What are the benefits of a clinical ARP?
cARPs can provide a payment plan that effectively supports the relationship between physicians and their patients where, in some circumstances, fee-for-service does not suffice. Some of the potential benefits of cARPs:
- Better predictability and stability of physician revenue.
- Potential to use the model to help support innovation and improvements in service delivery:
- Improved continuity of care
- Enhanced preventive care
- More time for management of patients with chronic diseases and complex conditions
- Expanded team-based care
- Enhanced patient access
- More comprehensive care
- Enhanced implementation of Patient’s Medical Home
- Enhanced integration of care in the Health Neighborhood
- Practice efficiencies.
- May enable better work-life balance in some practice types.
- Potential for greater physician and patient satisfaction.
- May facilitate physician recruitment and retention.
- Providing value to the health system (e.g., reducing unnecessary emergency department and acute care utilization).
What is the level of autonomy for determining work scheduling, payment distributions and other internal governance matters when designing a new cARP?
Annualized and sessional models have significant flexibility in designing a new proposed clinical ARP for the goals, target patients, locations, services, service delivery model, internal governance, and work schedule. Physicians can work part-time or full-time, with no requirement for minimum participation. For the blended capitation model, the basket of services and location types (e.g., office-based) are defined, but there is significant flexibility for other aspects. If the services are provided in an AHS or third-party facility, the physician group must work in partnership with those parties to develop the details. The applicants must clearly demonstrate that the cARP meets the overall cARP goals and dimensions, including value-for-money to get the application approved.
Regarding internal governance, the Clinical ARP Application Overview (page 6) states “Physicians are responsible to manage, individually or as a group, their work scheduling, workload, shifts, and holiday schedules.” The level of individual physician flexibility for internal governance matters varies among cARPs, depending on the size of the physician group, whether the cARP is new or established, and/or how much the cARP is tied to AHS or other third party operations.
For example, in a new cARP, the prospective participating physicians can design the service delivery model and the internal governance rules. Ideally, it is best if these internal rules are outlined in a formal physician practice agreement, with clear decision-making and dispute resolution procedures. For more established ARPs, the internal governance rules may already be established so any new physician joining the cARP would need to abide by those rules.
In cases where a clinical cARP is heavily tied to AHS operations, the physician group needs to work in partnership with AHS to determine how things like work scheduling will be managed. The physician group may voluntarily decide to give AHS more control over internal governance.
Who are the key stakeholders in a clinical ARP?
The key stakeholders are Alberta Health (AH), Alberta Health Services (AHS), the Alberta Medical Association (AMA), and physician groups exploring or participating in a clinical ARP.
Who is a participating physician in a clinical ARP?
A physician becomes a participating physician (PP) in the clinical ARP once they sign a Letter of Participation (LOP) that is approved by the Minister. They can then be compensated for the provision of program services under the clinical ARP. Click to follow the link to Alberta Health’s Clinical Framework Explained document for further information.
Who is the authorized representative in a clinical ARP?
The authorized representative (AR) is a participating physician who has been authorized by the other participating physicians in the clinical ARP to function as their agent with respect to the clinical ARP. The AR is has a key role as the primary contact for Alberta Health and to relay information to the entire group of participating physicians. Click to follow the link to Alberta Health’s Clinical Framework Explained document for further information.
How are clinical ARPs governed?
The Medical Benefits Regulation, under the Alberta Health Care Insurance Act, enables the Minister of Health to establish clinical ARPs by issuing Ministerial Orders (MOs). There are two parts to the MOs:
- The Clinical ARP Program Parameters sets out the general rules for all clinical ARPs. It includes the roles and responsibilities of participating physicians and authorized representatives, rules for claiming and receiving compensation, and templates and rules for physicians who want to join a clinical ARP or who want to terminate their participation in a clinical ARP.
- The Conditions of Payment (CoP) sets out the details specific to each clinical ARP. It includes payment details, goals of the clinical ARP, program services provided by the participating physicians, a description of the patients to whom the program services will be provided, service delivery model, and details on the reporting requirements.
There may be other Health Services Agreements that also factor into the ARP.
The Clinical ARP Framework supports transparency, equity, and consistency across the clinical ARP program.
Can physicians withdraw from the clinical ARP and return to billing fee-for-service?
Individual physician:
It is extremely rare for any physician to terminate participation in a clinical ARP and request a return to the fee-for-service payment model. However, a physician may leave a clinical ARP program by providing the Minister with a Letter of Termination (LOT) with 30 days’ notice of the effective withdrawal date. and can then deliver care in a different FFS practice. Copies of the LOT must be provided to Alberta Health, Alberta Health Services, and the Alberta Medical Association.
Entire clinical ARP physician group:
If the physician group agrees that the clinical ARP model is no longer meeting their needs, they can return to fee-for-service by providing the Minister with a Letter of Termination (LOT) with 30 days’ notice of the effective withdrawal date. Copies of the LOT must also be provided to Alberta Health, Alberta Health Services, and the Alberta Medical Association.
Can facilities and/or sites be added to an existing clinical ARP?
Yes, the authorized representative can submit a request to Alberta Health for a new site (or sites) to be added to a clinical ARP. Consensus is required that all physicians providing service at the proposed site will join the ARP if the site is added from all participating physicians and community leaders. A full expansion application may be required to add new sites to an ARP if there is a need to expand the program funding.
How are the clinical ARP payment rates determined?
Clinical ARP rates are based on fee-for-service rates. Provincial base payment rates (PBPR) were originally derived from the 2002/03 fiscal year fee-for-service (FFS) billings for full-time (1.0 full time equivalent) physicians in a specific specialty using modified Canadian Institute for Health Information methodology (CIHI):
The calculation of the approved PBPRs was a twostep process in 2002/2003:
- The first is the calculation of FTE for each physician within a specialty.
- The second is the calculation of the rates based on the FTE classification of the physicians within a specialty.
The methodology uses FFS payments as a proxy for physician activities as follows:
- Physicians are ranked in ascending order based on their FFS earnings.
- Lower and upper boundaries, the 40th and 60th percentiles respectively, are determined in the ranked specialty group.
- Physicians with payments between the lower and the upper benchmarks are assessed a value of 1.00 FTE.
Once an FTE has been assigned to each physician within a specialty, the rate is then calculated using only physicians with 1.00 FTE. The rate is the mean of the payments of the physicians with a 1.00 FTE designation. In other words, the rate is the mean of the 40th and 60th percentile of FFS billing of physicians within a specialty. Definition of a Full-time Equivalent physician is based on the methodology developed in 1984 by Health Canada. All rates were adjusted in subsequent years by the same sectional increases awarded to fee-for-service physicians through periodic re-negotiations and sectional allocations.
How is the total funding for annualized and sessional clinical ARPs determined?
Compensation is based on several factors including, but not limited to:
- The payment rate,
- The number of approved full-time equivalents or hours,
- Application process,
- Data analysis,
- Estimated time required to provide services,
- Request for full-time equivalents (FTEs) or hours to deliver the services.
Do I get compensated for on-call availability in a clinical ARP?
Clinical ARPs do not compensate physicians for on-call availability, either during regularly scheduled weekdays or after-hours. However, program services provided while on call are eligible for inclusion as program service hours for payment. For example, if on call from 1700 hours to 0800 hours the next day (15 hours), and a total of two hours of patient care during this period (e.g., direct patient contact or patient-related phone calls), then two hours of program services would be eligible for payment.
Do I get compensated for travel in a clinical ARP?
No, travel is not eligible for compensation through the clinical ARP.
Do I get compensated for any teaching in a clinical ARP?
Teaching while providing program services (i.e., bedside teaching) as well as health education to Albertans is eligible for compensation through the clinical ARP. All other teaching (e.g., lecture based) is not funded by a clinical ARP.
Do I get compensated for any vacation or time off in a clinical ARP?
As with fee-for-service, physicians are not compensated for vacation or leave of absence in a clinical ARP.
Am I entitled to the same physician benefit programs in a clinical ARP as in fee-for service (FFS)?
Yes, clinical ARP physicians are entitled to the same benefits as FFS physicians, if eligible (e.g., Rural-Remote Northern Program, Business Cost Program, etc.).
How is clinical ARP funding distributed?
Clinical ARP physician groups can choose one of three mechanisms for distribution of funds:
- funding is sent from Alberta Health to Alberta Health Services (or a third-party organization), who then distributes the funds to physicians based on criteria agreed upon by physicians;
- funding is sent from Alberta Health to a clinical ARP Program bank account and then the Program distributes funds to physicians based on criteria agreed upon by physicians, or;
- funding is sent from Alberta Health directly to individual physicians (sessional ARP only).
How do I pay a locum when I take time off?
If participating physicians qualify for the Specialist Locum Program or the Rural Locum Program, the AMA will pay the locum and the clinical ARP reimburses the AMA. If participating physicians arrange for a private locum physician to provide any program services, the participating physicians must make payment arrangements directly with that locum physician. Locum physicians may not claim benefits directly from Alberta Health.
Do clinical ARP physicians receive the same annual payment increases as fee-for-service (FFS) physicians?
Historically, clinical ARP payment rates have been adjusted by the same sectional increases awarded to FFS physicians. However, any changes in clinical ARP payment rates are subject to review and approval by the Physician Compensation Committee (PCC), which has representatives from both Alberta Health and the Alberta Medical Association (AMA).
Can a clinical ARP Participating Physician receive any fee-for-service (FFS) payments?
If all program services, the patient population, and facility have been included in the Conditions of Payment (CoP) the clinical ARP must be billed. However, if there are specific program services or specific patient populations or specific facilities not included in the CoP for the clinical ARP, then the physicians can bill FFS. Physicians will have separate business arrangement numbers for FFS and the clinical ARP. The physician is expected to follow the CoP in their specific clinical ARP.
Can a Participating Physician work more or less than 1.0 full time equivalent (FTE) in a clinical ARP?
Physicians can work any portion of an FTE up to the approved individual and program maximums for the clinical ARP, as outlined in the Conditions of Payment (CoP). A physician may be able to work up to a maximum of 1.5 FTEs in a fiscal year (April 1 to March 31), providing that the sum of all individual physician FTE totals is within the maximum FTE funding for the program and it meets all other qualifying conditions as outlined in the CoP (e.g., the minimum participating physicians or FTE rule). All changes to individual physician FTEs should be approved by the authorized representative to ensure the program remains within the maximum full time equivalent allotment.
Are the terms “shadow billing” and “service event reporting” interchangeable?
Yes, they are used interchangeably. Both refer to the submission of Schedule of Medical Benefit (SOMB) codes or approved ARP S-codes for clinical ARP program services provided by the physician.
Why is it important to shadow bill for all services provided in a clinical ARP?
The clinical ARP Ministerial Order requires physicians to submit claims for all clinical ARP services provided to qualify for payments. Shadow billing data is a key factor in determining the level of future funding approved for the program (i.e., for future program expansion requests).
What services should physicians report when shadow billing?
Program services can be provided by direct or indirect patient care. For all indirect and direct patient care activities, it is important to capture the complexity and time spent. As with FFS, ARP participating physicians submit claims using the appropriate codes from the Schedule of Medical Benefits (SOMB). If is no applicable SOMB code to capture an indirect program service provided (e.g., telephone call, report writing, review of lab results), then the approved ARP S-code is used to report the service.
Do physicians need to submit service claims to Alberta Health?
Like FFS, participating physicians are required to submit claims for all services provided. The clinical ARP is assigned a specific ARP business arrangement number for claims submissions. Claims submitted under the clinical ARP business arrangement number are paid at $0 (shadow billing).
Do clinical ARPs require a lot of administrative work in addition to shadow billing?
Under a clinical ARP, a Claim for Benefits is documentation that proves participating physicians have provided program Services to Patients, and compensation is contingent on the submission of this documentation.
There are two types of Claims for Benefits documents.
- Service Event Reports, which all participating physicians are required to submit.
- The program is required to submit monthly full- time equivalent (FTE) reports (for annualized clinical ARPs), invoices (for sessional ARPs), and quarterly and annual performance reports (all clinical ARPs).
Reports should be emailed to your Alberta Health Policy Analyst and copied to your Alberta Health Services Medical Affairs Representative and the AMA.