ICES | Emergency Department Services in Ontario 1993 - 2000 - page 5

during that year. Where changes over time were reported, calculations
excluded all EDs that did not report either fee-for-service or shadow billing data
in each fiscal year. Calculations were done in this way to ensure that the
movement of some EDs into or out of the fee-for-service system would not
distort trends over time.
The Organization and Funding of EDs
How many EDs are there in Ontario and how has the organization of
the ED system changed over time?
In 1992, there were 201 EDs in Ontario. The number of EDs in each of the
16 District Health Council (DHC) planning areas ranged from 5 to 23. By
March of 2000, 20 (9.5%) EDs had closed and another 7 (3.5%) had reduced
their services, leaving a total of 174 full service and 6 limited service EDs in
the province (and one temporarily closed ED in the federal hospital in Sioux
Lookout). The number of EDs affected in each DHC area varied considerably.
In three DHC areas there were no EDs that changed their status, while in one
DHC area, 4 of 11 EDs closed (see Exhibit 1). No new EDs were opened during
the study period. Appendix A lists all of the EDs in each DHC planning area.
How are ED services funded and how has this changed over time?
With the exception of physicians’ services, EDs are funded through hospitals’
global budgets. Such funding allocations cover costs of overhead, equipment,
nursing and other health human resources.
Most physicians working in EDs were paid on a fee-for-service basis by OHIP.
Some EDs participated in alternate funding plans (AFPs) where the hospital,
or the group of ED physicians, received a special budget for all physician
services. From this budget, physicians were paid a salary or a set amount
per shift worked.
In the early to mid-1990’s, most of these EDs were
academic institutions which did not shadow bill. During the study period,
there were several funding changes, either from fee-for-service to AFP or vice
versa. Appendix B provides a complete list of hospitals and their funding
status during the study period.
In January 1996, the Ministry introduced Scott
sessional fees for after-hours
(8 pm to 8 am) and weekend ED coverage in rural hospitals. During these time
periods, physicians received an hourly fee (initially set at $70 /hr) for their
services, and submitted shadow billings for each service rendered. During
regular weekday hours (8 am to 8 pm), physicians were paid fee-for-service.
In 1999, there were 71 hospitals where physicians billed Scott sessional fees
for part or all of the fiscal year (see Appendix B).
Also in 1996, the Ministry began offering AFPs to rural Northern Ontario
physicians as a recruitment tool. Community-sponsored contracts (CSCs)
were reserved for selected communities that required one to two physicians,
while Northern Group Funded Practices (NGFPs) were targeted to larger
physician groups. These special AFPs remunerated physicians for their office
practice and daytime ED visits. Nighttime and weekend ED visits were
remunerated using the Scott sessional fee system. Shadow billing was
In 1999, the Ministry began implementing a new AFP, called an Alternate
Funding Arrangement (AFA). It was offered to most EDs in Ontario, and where
accepted, it replaced fee-for-service, pre-existing AFPs, or Scott sessional fees.
Each physician group participating in an AFA was paid for a given number of
physician-hours per day at a set hourly rate. Total remuneration was based
on Ministry guidelines which took into account the ED patient census and
hospital type. Physician groups could adjust the hourly rate up or down to
reflect fluctuations in workload intensity, as long as the average rate did not
exceed the Ministry’s set hourly rate. All EDs with AFAs were required to
submit shadow billings.
Interim AFAs were introduced in three phases (see Appendix C), and all were
scheduled to expire between September and November 2001. However, to
provide all parties with adequate time to review the proposed permanent
AFAs, phases one and two have been extended to January 2002. The
revised expiration date for phase 3 is pending approval.
At various points during the study period, individual hospitals offered financial
bonuses to encourage physicians to work in their EDs. These bonuses were
paid for out of hospitals’ global budgets and were provided in addition to
physicians’ fee-for-service billings. There is no available data on the extent
to which this occurred.
Emergency Department Services in Ontario
Institute for Clinical Evaluative Sciences
Note that this is distinct from the practice of ‘pooled billings’ which occur in some fee-for-service
hospitals. In such cases, physicians bill OHIP, place their earnings into a pool, and each physician
is then paid a salary or set rate per shift from this pool.
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