Physician HHR planning in Ontario

Leonard Kaizer

Resident Rounds

June 8.2012

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.

2

Historical Perspective

1997 RBRVS Commission (OMA & CCO)Submission from OMA section for Hematology and Medical OncologySuggestion that AFP might be a consideration

3

Historical Perspective

4

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

5

Historical Perspective - STTF

6

Benchmarks

Historical Perspective - STTF

7

Role statements

Historical Perspective - STTF

8

Model of care and compensation

Historical Perspective - SSTF

9

Need for data

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

10

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

11

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

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

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

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

17

Medical Oncology Historical PlanningNew Cases as a Standard Measure of Workload

18

Reference Year Community AcademicSystemic Therapy Task Force Report

2000 175 160

Human Resource Planning for Medical Oncology in Ontario

2005 210 145

Principles for Allocation of ONTMOA APP Positions

2007 210 145

Regional Systemic Treatment Program Provincial Plan*

2009 247 188

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

19

Medical Oncology Historical Planning RSTP Provincial Plan September 2009

20

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

21

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

22

Allocation Methodology - Principles

1. The allocation process should be fair, clear, transparent and data driven.

2. Allocations will be assigned to enable additional patient services. 

3. 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)

4. In assessing current HHR resources, all medical oncologists, where possible, will be counted.

5. 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.

6. Modifiers to workload measures will be defined.

7. Additional considerations will be made for special circumstances

23

Measuring SupplyCensus of Physician Supply 2011

Definition Total FTEs 2009-10

Total FTEs 2010-11

AFP X X

AFP-EX X X

AFP-Hired X X

AFP-Unfilled X X

FFS X X

FFS-C X X

CF-C X X

GPO X

APN X24

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.

25

Allocation Methodology – Inputs into Core Model

HHR census: October, 2011o Total FTEs, clinician scientists, complex hematology

NACRS treated cases: Oct 2010 – Nov 2011 OHIP consults: November 2010 – October 2011 RVP consultation

o Centers for consideration of allocation (incremental work)o Regional perspective

– Grouping– Commentary

26

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

27

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

28

Allocations 2007, 2010

29

FACILITY Allocation 2007 Allocation 2010

LHIN 1 Windsor* 0.5

LHIN 2 London* 0.5 London 1Owen Sound 1

LHIN 3 Grand River 1

LHIN 4 Niagara 1 Hamilton Brantford 1Niagara 1

LHIN 5/6 Trillium 1

LHIN 7 PMH* 2.8Sunnybrook* 0.6

PMH (1)

LHIN 8 Markham* 0.6 Markham 1York Central 1

LHIN 9 Durham 1

LHIN 10 Kingston* 0.5Belleville* 0.5

Kingston 1

LHIN 11 Ottawa 1 Ottawa 1

LHIN 12 Barrie 2

LHIN 13 Sudbury 1

LHIN 14

TOTAL ALLOCATION 10.0 12.0 (13.0)

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.

• A prospective model for resource prediction and planning should take many other factors into consideration – patient travel, all human resources, LHIN demographics, …

30

Cancer Incidence by LHIN5 Year Projection

31

LHIN LHIN name

Estimated incidence Count2008-2012

Estimated incidence Count2013-2017 Growth Increase

1 Erie St. Clair 18,501 20,702 12% 2,2012 South West 27,409 31,208 14% 3,7993 Waterloo Wellington 17,659 20,853 18% 3,193

4 Hamilton Niagara 40,606 45,510 12% 4,9045 Central West 15,678 19,411 24% 3,7336 Mississauga Halton 26,181 31,640 21% 5,4587 Toronto Central 27,132 29,079 7% 1,9488 Central 40,750 48,746 20% 7,9969 Central East 40,173 46,754 16% 6,58010 South East 15,114 16,964 12% 1,85111 Champlain 31,487 36,176 15% 4,688

12North Simcoe Muskoka 13,577 16,257 20% 2,680

13 North East 18,254 20,124 10% 1,86914 North West 6,794 7,512 11% 717Grand Total 339,316 390,934 15% 51,619

32

Future state – What will the system you work in be like?

1. The burden of disease is increasing dramatically – incidence and prevalence

2. Financial reality means constrained resources – timely and appropriate care at risk

3. Human Resource issues are imminent – projected shortages….. It is true!!

4. Patient expectations are changing – improved patient experience means better integration and coordination of care and enhanced patient engagement in self management.

Burden of Disease

33

Burden of Disease

34

Burden of Disease

35

Manpower shortages?

36

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

37

Models of Care - Principles

38

• 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

Systemic treatment

Suspicion of cancer and diagnosis

Consult Chemo treatment

Well-follow-up

End-of-life care

No

Biopsy

Staging tests

Check in with med onc

APNGPOOnc Onc Onc

APN

GPO

Cancer in remission?

Yes

Yes

Can refer to a Medical Oncologist or a Hematology Oncologist

Palliative Care

Systemic Treatment Visits by Provider

Onc

Oncologist may or not be present

May or may not be necessary

APN

Palliative MD

Pharm APNGPO

Pharm

Urgent care & symptom

management

APN Onc

GPO

Follow up with oncologist Onc

Discharge back to family practitioner

Usually performed by family doctor and/or surgeon

Onc

Pharm

Pharm

Further treatment? NoRe-stage cancer

Palliative Care

Onc

Onc

Onc

Onc

Oncologist must be present

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.

40