The Memorandum of Agreement (MOA) signed on May 3, 2022, included a commitment from the NLMA and the provincial government to establish Blended Capitation as a new payment schedule of the MOA. The final agreement was arrived at with the assistance of a mediator and officially released on April 3, 2023.
Blended Capitation is a voluntary payment option for independent community-based family physicians. The payment model includes a bi-weekly capitation payment ($180.97 per rostered patient adjusted by a complexity modifier) for providing a “Basket of Services”. This is blended with a partial fee-for-service payment for direct patient encounters based on 25% of the MCP Fee Schedule rate. All codes that are “Out of Basket Services” are billed at 100% of the MCP rate. There is no negation if a rostered patent receives care elsewhere. If a physician sees a non-rostered patient, they will receive 100% for “In Basket Services” up to $56,000 per year, and 100% for all “Out of Basket Services”.
The new model represents a 21.8% increase in clinical compensation based on average family physician MCP billing rates, on top of the 13.3% increase last year. Those who choose to enroll in the new payment model will also receive income guarantees to facilitate the transition. This includes a guaranteed income floor in the first two years based on an individual’s previous two-representative years billing average, plus a 10.9% premium payment applied in the first year. In addition, physicians will receive a one-time Transition Grant of $11,250 and a one-time Start-up Grant of $10,000 in recognition of start-up costs. Physicians who choose to enroll in the Blended Capitation Model can also qualify for an annual $7,500 Quality of Care Bonus and an annual Procedures Bonus of $2,500 for physicians who bill more than $1,200 in procedures annually. The Capitation Rate has also been boosted in value to help pay for two-weeks of locum coverage. If a physician does not use locums in a year, the locum funding stays with the physician. Monthly EMR subscription costs will be paid by the provincial government. Physicians who agree to join the Blended Capitation Model will group together (minimum of three) to provide after-hours care and act as a team in the provision of care.
The agreement is appended as Schedule R of the Memorandum of Agreement (MOA) and is available in its entirety here.
More information can be found in the Frequently Asked Questions (FAQs) section and the NLMA/CFPC info document below.
The Family Practice Renewal Program (FPRP) began accepting applications/expressions of interest from physicians interested in enrolling in the blended capitation payment model on April 3, 2023. The FPRP is inviting family physicians, who are interested in participating in the BCM program, to submit an expression of interest. At this point, the intent is to capture interested physician names and contact information, to facilitate follow-up at a later date. Please note this form is an expression of interest only and represents an ongoing process—there is no deadline for submission.
To submit your expression of interest, please click here.
Please note that detailed program requirements are in development. The FPRP is working on formal policies and processes to guide program implementation and recruiting staff to facilitate a smooth transition to the new model.
The NLMA has launched an advisory service to support physicians who wish to explore what moving to the Blended Capitation Model means for their individual practices. We have contracted a consultant with whom you can book a meeting to explore how you can use your EMR data to define your panel of patients, and to predict your future income. This information can help inform your decision on whether to move to Blended Capitation. The advisory service will also bring in support from a peer group of physicians who have been involved in the project over the past year, and who can share their perspectives on the benefits and realities of blended capitation.
The first block of appointments is available now, please visit our booking webpage for meeting times.
More appointment availability will be added in the coming weeks as we gauge demand. If there is no current availability for an appointment, we invite you to express your interest by emailing [email protected].
Starting October 30, 2023, doctors will be accepted into the program, which means they will have access to the one-time bonuses and the income guarantee. The billing system for capitation claims and partial fee-for-service claims will be ready for a test group of physicians no later than April 1, 2024. Once the reliability and accuracy of the billing system are confirmed, on or before July 1, 2024, the billing system will be open to all other applicants who have been accepted into the program. In the coming months and years, the NLMA will monitor the program to determine if changes need to be negotiated in the MOA.
Exemption from After-Hours Expectations During Transition Period
The provincial government has agreed to the NLMA’s request to amend Schedule “R” of the MOA to enable certain groups to apply for an exemption from the After-Hours obligations of the Blended Capitation Model during the transition period.
For the first two years of the program, groups that already provide regular, ongoing provision of services to the NL Health Services, such as hospitalist services, primary care services for unattached patients, hospital emergency room coverage, anesthesia services, obstetric services, and long-term care services, will be permitted to redistribute their after-hours service obligations to the Group’s nurse practitioner (NP) or, if the Group has not hired an NP, to seek an exemption from the Blended Capitation after-hours requirement. Groups may apply to the FPRP to determine if members of the group qualify for exemption. For a physician to qualify, they must be providing at least two hours of the types of services described above to NLHS for every one hour of after-hours BCM service exempted or redistributed. Groups that do not provide any of the types of services outlined above do not qualify for the exemption/redistribution.
This exemption will be in effect until August 31, 2025.
An application will be developed at a later date and communicated to BCM applicants who wish to apply for this exemption.
The full amendment to Schedule R is available here.
Member Consultations Presentation
Member Consultations Video
NLMA is continually adding to these questions. If you have a question not included below, you can email it to [email protected].
Enrollment in the Blended Capitation payment model is completely voluntary. Physicians enrolled in the model may voluntarily choose to go back to fee-for-service.
Yes, the NLMA will be launching an advisory service where you can explore the implications for your own practice. We will communicate with you soon about how to book an appointment.
A new billing system is being developed that will extract roster numbers from each physician’s EMR. While the details have not yet been finalized, it is expected that this data will be collected at least every two weeks for the purposes of the bi-weekly capitation payment.
Capitation revenue will still be paid to physicians for all rostered patients. The capitation rate remains the same regardless of how many appointments they have in a year.
That detail is not part of the negotiated agreement, but we expect it will be addressed during implementation.
That’s right. Each physician has their own roster but the group works together to provide all of their patients access (patients are attached to the group/practice). As well, a service provided to the patient of another physician in the group will receive 25% of the MCP rate. Therefore it will be important that physicians have a common understanding with each other about how to balance workload and collaborative activities.
The transition grant is automatically paid with no receipt requirement.
The fee-for-service component will only be paid when services are being provided, but the capitation payment will continue on a 26 pay period basis. This feature assists with the cash flow for a practice.
There is no change to the MCP adjudication system as a result of Blended Capitation. The MCP portion of a physician’s income will become less financially significant as physicians will receive 25% of the value of MCP billings, which will represent about 20% of their overall income. The 80% of income that is derived from capitation will be freer from administrative burden with a more straightforward billing process.
The consultation code (101) is an “out-of-basket” service and is billed at 100% FFS for all patients. This code is only used by family physicians who have a focused/specialized practice and who have been approved by the department to bill a consultation. If the physician then needs to follow a non-rostered patient for a period of time, the rechecks/partials assessments would count toward the $56,000 FFS cap for non-rostered patients.
A group of physicians in the Blended Capitation Model do not need to co-locate in the same physical space. After-hours care for patients within the group can be provided virtually and in-person.
No. Members can apply to enroll in the Blended Capitation Model prior to making arrangements with a group.
Yes. There will be a template “association agreement” that will address mutual obligations to successfully implement the Blended Capitation Model. This will be based on the template used in Ontario.
A grace period concept exists in other provinces with group models that have a mandatory group size, and this province will have similar flexibility. The agreement tasks the Family Practice Renewal Committee (FPRC) with establishing rules and procedures to allow Blended Capitation Groups that drop below the mandatory group size the opportunity to reach the minimum size of three.
Yes. Blended capitation requires a relationship between a patient and a most responsible provider. Under the Blended Capitation Model, two doctors can choose to share that care and see each other’s patients for both after-hours care and for routine medical appointments. However, patients would need to be rostered to one doctor for the purpose of payment.
The future of team-based care has two paths. Under the Blended Capitation Model, physicians can group together as a physician-only team or they can choose to add nurse practitioners and/or registered nurses to their team. All private family physicians, regardless of payment modality, will also have an opportunity to affiliate with the new provincial Family Care Teams and collaborate with providers on those teams who are employees of the provincial health authority.
Co-location is not a requirement; groups do not have to be under the same roof.
The objective of the performance indicators process is to encourage continuous improvement and/or maintenance of accessibility and high-quality care. Therefore, there are no specific targets or goals attached to these, with the exception of after-hours access.
The approach for defining and measuring access relies on three performance indicators, listed below:
- Percentage of same-day or next-day appointments available to attached patients.
- After-hours access provided to attached patients. This indicator will be based on the after-hours service expectations, which is driven by a formula.
- Relational continuity, meaning the ongoing therapeutic relationship between a family physician, including their team, and an Attached patient. This indicator will measure the proportion of visits by attached patients to their family physician, and to their family physician’s Blended Capitation Group.
The after-hours requirement does not require more hours of work per week. It only requires the group to schedule a portion of its work outside the 9-5, Monday-Friday window.
There is a formula for the number of hours per week of after-hours care linked to the total number of rostered patients. For example, a group with 3,600 patients must provide a minimum of 6 hours of after-hours care each week. This obligation is divided among the doctors within the group (e.g., for three doctors it could mean 2 hours each per week, or 6 hours per doctor for one week out of three). The after hours requirement increases in proportion to the number of patients attached to the group.
This is a decision of the group, and will be guided by FPRC policy. Here are some examples:
In a group of three physicians serving 3600 patients, the obligation is 6 hours per week for the whole group.
- Option 1: The physicians choose to take turns providing a Saturday clinic on rotation (one Saturday every third week for 6 hours). When a physician provides the Saturday clinic they can book one of their regularly scheduled clinic days off, to maintain a normal workload.
- Option 2: on two days a week each physician might open at 8:00am or close at 6:00pm. They can also keep the same number of total hours each day to maintain a normal workload.
- Option 3: every week there is a Wednesday clinic from 5-8pm and a Saturday clinic from 9am to 12noon, for a total of 6 clinics every three weeks. Each of the physicians may cover two of the clinics in a three week period, and take time off during the week to maintain a normal workload.
In a group of 4 physicians serving 4000 patients, the obligation is 6.8 hours per week for the whole group. If three physicians have panels of 1200 patients each, and the other physician has a panel of 400 patients, the physicians can choose to divide the after-hours expectation according to their patient loads. For example, once a week each of the three physicians with larger panels could stay open two extra hours, and the physician with the smaller panel could extend by one hour. To accommodate for the later hours, they could adjust the start time of their workday.
The basket of services may be provided in-person or virtually, as determined appropriate by the provider. CPSNL standards of practice apply regarding virtual care and the use of virtual care is regulated by the College. As well, there is currently a cap of number of virtual visits per day.
The expectation is that doctors in a group will make their after-hours care available to all the patients attached to physicians within the group.
Physicians will coordinate with other members of their group to provide primary care during “reasonable, regular hours each week of the year”. This obligation means that every doctor must make themselves available for reasonable and regular hours each week to schedule their rostered patients for routine appointments. It does not require every doctor to work Monday to Friday, 9:00am to 5:00pm. Doctors who typically take a day or a half day to do administrative work may continue to do so. Doctors who provide services to a hospital for a part of the week may continue to do so. In general, doctors will customize the “reasonable, regular hours each week” to the size of their roster and their other clinical obligations.
Physicians are also expected to use best practices in scheduling to provide timely access to appointments. This includes, where appropriate, the ability for a patient to access their physician or another physician in the group, or other team members, on the same day. If a physician spends four days a week seeing patients, they are only expected to arrange same-day or next-day urgent appointments for the days they are in the office. However, as a group, the doctors can arrange to cross-cover urgent appointments for days when a doctor is not working.
The program will monitor the percentage of same-day or next-day appointments made available to patients. The purpose of monitoring this indicator is to determine whether access is being maintained over time. If there is a decrease in access over time, groups are expected to take measures to restore this type of access to their practices.
Physicians who work part-time (e.g. two days a week with a roster size of 400 patients) may still enroll in the Blended Capitation Model as long as they provide comprehensive longitudinal services to their roster and meet access indicators. Physicians within the group may be part time as long as there is “reasonable, regular hours each week of the year”, including the required after-hours access, which can be shared among the overall group.
The data will flow to and be monitored by the Family Practice Renewal Program. If patient access is reduced significantly, this may trigger communications between the FPRP and the practice group about ways to maintain and improve access.
The Basket of Services may be provided in-person or virtually, as determined appropriate by the provider. CPSNL standards of practice apply regarding virtual care and the use of virtual care is regulated by the College. As well, there is currently a cap of number of virtual visits per day.
Locums will be paid by the blended capitation group. Capitation revenue will come to the group regularly over 26 pay periods, and this revenue is the main source of funding to pay locums when they are replacing a physician. The locum’s services will also be billed to MCP, and this serves as an additional source of funding to pay the locum.
If a group chooses not to use a locum during a physician’s leave, the capitation funding will remain within the practice.
Transition grants for adoption of the eDOCSNL EMR will only be available to physicians using a separate EMR. The grant is in recognition of the previous investment they have made in their EMR system. Physicians who are adopting EMR for the first time are protected within the two-year income guarantee against any productivity losses that may occur in the adoption process. This protection was not available to EMR users in previous years. In addition, EMR users will not have to pay EMR subscription fees.
The provincial government felt that cyber-security would be enhanced, communication within and between groups would be facilitated, and technical support to EMR users would be better scaled, with one system.
The CHR implementation has been pushed forward several times. Timelines to transition to that EMR remain unclear.