Alternate funding plans

Letters

CJEM 2002;4(1):3-6

To the editor:

Dr. Marshall is right that physicians should exercise caution and good judgement when assessing new payment plans.¹ However, the problems he ascribes to the Ontario Alternate Funding Agreement (AFA) are misleading. We would like to clarify several points:

The Ontario plan pays a lump annual sum, based on volume (other factors to modify workload are being developed), to emergency groups that sign on. This lump sum replaces fee-for-service (FFS) billings and is intended to exceed the amounts achieved through FFS, although the premium varies. There are no clauses requiring groups to divide this sum into a "salary," and each group is free to create its own distribution scheme. Thus, incentives for productivity, differentials based on training, experience, or for unsocial shifts are all a matter of discretion to the group members. This includes voting rights definitions within the group.

There are neither standards nor external monitoring of individual or group productivity.

There is no evidence from the 65 Ontario emergency departments (EDs) that have taken the AFA that productivity has been adversely affected.

FFS provides no funds for overhead. Under the AFA an individual physician's overhead is lowered as she or he does not need to submit FFS billings, while the group costs for shadow billing are at least partly offset by the AFA.

The AFA covers all non-scheduled visits to the ED. The plan was set up with the conversion of all FFS billings from the ED into the AFA pool, including the billings for patients seen by physicians other than the emergency physician on duty. It is up to the group to identify these funds and distribute them accordingly. Thus, any clawback for fees submitted by local family physicians indicates the lack of a local agreement, and any money lost in this way did not rightly belong to the emergency group in the first case.

The AFA will be particularly attractive to ED groups that already act cohesively and where the premium over FFS is considered worthwhile. It is least attractive to sites where individuals traditionally function as autonomous practitioners and wish to stay that way. It is certainly not for everybody, but gives Ontario physicians a choice they previously did not have. It is not perfect, but 65 EDs thought it was better than the status quo. If they are at any time disappointed in the terms or effect of the AFA they can withdraw with 90 days notice. It is very hard to ascribe a hidden government agenda for this program; the motive appears obvious: to stabilize physician staffing in order to improve public service and keep EDs out of the headlines. That is a motive we can all support.

Jonathan Dreyer, MD, CM 
Chair 
Howard Ovens, MD  
Vice-Chair 
Andrew Affleck, MD 
Past-Chair 
OMA Section of Emergency Medicine