Bulletin 220502 — Physician Services Agreement Initiatives effective April 1
Primary Care Contract Changes effective April 1, 2022, per the new Physician Services Agreement
To: All Primary Care Physicians
Category: Primary Health Care Services
Written by: Primary Health Care Branch; OHIP, Pharmaceuticals and Devices Division
Date issued: May 11, 2022
Physician Services Agreement Initiatives effective April 1, 2022
The Ministry of Health and the Ontario Medical Association are working together to implement changes in primary care contracts in accordance with the 2021 Physician Services Agreement.
Family Health Organizations (FHO) Managed Entry
For physicians interested in joining or becoming a Family Health Organization (FHO), monthly registrations for entry into a FHO will be changed from the current 20 per month in areas of high physician need to the following:
- In fiscal 2022/23 60 physicians per month into two streams:
- 40 physicians per month will enter in a prioritized stream for those seeking to practice in an area with a RIO score of 30 or above, for FHOs with less than 6 physicians, or physicians involved in ministry supported activities such as Ontario Health Teams subject to ministry discretion
- 20 physicians per month in a regular stream, these will be processed on a first come, first served basis (not prioritized).
- In fiscal 2023/24 40 physicians per month divided into two steams:
- 20 physicians per month will enter in a prioritized stream for those seeking to practice in an area with a RIO score of 30 or above, for FHOs with less than 6 physicians, or physicians involved in ministry supported activities such as Ontario Health Teams subject to ministry discretion
- 20 physicians per month in a regular stream, these will be processed on a first come, first served basis (not prioritized).
Any unused spots from one stream will shift to the other stream to be filled in that month, and furthermore any unused spots will be rolled over to subsequent months.
The 2023/24 approach will continue until the completion of bargaining/mediation/arbitration of the 2024 PSA.
The Managed Entry process does not apply to replacement physicians. Replacement of a departing FHO physician is outside of the Managed Entry process on a one physician out/one physician in (1:1) ratio.
New entry guidelines
The following guidelines will apply to new FHO groups or new locations to existing groups:
- Where all physicians in a group cannot be in the same location, there can be no less than 3 physicians in each location.
- Where a group has more than 1 location, all locations must be within a 5km radius of one another, where a RIO score is 0.
- In areas with a RIO score of 1 or more, consideration will be given to applications from groups who cannot locate within 5 km due to infrastructure limitations or any other relevant factors, having regard to the primary health care needs of the community.
Any application not granted can be referred to the Physician Services Committee for resolution.
The above guidelines do not apply to existing FHOs adding physicians to their pre-existing group locations.
Regardless of the number of locations, the hours of service (daytime, after-hours, and weekends) will be posted in the office, on telephone answering machines, on-line and shared with Ontario Health (more information to follow on this process). This will ensure that patients know the hours of service of their physician group.
In addition, the new group must have a shared EMR that provides all physicians in the group access to the medical records of Enrolled Patients (per Section 9.2 of the FHO Agreement).
The Lead Physician of a group can make a request to add a physician to an existing FHO or form a new FHO via email to firstname.lastname@example.org.
Complexity Based Capitation (FHO/FHN)
A bilateral Diagnostic Risk-adjusted Acuity Modifier Advisory Group will be established and tasked with implementing an adjustment to the current age-sex based capitation rates to include a new risk-adjustment model based on the CIHI’s Population Grouping Methodology by no later than April 1, 2023.
The financial results achieved by repurposing of the Preventive Care Bonus for Colorectal Cancer, Mammography and Pap Smear for FHN and FHO (with Proration of Influenza and Childhood immunizations preventative care bonuses for FHN and FHO physicians with rosters less than 1,000 patients) and the change in fee-for-service pooling (described below) will be redirected into this new capitation methodology.
There will be no changes to the above Preventive Care Bonus payments until complexity-based capitation is implemented
After-Hours Clinics (FHO)
After-hour clinic requirements will be revised effective July 1, 2022, and subject to the provisions of FHO_After-Hours Exemptions the Group will commit to providing evening (Monday to Thursday starting at or after 5 pm but no later than 7 pm for a minimum three-hour consecutive block), and weekend (Friday evening, Saturday or Sunday) 3-hour consecutive blocks for scheduled and unscheduled patients.
Weekend coverage requirements have changed
- If a FHO is required to provide one block of weekend coverage, that block will be on Saturday or Sunday.
- If two weekend blocks are required, they may be scheduled any time on Saturday or Sunday, provided there is no overlap between the blocks.
- If three weekend blocks are required, the FHO may schedule those blocks on Friday evening, Saturday or Sunday, provided there is no overlap between the blocks.
- Where four or more weekend blocks are required, one block must be provided on a Saturday, and one block on Sunday, and any remaining blocks as determined by the FHO, provided there is no overlap between the blocks.
The required after-hours and weekend blocks per week by group size are effective July 1, 2022 and are as defined in the table below.
After Hours Table for Groups without After-Hours Exemptions
|FHO Group Size (# of Phys)||Current Requirement||Total Evening and Weekend Required effective July 1, 2022 *||Required Evenings effective July 1, 2022||Required Weekends effective July 1, 2022|
*The current contract requirements will apply for groups of less than 6 during the transition period.
After Hours Table for Groups with After-Hours Exemptions
After applying the after-hours exemptions to the group, the following table shows the number of after-hours clinics a group will be required to perform if there are 4 or less physicians who do not have an exemption.
|FHO Group Size (# of Physicians After Exemption)||Current Requirement||Total Evening and Weekend Required effective July 1, 2022 *||Required Evenings effective July 1, 2022||Required Weekends effective July 1, 2022|
Effective July 1, 2022, the group exemption from after-hours coverage for physicians in a FHO, where more than 50% of physicians provide specified services, will be replaced as follows:
There will be an individual exemption from after-hours coverage where more than 50% of physicians in a group provide the following "Exemption Services" after 5 pm weekdays and/or on weekends:
- Regular public hospital emergency room coverage; and/or
- Public hospital anaesthesia on-call services on a regular basis; and/or
- Obstetrical deliveries outside of regular office hours; and/or
- Regular after-hours care of hospital in-patients; and/or
- Provision of palliative care as indicated by at least 4 palliative care patient home visits per week averaged over a 3-month period; and/or
- Provision of services in an LTC/nursing home (for non-enrolled patients) as demonstrated by at least 10 patient visits per week averaged over a 3-month period; and/or
- Complex continuing care on-call as established by a call schedule in a complex continuing care facility.
In addition to the exemptions set out above, Northern and Rural FHO groups are contractually required to have at least 50% of their physicians maintain active in-patient hospital privileges; as a result, Northern and Rural FHO groups are required to provide no more than 5 after-hours blocks.
The FHO will be required to provide the total after-hours and weekend coverage for the group, based on the FHO group physician size calculated after removing the exempt physicians.
In order to qualify for the after-hours exemption, the individual physician must be engaged in the services listed above in (i), (ii), (iii), and (iv) for at least 6 hours per week-averaged over a 3-month period or provide service as specified in (v) and (vi) or be on call as specified in (vii).
Aspirational Parameters for FHO Weekly Patient Access and for Virtual/In-person Split for FHO and Other Primary Care Physicians
Effective July 1, 2022, for FHOs, for every 1300 enrolled patients (i.e., on a pro-rated basis) FHO physicians are encouraged to meet or exceed the following parameters:
- 88 face-to-face and virtual patient encounters weekly, with 60 percent or more being face-to-face patient encounters.
- Since this is a group endeavor, the averaging would be measured quarterly (over a three-month period) for the entire group
Services are to be provided by the enrolling physician or another physician (including contracted physicians and physician residents) in the enrolling group to patients enrolled to the group and includes in-basket and out-of-basket services.
For non-FHO primary care physicians (Family Health Networks, Group Health Centre, Rural and Northern Physicians Group Agreement, Blended Salary Model, St. Joseph’s Health Centre, Weeneebayko Area Health Authority, Sioux Lookout Regional Physicians Services Agreement, GP Focus HIV, GP Focus Care of the Elderly, GP Focus Palliative, Toronto Palliative Care Agreement, Inner City Health Associates, Shelter Health Network, Sherbourne Physicians Group, Family Health Groups, and Comprehensive Care Model), they are encouraged to have 60% or more of their weekly patient encounters on an in-person as opposed to a virtual basis. Since this is a group requirement, the averaging would be measured quarterly (over a three-month period) for the entire group.
Weekend Access (A888 Equivalent) for FHO patients
To support increased access to scheduled weekend visits, effective July 1, 2022, there will be a newly created code of equivalent price to A888 that can be billed by FHO physicians for providing services to their groups’ enrolled patients for unscheduled visits on Saturday, Sunday, or Holidays, so long as the physician offers at least three scheduled visits for each three-hour Saturday, Sunday, or Holiday block.
Increased Mandatory Group Size for FHOs
The minimum size for new FHOs established after April 1, 2022, will be 6 physicians.
All existing FHO groups with less than 6 physicians are required to reach a minimum size of 6 no later than March 31, 2023.
Existing FHOs of less than 6 physicians will be permitted to continue as such, provided the FHO agrees to implement and maintain the same access requirements, including after-hours and weekend access, as FHOs with at least 6 physicians, and provide such agreement, in writing, no later than March 31, 2023.
The ministry and the OMA will establish guidelines permitting FHOs of fewer than 6 physicians in rural, remote or underserviced communities. Information on these guidelines will be provided in a future INFOBulletin.
FHO Group Maximum Roster
Effective July 1, 2022, average FHO roster sizes should generally be no greater than 2400 patients on average per physician.
The practices of existing FHOs with an average roster size of greater than 2,400 patients will be reviewed jointly by OMA and MOH representatives. If it is determined that these practices are structured and operating to comply with their contractual obligations, they will continue as such. Any practice which does not comply with those obligations will be provided with an appropriate opportunity to become compliant. If the practice does not meet the obligations within the time specified or any extension agreed to by the parties, appropriate steps will be taken to reduce the average roster size per physician to 2,400 or such other larger number as the parties agree, within such time period as is agreed by the parties, and in compliance with CPSO policies for reducing patients in a practice.
The Maximum FFS Limit will move from Group Pooling to the individual physician
Effective once a complexity modifier is in place for the FHN and FHO model (anticipated to be April 1, 2023), all eligible groups will no longer pool their fee-for-service limits at the group level. Instead, it will be applied at the individual physician level. The ministry and the OMA will be developing criteria for exemptions which will be communicated to physicians in an upcoming INFOBulletin.
Enhanced FHO Group Coverage
Effective July 1, 2022, if a patient’s regular physician is not available during weekday hours, the FHO will ensure all enrolled patients presenting with a time-sensitive condition are offered the option of seeing another FHO physician (whether face-to-face or virtually as clinically appropriate) on the same or next day, or an after-hours clinic that day or the following day. This requirement may be delegated to an allied health provider affiliated with the FHO if clinically appropriate.
FHOs are encouraged to consider including the following illustrative examples as time sensitive conditions:
- significant new or worsening pain (including pain caused by recent injury)
- new onset or change in symptoms of infection including fever, rashes, gastrointestinal changes, urinary changes, respiratory changes
- exacerbation in chronic conditions (for example back pain, heart disease, lung disease or abdominal or gynecological disease)
- concerns regarding pregnancy and newborns and infants
- decompensation in mental health or substance use
- time sensitive prescriptions that cannot be managed in other ways
Examples of non-time sensitive conditions include:
- annual health exams and preventative screening visits
- completion of forms (for example tax disability, insurance, school trips/camp)
- routine follow up of chronic physical and mental health conditions
Modernized booking process for FHO and FHN enrolled patients
All FHOs and FHNs will endeavor to have an online booking system available for their patients by March 31, 2023, and are encouraged to communicate with Ontario Health in achieving this objective. Ontario Health has developed service standards which are available on their website.
All other primary care models are also encouraged to have an online booking system available for their patients and can also communicate with Ontario Health in this regard.
Primary Care; Physicians; 2021 Physician Services Agreement (PSA); Managed Entry; Complexity; Acuity Modifier; After-Hours; After-Hours Exemption; FHO Weekly Patient Access; A888; Group Size; Maximum Roster Size; FHN Migration; Fee-For-Service Limit; Hard Cap; Enhanced FHO Group Coverage; Modernized Booking Process