Any office-based comprehensive primary care clinic with a desire to advance the Patient’s Medical Home is eligible for the BCM demonstration project.
Ideally, all physicians within a prospective clinic will be interested in joining the model and practice exclusively in an office-based setting. However, clinics with at least 80% physician interest will be assessed for participation on a case-by-case basis.
The goal of the BCM is advancement of the Patient’s Medical Home and delivering a quality care experience to patients through improved access, continuity and comprehensive care. These driving principles are critical to success in the BCM.
The BCM demonstration project commenced in November 2016, with the first clinic joining in 2017. The demonstration project is for early adopters of the BCM so we can evaluate and learn about implementation. As an incentive, during this learning period, participants will be provided with quality improvement support from the AMA and receive a one-year negation-free period.
The demonstration project allows the viability of the model to be explored in a live setting prior to full scale implementation.
We have a target of 10 clinics to participate in the model over the course of the demonstration period. The end of the demonstration period has yet to be determined.
The BCM blends a mix of patient-based (capitation) payments and volume-based payments (through FFS) to compensate clinics.
Clinics will receive a set capitation payment for each patient they have formally affiliated. The capitation payments are calculated based on comprehensive health information that considers the patient’s age, sex, and health profile group, which includes diagnostic codes, prescription drug utilization and overall system utilization. The capitation payment is intended to compensate physicians for any “in-basket” services provided. The clinic receives 85% of each patient’s total capitation rate in equally divided payments 24 times over the year. Capitation rates are based on CIHI Population Health Profile Groupings. There are over 9,560 different cohorts. Capitation rates are updated annually for affiliated patients.
Physicians are eligible to receive the remaining 15% of the patient’s total capitation rate through the provision of services. For in-basket health services, physicians will be paid the equivalent of 15% of the FFS rate, up to a maximum of 100% of the patient’s capitation rate. All out-of-basket services will be paid at 100% of the FFS rate.
All other payments, such as the Business Cost Program, Rural Remote Northern Program, and any payments or in-kind services provided via PCNs will not change.
As part of the decision-making process before joining the BCM, clinics will be provided with the opportunity to participate in financial modelling to simulate BCM payments and negation based on a clinic’s previous three years of billing. The financial modelling will help the clinic to understand how total compensation on BCM compares to Fee For Service.
Negation occurs when a patient affiliated to a BCM clinic seeks in-basket services outside that clinic. When a patient receives an in-basket service outside the BCM clinic, the clinic is financially negated for the cost of that service. The negation rate is 100% of the FFS cost of the in-basket services provided outside the clinic. The clinic cannot be negated more than 85% of the capitation rate for each patient.
Negation can be mitigated by implementing practice change, for example:
- Having discussions with patients when they are affiliated and asking patients to call the clinic first for any health care needs;
- Ensuring access for patients to get an appointment when they need; and
- Using alternative modes of care (e.g., virtual or phone visits, optimizing an interdisciplinary team).
Not all negation is avoidable. Because of this, 14% of the total dollar value of negation will be forgiven
The basket of services has been developed to reflect the typical medical services delivered by a family physician in an office-based setting. Any health service included as part of the basket of services is referred to as an “in-basket service”. These services will be used when determining blended capitation payment along with other factors as described further in the How will physicians be paid in this new model? tab of this FAQ.
The basket of services is regularly reviewed and updated.
To formally affiliate a patient to a BCM clinic, both the physician and patient will sign a form agreeing to a physician-patient relationship and its associated expectations and benefits.
Completed forms will be collected by clinics, who will then submit the corresponding patient information electronically to Alberta Health through the Central Patient Attachment Registry (CPAR).
A special interest clinic could include women’s health, pediatric, contraceptive (vasectomy, IUD), weight loss, etc.
Episodic care for patients not affiliated under the BCM is not aligned with the principles of the BCM in keeping with the Patient’s Medical Home and continuity. A clinic is only allowed two in-basket services for non-affiliated patients per two-year period.
Depending on context, it may be possible to operate a specialty interest clinic within or outside the BCM. This would be explored on a case-by-case basis.
Factors to consider include whether the services provided are in-basket or out-of-basket.
Yes, you are free to work elsewhere under FFS models.
Yes, part-time and full-time physicians can work within the BCM.
The number of patients affiliated will vary by clinic. The ideal panel size depends on your ability to provide access to all patients on your panel in a timely manner.
Support offered from the AMA can help you to determine your demand and supply to begin to understand what your ideal panel size is as a clinic and as an individual physician.
Through APP Online, participating clinics will have access to a Capitation Payment Summary, which will list all patients affiliated to the clinic and their associated capitation payment, any FFS payments, and total negation. Clinics will also have access to a Formal Negation Report, which will show all services that affiliated patients have received outside of their home clinic for each pay period.
Clinics that transition to the BCM will be granted a one-year negation-free period, in which the clinics will have access to reporting through APP Online for information purposes only. It is recommended clinics use the reporting available to them during this time to adapt their service delivery model.
Clinics on the BCM will likely see increased need for administrative work, for example, reviewing monthly negation reports. There will initially be an increased workload obtaining signed affiliation forms.
From the decision to join BCM to a clinic “going live” can take 5-6 months of preparation before the first year of support and negation-free period begins. Recommended preparatory work can include reviewing the business structure of the clinic and ensuring adequate documentation of policies. Clinics are strongly encouraged to amend or create a practice agreement that reflects business processes aligned to the BCM and the Patient’s Medical Home.
During the demonstration project, clinics will be provided with facilitation support for process redesign (administrative and clinical) via the AMA. The level of support will vary based on clinic needs and experience with quality improvement. The clinic relationship with the PCN does not change and clinics are welcome to receive support and interdisciplinary team members from their PCN.
Clinics seeking more information or that are interested in joining the model as a demonstration project are invited to contact the BCM Implementation Team at actt@albertadoctors.org to express their interest in participating.