Physician HHR planning in Ontario

1. Leonard Kaizer Resident Rounds June 8.2012 Physician HHR planning in Ontario

2. Objectives – to Review: • History of manpower planning for medical oncology in Ontario • Current model for service delivery and HHR planning for systemic treatment – RSTP Provincial Plan • HHR forecasting and allocation 2010 + • Future state – What will the system you work in be like? • burden of disease, manpower projections, and models of care.

3. Historical Perspective • 1997 RBRVS Commission (OMA & CCO) • Submission from OMA section for Hematology and Medical Oncology • Suggestion that AFP might be a consideration

4. Historical Perspective

5. Historical Perspective - STTF • Delivery of systemic therapy threatened by the scarcity of health professionals • Task Force mandate was to make planning recommendations to avert a crisis • Expand training programs • Expand roles of nurses and other providers • Workload standards for key providers • Specific recommendations for medical oncology

6. Historical Perspective - STTF Benchmarks

7. Historical Perspective - STTF Role statements

8. Historical Perspective - STTF Model of care and compensation

9. Historical Perspective - SSTF Need for data

10. Historical Perspective • Combination of RBRVS and STTF led to the initial AFP agreement in 2002 and allocations to CCO, PMH and community (COMET) programs • Since 2002 there have been several reports which have addressed physician workload and the need for incremental physician resources and evolution of model of care • Human Resource Planning for Medical Oncology in Ontario (2005) • Regional Systemic Treatment Program Provincial Plan (2009) • Since 2002 there have been 4 incremental allocations of medical oncology positions, the last in 2010

11. Current State • Although we are much further ahead, we are still trying to deal with the same demands as we were in 2000 • Demand for health human resources • Demand for better data, especially information on physician resources and activity • Demand for better processes to deliver care to patients

12. Current model for service delivery and HHR planning for systemic treatment – RSTP Provincial Plan

13. Current model for service delivery and HHR planning for systemic treatment – RSTP Provincial Plan

14. Current model for service delivery and HHR planning for systemic treatment – RSTP Provincial Plan

17. Current model for service delivery and HHR planning for systemic treatment – RSTP Provincial Plan

18. Medical Oncology Historical PlanningNew Cases as a Standard Measure of Workload

19. Medical Oncology Historical Planning RSTP Provincial Plan September 2009 • Methodology • Measured baseline treated cases 2007-8 and projected treated cases over time (11% & 17% 5 year lower and upper demand) • Used a factor of 1.2 (validated) to convert treated cases to new consult projections (historical benchmark) for upper demand. • The projected new consult demand was related to 2007-8 HR baseline consult rates (188 Academic and 247 Community), recognizing they were higher than benchmark (145A and 215 C) • Assumed that A:C ratio for new cases was going to move from 50:50 to 25:75 • Concluded the demand would be 40 new positions by 2012-13

20. Medical Oncology Historical Planning RSTP Provincial Plan September 2009

21. Planning and Forecasting • Current forecasting is still tied to new patients (incidence) • Benchmarks for medical oncology service provision (planning documents) • Relating growth in incident cases to benchmark service provision yields a number of AFP positions for the province • The active treatment of prevalent cases is becoming a larger proportion of our ongoing work and is not factored into these estimates • Data collection outside level 1 + 2 ICPs is less robust • Assumption that 75% positions go to Level 2 + 3 centers

22. What has happened since 2009 to implement this HHR plan? • Two HHR requests, involving CCO (planning + forecasting) and ONT-MOA (negotiation) • Joint allocation process – 2010 + 2012 • Consideration to POAFP • Provincial recruitment to AFPs in general since 2009

23. Allocation Methodology - Principles • The allocation process should be fair, clear, transparent and data driven. • Allocations will be assigned to enable additional patient services.  • Allocation will be made to institutions, through regional programs. Institutional level allocation will be authorized through a consultative process involving the RVP and medical oncology leads for the region (i.e. Head, Cancer Centre and Regional Quality Lead, systemic Treatment) • In assessing current HHR resources, all medical oncologists, wherepossible, will be counted. • In assessing current activity, all activity, where possible, will be considered and benign work will be excluded. This will be done using a mix of data sets. • Modifiers to workload measures will be defined. • Additional considerations will be made for special circumstances

24. Measuring SupplyCensus of Physician Supply 2011

25. Measuring SupplyCCO Census of Physician Supply 2011 • Currently there are 286.89 total MO FTEs in Ontario • This represents an increase of 28 FTEs since 2010 • 12 allocations • Some new FFS positions • Of the 286.89 total MO FTEs, 153.55 (53.5%) are associated with level 1 academic centers.

26. Allocation Methodology – Inputs into Core Model • HHR census: October, 2011 • Total FTEs, clinician scientists, complex hematology • NACRS treated cases: Oct 2010 – Nov 2011 • OHIP consults: November 2010 – October 2011 • RVP consultation • Centers for consideration of allocation (incremental work) • Regional perspective • Grouping • Commentary

27. Allocation Methodology – Model 2012RANK = Sum Activity/Adjusted FTE • SUM Activity • Take Total FTE from census • Adjust contribution of CS and CMH to establish Adjusted FTE • Adjusted FTE • Take SUM OHIP consults and NACRS derived treated cases • Remove non medical oncology treated cases -gynecologic oncology • Adjust for academic vs. community • SUM Activity /Adjusted FTE = RANK score

28. Allocation Methodology – Model 2012 • Discussion reserved for the bottom of the allocation if there are insignificant differences between institutions or if there are obvious outliers – based on last position +/- 5%. • Other measures of activity • Billings per FTE • LHIN demographics - Incidence and Import/Export ratio • APN & GPO totals • APP allocations empty or filled by extenders • RVP inputs • Consideration to 2nd allocation

29. Allocations 2007, 2010

30. What is wrong with this picture? • Currently available data to measure human resources and clinical activity has strengths & weaknesses. The allocation model is fair and reasonable given these limitations • We are undervaluing work related to cancer prevalence and oral chemotherapy • The stated allocation principle is to direct positions to increase capacity for new clinical activity. However, the final methodology uses retrospective data to define RSTP centers who are in greatest HHR deficit. We assume that allowing “catch up” will enable future growth. • Aprospective model for resource prediction and planning should take many other factors into consideration – patient travel, all human resources, LHIN demographics, …

31. Cancer Incidence by LHIN5 Year Projection

32. Future state – What will the system you work in be like? • The burden of disease is increasing dramatically – incidence and prevalence • Financial reality means constrained resources – timely and appropriate care at risk • Human Resource issues are imminent – projected shortages….. It is true!! • Patient expectations are changing – improved patient experience means better integration and coordination of care and enhanced patient engagement in self management.

33. Burden of Disease

34. Burden of Disease

35. Burden of Disease

36. Manpower shortages?

37. Models of Care Program • “1. Develop new models of care delivery to support evidence-informed, efficient, patient-centered care. • 2. Implement the models and address necessary remuneration, regulatory, scope of practice and other policy changes. • 3. Develop and implement a mechanism for continuous evaluation, modification and improvement of the models.” • Ontario Cancer Plan III

38. Models of Care - Principles • Innovative approaches to models of care delivery in oncology • Based on best-practice • Patient-centered • Collaborative, multidisciplinary, team-based care • Working to optimize the use of scarce and expensive physician and other human resources • Maximizing existing health human resources by fully utilizing potential of current scopes of practice • Bending cost curve • Build on principles of ECFAA and OCP to work towards fully integrated cancer system, alignment of physician resources and accountability with system level resourcing and planning

40. Objectives – to Review: • History of manpower planning for medical oncology in Ontario • Current model for service delivery and HHR planning for systemic treatment – RSTP Provincial Plan • HHR forecasting and allocation 2010 + • Future state – What will the system you work in be like? • burden of disease, manpower projections, and models of care.