Practice Management - Europe PMC

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The alternative is capita- tion payment as a Health Service Or- ganization (HSO). As participating family physicians, we feel that it is im- portant to describe thisĀ ...
Practice Management

W. E. Seidelman C. A. Moore D. W. McLean

Paying for Primary Care: Innovation in Ontario Dr. Seidelman is director of service in the Department of Family Medicine at McMaster University. Dr. Moore is chairman of the Department of Family Medicine at McMaster University. Dr. McLean practices family medicine in Hamilton. Reprint requests to: Dr. W. E. Seidelman, McMaster University, Department of Family Medicine, 1200 Main St. W., Hamilton, ON. L8N 3Z5

The other payment mechanism is a than that of the hospital district, the potential supplement based on hospital HSO is not penalized. days saved. This is known as the Ambulatory Care Incentive Program Why an HSO? (ACIP). ACIP payment is determined Generally speaking, the HSO mechby comparing the rate of hospitaliza- anism enables the physician to orgation and duration of stay for patients of nize his practice in a way that allows a particular HSO with the average ex- him to focus his skills on the patients perience for the population of the hos- needing more attention. The physician pital district in which the HSO is lo- can use the services of other health cated. If the patients of the HSO are professionals-nurse practitioners, sohospitalized for fewer days than the cial workers, etc.-in his practice district average, the HSO will receive without being financially penalized for a third of the potential hospital costs not actually performing the service 'saved'. (See Table 2.) that patient receives. At present, ACIP payments are calThe ACIP payment offers the potenculated on a monthly basis five months tial of an additional revenue source T HE GOVERNMENT of Ontario later (e.g. May's hospital experience is which may be used to augment pracprovides an alternative mechanism calculated in September). If an HSO's tice services. While the objective of of paying for health services which hospital experience should be greater the ACIP is to reduce hospitalization, offers attractive advantages to family physicians. The alternative is capita- TABLE 1 tion payment as a Health Service Or- Age-Sex Capitation Rates (General Practice). ganization (HSO). As participating Effective Dec. 1981-Nov. 1982 family physicians, we feel that it is imFemale Rate Male Rate portant to describe this mechanism to $ $ $ $ our colleagues. Annum Month Per Annum Per Per Per Month Age Range The overall goal of the HSO pro5.83 69.96 75.84 6.32 gram is to enable physicians to 00 - 04 43.32 3.24 38.88 3.61 0509 broaden the scope of primary and com33.84 2.82 35.88 2.99 munity health services which, it is 10- 14 55.92 4.66 37.44 3.12 1519 hoped, will result in a reduction of 84.60 7.05 40.44 24 3.37 20hospital utilization. 93.24 7.77 43.56 3.63 There are two major components of 25- 29 86.04 7.17 47.16 34 3.93 30the payment mechanism. The first is 48.00 6.29 75.48 4.00 35 39 capitation payment which consists of a 73.44 6.12 50.28 44 4.19 40 monthly payment for each identified 72.96 6.08 53.40 4.45 45 49 rostered patient of the practice who has 60.12 6.31 75.72 5.01 54 50 valid health insurance. A rostered pa6.51 68.16 78.12 5.68 tient is one who contracts to receive all 55- 59 87.12 7.26 80.88 6.74 64 60of his or her primary care at the prac8.04 96.48 92.40 7.70 6569 tice. The capitation rate is calculated 113.40 9.59 115.08 74 9.45 70 annually. It is determined by the pre11.43 137.16 135.00 11.25 vious year's experience in the fee-for- 75 - 79 166.08 13.84 161.76 13.48 84 80all insured for service system patients. 85- 89 17.06 204.72 202.44 16.87 The rates are also weighted by the age 19.14 229.68 221.28 18.44 and sex of the patients, so that, for ex- 90- 94 19.14 229.68 221.28 + 18.44 95 is rate a paid ample, higher capitation for aged patients. (See Table 1.) Average annual payment $66.56 per patient. CAN. FAM. PHYSICIAN Vol. 28: MAY 1982

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it is intended to do so only ftor those people whose care may be reaisonably obtained elsewhere-the h()me, a nursing home, etc. It is not nneant to keep out of hospital people w,uno neea to be hospitalized. HSO physicians, by virtue of the capitation payment, are encouraged to utilize commu rntyresources (home care, VON, public health, etc.) which may be umsed as a substitute for hospital inpatieint care, thus facilitating early disch,arge or placement for extended care. T'he HSO can also experiment with inrnovative approaches to patient care, practice management (for example, coI nputerization) and quality control s ACIP makes possible the effec use of these resources without financial penalty. By agreeing to become an HISO, the the practice contracts to provide primary care services for those ,insured patients on its roster. If an HSC patient should receive care from a n on-HSO physician who bills the health insurance plan, the patient's monthly capitation payment is deducted firom the HSO. The amount of negative capitation deducted for a patient ca ne er exceed the monthly capitation I Fee. Te HSO physician receives a c omputer printout of the names of those practice patients who have gone elsewhere for ---

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TABLE 2 Ambulatory Care Incentive Paymi HSO DIstrict 3,458 409,490 Population 49 5,408 Admissions 13 14 Average per 1000 415 52,681 Total days stay 446 Total days expected 31 Total days saved $182.42 Per diem rate for district

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-31 days x $182.42 = $5,677.28 ACIP payment = $5,677.28 . 3 = $1,892.43

care which was billed to the insurance cant departure from the established tradition of fee-for-service. It is not plan. intended to be a substitute for fee-forservice, but rather an alternative payThe Process of Registration ment mechanism available for those Initiating an innovative payment physicians style of practice may mechanism in a well-established uni- be adaptablewhose to it. versal system requires significant Critics of the HSO payment system changes in approach to ensure that ap- argue it represents 'the thin end propriate payment is received. The of thethat a National Health wedge' fee-for-service system is self checking: Service similar of to that of the United the billing card serves as the record of Kingdom. That possibility highly that patient and service. The HSO sys- unlikely for a number of isreasons. tem requires a different mechanism of First, there is the long established traverification. Initially, this was based on a roster of patients who had re- dition of fee-for-service in Ontario. ceived service from the practice. The Second, the diverse approaches to health insurance in different Canadian reliability of the roster was variable provinces assure a competitive fee-forand government and professional con- service system. Third, the capitation cern over possible double payment re- rate for HSOs is determined by the feesulted in the process of registration- for-service experience. Thus, the HSO the patient signs a form registering physician's income is dependent on with that HSO. A practice is given 12 system. Finally, it months to complete registration. In re- isthenotfee-for-service a which locks the mechanism ality, many of the patients who are physician in: he may revert to fee-forhealthy and do not require care will not service at any time. register in that period. Thus, the A provincial association of health number of patients initially registered and HSOs has recently been centres will not reflect all the patients who formed to represent the interests of identify with that particular practice. The association serves those groups. Obviously, registration of a practice not only as an external advocate for within a year will place some stress on health centres and HSOs, but also for the practice staff. This is offset somewhat by the elimination of detailed problem solving, program developfee-for-service accounts. Once a prac- ment, and quality assurance. tice is registered, only those patients who are not yet signed up need to be registered as they come in. Approxi- An Expanded Role mately 85-90% of a practice will regisAs a new and different payment syster in that first year. Monthly printouts tem, HSOs have been subjected to are provided of a practice roster, with considerable political scrutiny, resultdetails of those patients who received ing in a tightening up of accounting primary care elsewhere and the result- procedures. HSOs, by virtue of their ing 'negative capitation'. The other difference, do not enjoy the same deadministrative requirement is an en- gree of professional support as their counter form which provides a profile fee-for-service colleagues. We hope of a practice's clinical activities. This that with the passage of time, the supencounter system will probably soon porters of the traditional system will be computerized. recognize the value of a pluralistic health care system that provides an opA Significant Departure portunity for those family physicians Capitation funding as a Health Ser- who wish to expand their role in the a vice Organization represents a signifi- community.

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CAN. FAM. PHYSICIAN Vol. 28: MAY 1982

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Missed Diagnosis: Did the Patient Have a Case? AS THE LAWSUIT following the events described on page 899 progressed, examinations for discovery were held. The patient, of course, was unable to give any information nor was his mother, a recent immigrant. The brother, who had brought the patient to the emergency department on the first day of his illness, had difficulty recalling the events of that day. The interne, the emergency department nurse and the emergency physician described their roles in the patient's initial management. Several experts were consulted by the emergency physician's defense counsel.

the emergency physician's initial examination of the patient was inadequate. He pointed out that bacterial meningitis usually presents with signs of disorientation, high fever, headache, vomiting, neck stiffness and sometimes hearing loss, arthralgias and skin lesions. Of those signs, the patient presented with headache, vomiting and moderate fever. This expert drew attention to the fact that the other signs had not been sought and he felt that the failure to look for those signs could not be excused. He concluded that the initial emergency department care fell below the usual standard of medical competence which a medical practitioner should exhibit.

The Acute Care One expert pointed out that the phy- Physician's Opinion

The Neurologists' Opinions

sicians who initially examined the patient did not look for signs of meningeal irritation, did not perform a neurological examination and did not consider bacterial meningitis as a possible cause of the patient's symptoms. Had these examinations been done and such consideration given, an earlier diagnosis might have been made. However, he also expressed the opinion that if the patient's relatives had brought him back to the emergency department on the following morning as they had been advised to do, his ultimate response to treatment might have been more favorable. He noted that the earlier diagnosis of bacterial meningitis is made and appropriate antibiotic therapy instituted, the better the prognosis for recovery. Another neurologist concluded that CAN. FAM. PHYSICIAN Vol. 28: MAY 1982

A third expert, a physician with experience in emergency care service, considered that there was no suggestion of fault or negligence by the interne or the emergency physician during the initial emergency room visitation. He drew attention to the fact that the patient presented with a constellation of non-specific symptoms and signs which could not be categorized. He stated that the diagnostic terms "gastroenteritis" and "influenza", plus a variety of others, are commonly used to describe a non-specific syndrome, usually viral in nature, that may include headache, fever, malaise, muscle aches and pains, cough, sore throat, nausea, vomiting and diarrhea. He went on to note that any or all of the symptoms may be present. He felt that the emergency physician had

conducted a reasonably thorough examination and had given appropriate advice (instructions to the -relatives to maintain the patient's hydration, to awaken him every four hours and to bring him back to the emergency department if he worsened or failed to improve.) This expert, however, made the very relevant statement that the emergency physician could be criticized because he failed to recognize that the patient was too sick to be sent home. It was precisely on this basis that a court found a physician negligent in a similar, much publicized legal case several years ago-a decision that was upheld in the Court of Appeal.

Settlement Having carefully considered the expert reports, it was felt that the emergency physician's position could not be successfully defended if the case went to trial. The legal action was therefore ended by payment of an appropriate settlement to the patient. The codefendant hospital also participated in the settlement, since the interne and other hospital personnel were involved. Food for thought? Do you have any questions or comments about such equivocal medicolegal issues? Send your queries to: Medicine at Law, CANADIAN FAMILY PHYSICIAN, 4000 Leslie St., Willowdale, ON. M2K 2R9. We'll attempt to have them answered in upcoming issues. Queries should be signed, but anonymity will be protected. 1017