ENVIRONMENTAL SCAN Hospital-Based Physician Issues Related To the Physician Services Framework Agreement

Transcription

1 ENVIRONMENTAL SCAN Hospital-Based Physician Issues Related To the Physician Services Framework Agreement Ontario Hospital Association (OHA) 200 Front Street West Suite 2800 Toronto, ON M5V 3L1 Prepared by Provincial Health Human Resources Strategy and Professional Issues Tel: (416) Fax: (416) Ontario Hospital Association (OHA) Environmental Scan for OHA Hospital-Physician Issues Plenary

2 TABLE OF CONTENTS 1.0 INTRODUCTION...P EXTERNAL ENVIRONMENT AFFECTING PHYSICIANS...P NATIONAL PHYSICIAN SUPPLY STATISTICS...P PROVINCIAL PHYSICIAN SUPPLY STATISTICS...P OTHER HEALTHCARE PROFESSIONALS...P ENVIRONMENTAL TRENDS...P BACKGROUND NEGOTIATIONS BETWEEN OMA AND MINISTRY...P BILATERAL AGREEMENT...P OHA AS THIRD PARTY...P NEGOTIATIONS...P PHYSICIAN SERVICES FRAMEWORK AGREEMENT...P AGREEMENT PRIORITIES AND GOALS...P HIGHLIGHTS OF THE AGREEMENT HOSPITAL CARE...P REASSESSMENT PROCESS...P HOSPITAL ISSUES AND PRIORITIES IDENTIFIED BY OHA SURVEY...P PURPOSE OF SURVEY...P SURVEY RESULTS...P. 8 LIST OF APPENDICES...P. 13 Environmental Scan for OHA Hospital-Physician Issues Plenary

3 1.0 Introduction Hospital-physician relations have been affected in the past few years by changes in the health care system. For the most part, hospitals and physicians still remain at the heart of our health care system. Given the integral nature of the relationship between hospitals and physicians, systemic changes affecting one, are bound to have an impact upon the other. The upcoming round of negotiations between the Ontario Medical Association (OMA) and the Ministry of Health and Long-Term Care (the Ministry ) will renew the 2004 Physician Services Framework Agreement expiring March 31, 2008 ( the Agreement ). These negotiations provide the Ontario Hospital Association (OHA) and its members with an opportunity to share ideas, and to identify priorities to inform both the OMA and the Ministry on issues of importance to hospitals. As a primary strategy to enable the OHA to represent the interests of hospitals regarding issues arising from these negotiations, for the first time we are conducting a consultation process similar to that which is conducted for hospitals participating in central bargaining with major hospital unions. The results of this consultation will serve to inform our discussions with the OMA and the Ministry related to the upcoming negotiations in the new Master Agreement. The purpose of this paper is to provide OHA Members with background information in advance of the plenary including: OMA and Ministry agreement negotiations process, including OHA s potential role; An overview of the 2004 Physician Services Framework Agreement; Results of the May 2007 survey of senior administrators and physician leaders regarding issues and priorities arising from the 2004 Agreement; Identification of issues and priorities for OHA s Reference Group on Hospital Physicians Issues (RGHPI) to begin to shape with respect to the 2008 round of negotiations for a new Master Agreement. 2.0 External Environment Affecting Physicians There are many political, economic, population, workplace, technological, and geographical environmental factors that could influence the outcome of the 2008 round of negotiations between the OMA and the Ministry. Given the recent discourse regarding physician shortages, recruitment and retention will be priorities for both parties. The following is a snapshot of some key statistics regarding the physician workforce. 2.1 National Physician Supply Statistics According to a report of the Canadian Institute for Health Information (CIHI), Supply, Distribution and Migration of Canadian Physicians (2006), the physician workforce increased by 4.9% between 2002 and Over the same period, the Canadian population increased at a similar pace (4.0%). The physician to population ratio in Canada also increased slightly over this 5 year period, which can be explained by an increase in the number of family physicians. The total physician to 100,000 population ratio in Canada increased from 189 in 2002 to 190 in Environmental Scan for OHA Hospital-Physician Issues Plenary 1

4 2.2 Provincial Physician Supply Statistics However, the number of physicians in Ontario only increased 1.9% between 2001 and Over the same period, the population of Ontario increased by 4.6%, thus decreasing the total physician to population ratio from 179 to 174 physicians per 100,000. The majority of physician growth in Ontario was due to an increase in the number of family medicine physicians. Family medicine physicians increased by 3.9%, while specialists remained relatively stable (0.1%). Between 2002 and 2006, the physician to population ratio remained unchanged at 84 for family medicine physicians, and declined form 94 to 90 for specialists. Between 2002 and 2006, the average age of an Ontario physician increased from 48.5 years to 50.1 years. Physicians in Ontario are, on average, a year older than the national average of For a provincial profile of the Physician Workforce, please refer to the CIHI Provincial Profile of Physician Workforce in Ontario ( ) (Appendix A) 2.3 Other Healthcare Professionals The Human Resources and Social Development Canada (HRSDC) Looking Ahead: A 10-Year Outlook for the Canadian Labour Market ( ) document (October 2006) predicts that a significant number of health occupations will face excess demand and face labour market pressures over the next ten years. These include Physicians, Optometrists, Chiropractors, Physiotherapists, Occupational Therapists, Nurses, Nursing Assistants, Medical Radiation Technologists, Nurse Aides, Orderlies, and other occupations. The expected excess demand in those occupations is due to the aging of the population leading to higher demand for healthcare services and factors that restrain supply growth, such as long training time and the limited capacity of educational institutions to accommodate large increases in enrolments. Intense competition for existing Ontario-educated health professionals from other provinces and abroad is a reality. A number of provinces have created websites, (such as run media campaigns, hold recruitment events in other provinces, and offer incentives to recruit health care professionals from other provinces. For example, Saskatchewan offers a Relocation Grant Program for Health Employees from Outside of Saskatchewan. The grant of $5,000 can be in addition to the Northern/Rural/Hard to Recruit Grant for Health Employees of up to $15,000. Health Care professionals are also recruited by hospitals in the United States through job fairs, newspaper ads, and on the internet. They may offer incentives such as signing bonuses, relocation assistance, funding for continuing education and professional development, and paid travel expenses. Ontario experienced an overall net gain of 25 physicians from inter-jurisdictional migration from 2002 to In the same period, 564 Ontario physicians moved abroad and 491 returned. 1 1 Canadian Institute for Health Information, Supply, Migration, and Distribution of Canadian Physicians 2006, (15 November 2007). Environmental Scan for OHA Hospital-Physician Issues Plenary 2

5 2.4 Environmental Trends The political, economic, population, workplace, technological, and geographical environmental trends in Ontario affecting hospitals and physicians include: Steady economic growth; Regionalization and integration of health care through the introduction of LHINs; Growing emphasis on accountability of health care organizations in the system (e.g. Wait times strategy); Movement towards for servicing of health care in a community-based environment Rising health care costs; Use of public-private-partnerships to construct, develop, and operate health care facilities; Population growth and aging; Greater reliance on immigration and growing population diversity ; Changing population attitudes and expectations toward health care; Shifting patterns of disease burden and population health; Growing, aging, and changing health workforce (gender, age structure, ethnic makeup, attitude toward work); Ongoing imbalance of health care labour force demand and supply Continued technological advancement; Increasing urbanization. These environmental factors will have profound impacts on health care practice, education, and HHR planning. There will be more: multi-disciplinary teams and inter-professional collaboration; rapid role changes and flexibility; new models of practice; improved assessment and recognition of international credentials and education processes; and more integrated and distributed education and training. 2 In response to the ongoing gap between demand and supply of physicians, part of the Ontario government s HealthForceOntario strategy was the creation of a marketing and recruitment agency to assist with attracting and retaining physicians to practice in Ontario. In addition, the government has increased the number of physicians trained from 702 in 2006 to 760 in There is a plan for 852 first-year medical school places in There has also been an increase in the number of training and assessment positions for international medical graduates from 90 in 2003 to 218 in The goal is for 200 additional positions per year. In summary, both parties are facing significant challenges in this round of bargaining a labour market where demand continues to outstrip supply, and an economic imperative to contain rising health care costs. 2 Diane McArthur, Executive Coordinator Health and Social Policy Cabinet Office, Health Professions, A View of the Future presented at The Michener Institute for Applied Health Sciences community forum Emerging Health Professions: A Look Ahead to 2010, September Ministry of Health and Long-Term Care, February , McGuinty Government Improving Access To Doctors, Press Release (4 October 2007). 4 HealthForceOntario, Year End Report 2007, (4 October 2007). Environmental Scan for OHA Hospital-Physician Issues Plenary 3

6 3.0 Background - Negotiations between OMA and Ministry 3.1 Bilateral Agreement As is the case with the 2004 Agreement, the renewal Agreement will remain bilateral between the OMA and the Ministry. Although it is recognized that physicians are the key drivers of hospital-based care, and that systemic changes affecting physicians are complex and have a significant impact upon hospitals, the OHA is not officially represented at the negotiating table. In the past, the Ministry has selected hospital CEOs to participate in the negotiations process in an ex-officio capacity as part of the Ministry team. These CEOs have indicated to the OHA that as part of the Ministry team, they were not in a position to communicate with the OHA for purposes of seeking advice and feedback on issues under discussion. 3.2 OHA as Third Party Over time, and beginning officially with the May 2003 Re-Opener Agreement, the agreements have acknowledged the need for relationships with other providers, including hospitals. The Re- Opener Agreement named the OHA as a participant in respect of two new tripartite (OMA, MOHLTC and OHA) committees the Hospital Clinical Services Payments Task Force (HCSPTF) and the Diagnostic Services Committee Development Team (DSCDT). This was the first time that the OHA was officially named as a party to the preliminary negotiation process. The 2004 Agreement acknowledges the need for stronger relationships with hospitals and other healthcare providers to deal with the significant changes to health care delivery. This Agreement established the Physician Hospital Care Committee (PHCC), the first trilateral committee with OHA representation (see Appendix B for Terms of Reference). The OHA also sits in a non-voting capacity on the Hospital on Call Committee (HOCC), the working group on Emergency Department Staffing, and has observer status on the Physician Health Human Resources Committee (PHRC). Although not a party to the agreement, OHA has a vital interest in ensuring that the value of hospital input is recognized. The OHA will assume a proactive stance in these discussions and intends to be an integral part of the decision-making process. The maximization of the opportunity will be dependent upon an effective strategy and timely information. OHA intends to shape the manner in which topics form the committee s agenda, as well as influence the outcome of discussions regarding hospital based clinical services. The OHA s Reference Group on Hospital-Physician Issues (RGHPI), consisting of hospital and physician leaders, will provide OHA with strategic advice throughout the process (see Appendix C for list of members) Negotiations The OMA and Ministry will each have two five member teams. The parties have not yet been made aware of the Ministry s spokesperson and team members. However, as in the past, it is anticipated that the Ministry will appoint two hospital CEOs to their team. We have been made aware that the OMA has identified its team, consisting of two specialists and two family practitioners (two of whom were part of the 2004 negotiations process). Mr. Stewart Saxe has been engaged by the OMA as spokesperson and legal counsel. Environmental Scan for OHA Hospital-Physician Issues Plenary 4

7 Physician Services Framework Agreement The 2004 Physician Services Framework Agreement between the OMA and the Ministry is a four-year agreement from April 1, 2004 to March 31, It is a comprehensive and complex framework for the terms and conditions pertaining to physician services in Ontario. The 2004 Framework Agreement was ratified by the OMA Council on March 30, 3005, following nearly 15 months of negotiations between the OMA and government. The parties adopted an interest based approach to the initial round of negotiations, which commenced in January An interest based approach differs from traditional bargaining tactics in that the parties do not come to the table with defined positions they identify interests and issues of mutual concern, and work together towards solutions. The OMA and Ministry each had two, nine member teams. John Oliver, President and CEO of Halton Healthcare Services, and Kevin Smith, President and CEO of St. Joseph s Health Care Centre and St. Mary s General Hospital, served as Ministry representatives. Four side tables were established to identify the issues and develop solutions, those being Primary Care, Hospitals, Academic Health Sciences Centres, and Other Issues. The first ratification vote resulted in almost 60% of Ontario doctors rejecting a first offer from government in May OMA Council officially rejected the offer in October In November 2004, the government proposed six adjustments to address OMA concerns related to the first offer. Between December 2004 and February 2005, the parties discussed concerns/adjustments in detail, which resulted in a tentative agreement being reached in March This agreement was unanimously endorsed by OMA Board of Directors and recommended for ratification by OMA Council. A telephone ratification vote resulted in 77% of physicians voting in favour of the agreement 4.1 Agreement Priorities and Goals The government s key goals for the 2004 Framework Agreement were as follows: 1. Targeted investments to achieve key government priorities i. Improve access to family physicians ii. Facilitate implementation of group practice model - Family Health Teams iii. Reduce wait lists and more efficient hospital services iv. Improve home care and long-term care services v. Stabilize academic health science centres 2. Stability resulting from a multi-year agreement i. Opportunity to realize strategic objectives including greater integration of health sectors ii. Predictable funding for government and for physicians 3. Recognizing the importance of the family physician in health care i. Focus on comprehensive primary care including chronic disease management, prevention, palliative care, etc. Environmental Scan for OHA Hospital-Physician Issues Plenary 5

8 4. Continuing shift from FFS (fee for service) to alternate funding models i. Provide academic physicians with greater flexibility and stability to meet complex clinical, teaching and research requirements ii. Address specific priority or other areas requiring alternate funding approaches (i.e. paediatrics, oncology, palliative care) 5. Living within our means i. Achieve change within available resources and with appropriate accountabilities A variety of service areas were targeted for enhancement, including: Primary care improving and extending comprehensive primary care; Providing integrated in-hospital and post-hospital care; Hospitals and community care, including long-term and chronic care; Academic health science centres; Rebalancing fee/income relativity between/within specialties; Professional issues. The 2004 Agreement invests in the following: Fee relativity and other initiatives to keep physicians practicing; Initiatives to recruit new physicians (North, AHSCs, new graduates); Alternate models of care to better meet physician and patient needs; Work life and other physician satisfaction issues. Most of the new funding was targeted at investments in specific initiatives and fees - with the exception of one across-the-board increase to all fees. This is unprecedented; previous agreements focused on across-the-board fee increases. 4.2 Highlights of the Agreement Hospital Care 5 The following section highlights aspects of the 2004 Agreement, particularly with respect to hospital care. Hospital Care Objectives for Hospital-Based Care The objectives of the Agreement with respect to hospital-based care are as follows: Increase access to targeted services including priority programs Lessen congestion in emergency departments Help to achieve greater hospital efficiencies Support provincial plan to expand community-based care including improved access to home care and long-term care services Strengthen linkages between hospital and community care 5 See Appendix D for detail regarding the Agreement initiatives, financial investment and timing, primarily related to hospital-based care. Environmental Scan for OHA Hospital-Physician Issues Plenary 6

9 Committees The Physician Services Committee (PSC), co-chaired by OMA and Ministry, is the senior committee responsible for matters arising from the Agreement and the relationship between the OMA and Ministry. Ministry appointments to the PSC include two senior hospital leaders; however, OHA has no representation on the PSC. The Agreement provides for OHA representation on two new tripartite committees, the Physician Hospital Care Committee (PHCC), and the Hospital Standardization Committee (HSC). OHA is a Party to the Diagnostic Services Committee (DSC), a trilateral committee reporting to the Minister of Health and Long-Term Care. Despite the impact of the Hospital On- Call Coverage (HOCC) agreement on hospitals, OHA has observer status on the HOCC Committee. OHA has been asked to consult on specific initiatives arising from various bilateral committees including the Paediatric Stabilization Committee and the Mental Health Working Group. Areas of Investments Targeted for Hospitals Most Responsible Physician (MRP) coverage and Patient Discharge (responding to Hospitalists) Critical Care and Trauma Emergency Department Care Stabilize funding and enhance capacity and flow-throw through ED AFA and other areas Paediatrics Regional consulting paediatrics AFAs, Paediatric Stabilization Program, specialty CDM premiums Anaesthesia Support OR capacity Anaesthesia extenders, increase fees Psychiatry Improve patient access to inpatient & acute services Laboratory Medicine Complete implementation of provincial approach Hospital On-Call Program Enhanced funding to improve coverage and respond to top-ups New funding for being on-call for LTC and Chronic Care facilities Alternate Funding Plans Increased funding to AHSC-AFAs New AFP for specialists providing hospital-based services in the North LTC and Chronic Care Funding to ensure residents have access to physicians particularly for on-call funding Home Care/Palliative Care Diagnostic Services Provincial level planning and coordination P-fee for inpatient diagnostics to be billed to OHIP FFF Diagnostic Medical Equipment Fund Primary Care Comprehensive Care Models GP Focused Practice Fee Increases (*includes age Premiums) Health Promotion and Disease Other initiatives Environmental Scan for OHA Hospital-Physician Issues Plenary 7

10 Professional Issues Benefits/Programs Thresholds for incorporation Fees/Fee Relatively ATB CTC Recommendations Specialty Review Internal Medicine Specialties Surgical Specialties Paediatrics/Psychiatry 4.3 Reassessment Process The parties agreed to a Reassessment (section 30) to evaluate the Agreement with respect to investments and appropriateness of the incentives and changes within the health care system. A total of $15 million ($7.5 million for the 2007/08 fiscal year) was assigned to assist with issues identified during this process. The Ministry and OMA finalized a Memorandum of Agreement, which was approved by the OMA Board in June The majority of the new incentives and fees will take effect in the fall of 2007 and early The Memorandum of Agreement is available on OHA s website at Highlights of the Reassessment include: Wait Time Reduction Payment to surgeons who supported the development of the Wait Times Information System Establishment of a Wait Time advisory subcommittee reporting to the PHCC to support the role of physicians in managing access to Wait Times services Development of a most responsible physician program, which will include recommendations from PHCC s recent MRP report for remuneration of full-time hospitalists and community GPs. Recommendations from the Ministry s review of top-up payments will be taken into consideration Physician human resource initiatives targeted at retaining and repatriating physicians through various initiatives including: exploring opportunities for a retention incentive program; implementing a service recognition payment program; continuation of funding of the Northern Physician Retention Initiative for 2007/08; implementing a relocation support program. Establishment of a tripartite committee of OMA, Ministry and LHIN CEOs to communicate issues of province-wide interest Physician Working Environment initiatives including: review of hospital surgical/diagnostic/medical booking processes; developing an implementation plan to address recommendations to reduce administrative burden upon physicians; development of education packages for physicians, employers and insurers on best practices Environmental Scan for OHA Hospital-Physician Issues Plenary 8

11 Enhancements to various primary care premiums targeted at reducing unattached patients, increasing provision of obstetrical services in primary care settings; increasing the after hours premium for Comprehensive Care Model agreements; review of GPs practicing in focused practices Support of palliative care services in the community through a weekly management fee Review of the committee structures under the Agreement for rationalizing in the 2008 Agreement including reviewing the Diagnostic Services Committee Amendments to the Schedule of Benefits 5.0 Hospital Issues and Priorities Identified by OHA Survey 5.1 Purpose of Survey In anticipation of the Reassessment process, as well as the expiry of the Framework Agreement, in May 2007 OHA conducted a survey of CEOs, Vice Presidents, Medical and Chiefs of Staff. The survey was designed to: Identify priority issues for the Re-Assessment of the current Agreement; Identify issues and priorities which OHA can begin to shape with respect to the 2008 round of negotiations for a renewal of the Agreement; Support OHA representatives in providing input for both the Re-Assessment process and the next round of negotiations; Communicate the information as part of OHA's strategy for working with the Ministry and OMA, as appropriate. The survey identified 60 initiatives in the Agreement primarily impacting hospital-based care. Respondents were asked to rank each initiative on the basis of: importance of the initiative; the degree of impact upon hospital; priority for Re-Assessment proceed; and priority for the 2008 round of negotiations. 5.2 Survey Results 6 Although the response rate was low given the length and complexity of the survey, the overall results are consistent with the same ten initiatives that were ranked high for each of the five questions posed in the OHA 2007 survey to evaluate the 2004 Framework Agreement. Responses by OHA Region and Hospital Sector : Region 1 13% Region 3 38% Addiction & Mental Health 8% CCC & Rehab 21% Community 30% Region 4 Region 2 13% Region 5 21% 15% 6 Please refer to Appendix E for detailed survey results. Acute Teaching 26% Sm all 15% Environmental Scan for OHA Hospital-Physician Issues Plenary 9

12 Priorities for Negotiations Province-Wide Results The following top ten issues were identified as priorities for the negotiation of the renewal agreement: Existing and New AFPs Provincial Hospital On-Call Schedule of Benefits Palliative Care Family Health Teams Funding Arrangements DME Fund In-patient Services ED AFAs Fee Increase 79% 74% 72% 71% 71% 70% 70% 69% 93% 90% Re-Assessment Priorities Province-Wide Results The top ten priorities identified for Reassessment are depicted below. Provincial Hospital On-Call Existing and New AFPs ED AFAs In-patient Services Family Health Teams LTC and Chronic Care Specialty Fee Template Reviews Discharge Recruitment & Retention Chronic Care Subsequent Visit 46% 43% 42% 42% 41% 41% 40% 40% 64% 63% Although differences exist in the ranking of initiatives as priorities between the Agreement and the Re-Assessment, the two highest priority initiatives are the same; AFPs and Hospital on Call. Environmental Scan for OHA Hospital-Physician Issues Plenary 10

13 Summary Of the 60 initiatives identified, the same ten initiatives consistently ranked high for each of the five questions. Seventy per cent (70%) of the issues ranked of high importance by respondents were identified as priorities for the 2008 negotiations. The ten priority issues for negotiation of the renewal Agreement are: 1. Existing and New AFPs 2. Provincial Hospital On-Call 3. Schedule of Benefits 4. Palliative Care 5. Family Health Teams 6. Funding Arrangements 7. DME Fund 8. In-patient Services 9. ED AFAs 10. Fee Increase The top ten priority issues for Re-Assessment are: 1. Provincial Hospital On-Call 2. Existing and New AFPs 3. ED AFAs 4. In-patient Services 5. Family Health Teams 6. LTC and Chronic Care 7. Fee Template Reviews 8. Discharge 9. Recruitment & Retention 10. Chronic Care Subsequent Visit Issues ranked as high importance which were not identified as priorities for either the Renewal Negotiations or Re-Assessment are: Lab agreement Paediatric stabilization, Psychiatric stipend. The issues for consideration for 2008 negotiations in addition to the top ten priorities are: Paediatric stabilizations, Psychiatry stipend, AHSCs funding agreements Palliative care Environmental Scan for OHA Hospital-Physician Issues Plenary 11

14 Analysis of the priority issues by hospital sector for renewal of the Framework Agreement are as follows: Acute Teaching: Existing and New AFPs Funding Arrangements AHSC AFP Task Force Provincial Hospital On-Call Academic Physician HR Community Provincial Hospital On-Call In-patient Services ED AFAs Existing and New AFPs Schedule of Benefits Small: Provincial Hospital On-Call ED AFAs Family Health Teams Sessional Fee/Harmonization/DME Fund/Home Care/Locum Program/Recruitment & Retention Addiction & Mental Health: Existing and New AFPs Policies and Procedures Complex Continuing Care and Rehabilitation: Schedule of Benefits (85.7%) Fee Increase (71%) Chronic Care Subsequent Visit (71%) Chronic Care On-Call Funding (71%) LTC and Chronic Care (57%) Hospital Comments With Respect to the Top Ten Priority Initiatives The survey asked hospitals to provide general comments pertaining to the priorities. Appendix F contains the hospital comments for each of the top ten priority initiatives for the renewal of the Framework Agreement. Environmental Scan for OHA Hospital-Physician Issues Plenary 12

15 LIST OF APPENDICES Appendix A: CIHI Provincial Profile of Physician Workforce in Ontario ( ) Appendix B: Appendix C: Appendix D: Appendix E: Appendix F: Appendix G: PHCC Terms of Reference RGHPI Member List and Terms of Reference Overview of the 2004 Physician Services Framework Agreement Evaluation of 2004 Physician Services Framework Agreement Hospital comments for the Top Ten Priority Initiatives Committees Under the 2004 Framework Agreement Documents available on OHA s Website OMA/Ministry of Health and Long Term Care 2004 Physician Services Framework Agreement 2004 Re-Assessment Memorandum of Agreement. Environmental Scan for OHA Hospital-Physician Issues Plenary 13