Beware alternate funding plans

Letters

CJEM 2001;3(4):265

To the editor:
The introduction of salaried positions in community hospitals will change emergency medicine. Until recently, physicians practised autonomously under a fee-for-service (FFS) payment scheme. Now, for the sake of a short-term pay raise, many physicians are jumping to alternate funding plans (AFPs). But under an AFP, group dynamics will change and independence will be lost.

Governments and hospital administrators will monitor productivity. Physicians below the standard will be singled out and, presumably, dealt with. Under FFS, hard-working physicians are rewarded, but under an AFP they will subsidize slower moving physicians -- a situation that will lead to frustration and decreasing productivity. Within AFPs, money earned by individuals would be controlled by and directed to others. For example, groups could divert clinical funds to educational activities, whether or not all members of the group actually require or benefit from those activities. Under this scheme, harder-working physicians would fund a disproportionate amount of the cost. In the future, groups may decide to divert clinical funds to other activities, further eroding hard-earned incomes.

AFPs look like a sweet deal to some, but we should consider what is being offered and at what cost. Our government's main goal is to control costs, not to give emergency physicians a raise. AFP contracts rarely cover expenses for management and shadow billing, for additional coverage during busy periods, or other group expenses. When family physicians see their patients in the ED these funds are subtracted from the ED's AFP income. In one Ontario centre, this factor reduced payments to emergency physicians by $300 000 within a $1.2 million contract and led to a much lower pay rate than specified in the AFP contract.

The group economics associated with AFPs raise other difficult issues. Should all in the emergency medicine group have equal voting power regardless of hours worked, patients seen or income generated? What are the penalties for tardiness, long lunch breaks and poor productivity? Should people with different skills, experience and work ethics be paid equally? Will AFPs kill motivation and make physicians regress toward the lowest common denominator?

Let's look before we leap.

Thomas Marshall, MD
Peterborough Regional Hospital
Peterborough, Ont.
thomas.marshall@sympatico.ca