during weeknights and regional coverage on weekends. All 3 hospitals would have coverage for every after-hours shift, whether on a local or regional basis, as decided by the group with agreement by the MACs.
• There can be no concurrent cross-coverage within the same hospital or between regionally covering groups.
• The group must provide direct first call to the ER and Inpatient Units. Members of the call group must directly answer pages to the emergency department and in-patient areas for problems in their specialty. Calls cannot be "filtered" by another specialist. HOCC funds direct first-call coverage only.
• The departments of the involved hospitals must provide letters of support from their respective Chiefs of Emergency Medicine and/or MAC Chairs to confirm that the particular group provides direct first call.
• Physicians applying for consideration to be moved to Level II HOCC funding must agree to participate as a group, not as individuals.
• Groups participating in Level II regional coverage will be subject to the same requirements as other Level II specialists.
• Groups not participating in Level II regional coverage will continue to be eligible for Level III funding.

Note: Those Ophthalmologists providing emergency retinal surgery on separate call schedules may also apply for Level II status through direct application to HOCC, however they can only be registered for 1 HOCC stipend.

For purposes of HOCC funding, "retinal surgeons" will be defined as Ophthalmologists with greater than $70,000 billings in retinal/vitreol surgical services and greater than $4,000 in retinal/vitreol after-hours billings at 1 of the 5 main centres.

Rurality premium

HOCC provides premiums for rural physicians as follows. Each hospital eligible per the 2008 OMA Rurality Index of Ontario (in other words, with a rurality index greater than 45) shall receive an annual financial incentive of $15,844 (see note below) for GP on-call funding. This incentive is in addition to the on-call funding as set out in the MOHLTC-OMA Agreement.

General Practitioner/Anaesthesia premium

The General Practitioner (GP)/Anesthesia premium is intended to assist in retaining GP/Anesthetists in rural communities. Each eligible hospital (as determined by the HOCC Administration) that does not have a Royal College certified anesthetist associated with it and where general practitioners provide a minimum of $10,000 of anesthetist services per year will receive an additional $15,844 (see note below) annually. This incentive is in addition to the on-call funding as set out in the MOHLTC-OMA Agreement.

Note: MOH and OMA have worked together to implement physician compensation increases in accordance with the 2021 Physician Services Agreement (PSA). Accordingly, an increase of 2.0100% to the rate has been applied to HOCC payments effective April 1, 2023.

Funding amounts, programs and calculation guidelines

Specialty groups and funding amounts

The table below shows the distribution of specialties of practice into 4 distinct groups, for which different funding amounts are available. The total number of physicians providing on-call service in each rota determines the amount of funding.

Base HOCC program

Available funding is shown in the table below (HOCC funding stipends by General Practitioners (GP)/Specialty Group and number of participating physicians).

Interim Enhanced HOCC program

The 2004 Physician Services Agreement provided for increases to Base HOCC funding over the term of the agreement, provided eligibility criteria are met.

To be eligible for Enhanced HOCC funding amounts, physicians must sign a written declaration confirming they will accept no direct or indirect top-up payments/compensation for on-call service. Participation in this “Interim Enhanced HOCC program” is voluntary, however physicians must agree to participate as a group, not as individuals.

HOCC funding stipends by GP/Specialty Group and number of participating physicians

Funding table - Updated April 2023 - See Note

Base HOCC Funding - Current annual - See Note

^*for physicians providing on-call in Level A, B, 1, 2 or 3 hospitals (as set out in the Alternative Funding Agreement for Emergency Services)

Enhanced HOCC Funding - Current annual - See Note

^* for physicians providing on-call in Level A, B, 1, 2 or 3 hospitals (as set out in the Alternative Funding Agreement for Emergency Services)

Guidelines for Level IV payment

Effective February 1, 2015, the submission of Level IV Specialist Reports (Appendix “C” form) and call-in fees was replaced with monthly payments (see PSA Increase Note below) based on call in fee utilization at eligible hospitals in FY 2014/15.

Level IV payments are eligible for the following specialties:

• dermatology
• immunology
• physical medicine and rehabilitation
• rheumatology
• nuclear medicine
• interventional radiology
• radiation oncology
• gynaecologic oncology

Note: MOH and OMA have worked together to implement physician compensation increases in accordance with the 2021 Physician Services Agreement (PSA). Accordingly, an increase of 2.0100% to the rate has been applied to HOCC payments effective April 1, 2023.

The following historical information is archived content regarding Level IV HOCC prior to February 1, 2015.

• Level IV payments $103.54 call-in fee will be made to certified specialists practising in the specialties of:
  • dermatology
  • immunology
  • physical medicine and rehabilitation
  • rheumatology
  • nuclear medicine
  • interventional radiology
  • radiation oncology
  • gynaecologic oncology
• staff who are available to provide on-call hospital services in those specialties, and who perform a special visit (at the hospital) in the evening, night, on weekends or on holidays [HOCC Agreement, Article 3.4.4]
• where a special visit is defined, for HOCC purposes, as “one initiated by a patient or patient’s representative(s) where the physician is required to travel from one location to another to see the patient from a location outside any premises of, or operated by or on behalf of, the hospital special visit premiums only apply to non-elective or emergency calls” [see the Schedule of Benefits, General Preamble, 23.a-c, p. GP-53, July 1, 2003 ed.]
• a specialist shall be limited to 2 call-in fees per calendar day [HOCC Agreement, Article 3.4.4]
• for a physician to be paid 2 call-in fees in a calendar day each claim must arise from a distinct special visit - claims made for attending to additional patients during the same special visit as that for which the first claim was made are not eligible for payment
• call-in fees will be paid for special visits made to OHIP-insured patients only - the patient encounter must have generated OHIP-eligible fee-for-service claims
• no physician who receives Level II funding for his/her participation in an Obstetrics and Gynaecology on-call group may submit a Level IV claim for Gynaecologic Oncology