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OMA Position Paper

OMA Policy on Accountability

in the Health-Care Sector

hysicians in Ontario have a long-standing tradition of being accountable
— foremost to their patients, but also to the College of Physicians and
Surgeons of Ontario, to the Ministry of Health and Long-Term Care, and to
hospitals.1 They are now facing demands to demonstrate that accountability
from health consumers, from a government that is concerned with the rising
cost of health care, and through increased regulation. This is exemplified by
legislation providing for hospital service accountability agreements2 and for
agreements between the Ministry pcomm/omr/mar/08accountabil- patients may be accountable in
and the Local Health Integration ity.htm) described various aspects of health-care systems. One is issue-spe-
Networks (LHINs).3 This increased accountability that are currently rel- cific and time-limited, and the other
demand for accountability is a soci- evant to physicians, including regu- is systemic. Care contracts relate pa-
etal trend, not limited to physicians latory frameworks. It also reviewed tient behaviours relevant to a specific
or to the health-care field. Govern- some of the issues related to the condition and are time-limited.5 In
ments — federal and provincial — are measurement of performance in contrast to these quite specific care
requiring accountability from their accountability systems. Those will contracts, there are system-wide
Ministries and agencies, and expect- not be reiterated in this document. examples of patient accountability,
ing formal evaluations of their pro- There are several exceptions to such as are used in the German
grams. After years of scandal in the the accountability framework in health-care systemiv,v and West Vir-
corporate world, shareholders and Ontario. Because of the way that ginia’s Medicaid,vii,viii These sys-
regulators are demanding more ac- LHINs are structured legislatively, temic accountability provisions have
countability from corporations as well. physicians are outside the direct consequences for patients that raise
Accountability is the requirement authority of the LHINs and there- moral and ethical issues.6 A compre-
to answer for what you have or have fore have no accountability relation- hensive examination of the issues
not accomplished that is of signifi- ship with them. However, LHINs do and the evidence would be indicated
cance and of value.i It is a relationship have a planning and oversight func- before the issue of systemic patient
between individuals, but also a pro- tion for institutions and agencies accountability is addressed expressly.
cess that requires review of perfor- with which physicians are inter- That is beyond the purview of this
mance, including corrective actions dependent. It is therefore important document.
and consequences. ii Performance that LHINs engage physicians in In this document, the ways in
review often includes disclosure of deliberations, and that physicians which health-care systems and cor-
performance measurement data that participate in those deliberations.4 porate systems have begun to address
have been collected, aggregated, and Under the current Ontario regula- accountability are described. Often,
analyzed. tory framework, patients do not share descriptions of accountability mech-
The 2007 OMA Background Paper accountability for the behaviours anisms in the research literature do
on Physician Accountability (posted that influence their health and health not meet the formal definition of
online at: care. Broadly, there are two ways that accountability given above. They are

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OMA Policy on Accountability

beginning processes that do not fit dynamic that exists in the physician- rect interpretation of a procedure is
the criteria with regard to perfor- patient encounter that cannot be communicated to the referring physi-
mance review or consequences. reduced to following a set of pre- cian and the patient. One physician
Accountability principles for physi- scribed rules for all patients, such as likens practice guidelines to a jazz
cians, listed at the end of this docu- those given in practice guidelines. score with physicians working from a
ment, are ideals (see p. 24). They are Moreover, decision trees associated basic chord structure and melody line,
intended to reflect how physicians with practice guidelines can affect with latitude for improvisation.xii
are and should be accountable, but the physician’s cognitive processing There is variability in the quality
also how other participants in the in ways that are not always entirely of the guidelines that are available
system are, and should be, account- positive. Thus, if the physician’s — some are based on high-quality
able to physicians. This duality is of mind is set on filling in the blanks in evidence, but the evidence for others
utmost importance. a template, he or she may be less is less rigorous. Evidence-based clin-
The trend toward increased ac- likely to engage in open-ended ques- ical practice guidelines are available
countability and transparency is tioning with the patient. The infor- online from a variety of sources, inclu-
demonstrated in various ways, such mation in the template becomes ding the Canadian Medical Associ-
as evidence-based medicine, alter- more cognitively available, and the ation and the British National Health
native payment mechanisms, and questioning that could lead to other Service. 10 Specific specialties may
strategies that originated in the cor- information does not occur. have their own guidelines, such as
porate world, but have been adopted These decision trees may lead those produced by the American
by the health-care system. physicians to use cognitive “availabil- College of Radiology, which pro-
ity heuristics” in situations that may vide, along with technical standards
Evidence-Based Medicine be inappropriate for particular and practice guidelines, appropriate-
patients. These are situations in ness criteria to assist referring physi-
In recent years, there has been a shift which people assess the probability cians to make the most appropriate
to recognition of the value of large, of an event by the ease with which imaging or treatment decision.11 The
objective data sets as the basis for instances can be brought to mind. A Agency for Healthcare Research and
clinical decision-making. Dr. David physician who faces a decision tree Quality,12 instituted to improve the
Sackett of McMaster University, a will have the information in the tree American health-care system, has
pioneer in evidence-based medi- more readily available, rather than contracted with 13 designated evi-
cine, defines it as follows: the information that might be given dence-based practice centres, three
“The practice of evidence-based med- by a particular patient. Research has of which are in Canada: the Uni-
icine means integrating individual clini- shown that the availability of such versity of Alberta, University of
cal expertise with the best available heuristics can lead to errors in deci- Ottawa, and McMaster University.13
external clinical evidence from system- sion-making. 9,x Clearly, evidence- Those sites also have a variety of evi-
atic research.”7 based medicine is not a panacea. dence-based practice guidelines.
By itself, evidence-based medi- However, it can be useful as a tool for At least some Ontario physicians
cine is not an accountability mecha- physicians to help them keep abreast are using practice guidelines success-
nism. Only when it is combined of current research developments fully. A survey of Ontario surgeons,
with incentives and review is it an that could be valuable to them and radiation oncologists and medical
accountability tool. their patients, to reduce uncertainty, oncologists indicated that this sub-
The corporate world is now look- and to reduce practice variation. group of physicians uses Cancer
ing to evidence-based medicine as a Evidence-based clinical practice Care Ontario’s practice guidelines,
management model. Business man- guidelines are based on epidemiolog- considers them useful, and, in par-
agement science leaders, 8 advocat- ical and statistical logic. The best ticular, has confidence in their qual-
ing for evidence-based management guidelines are validated by clinical ity.xiii The 2007 Hospital Report: Acute
in the Harvard Business Review, sug- trials that are designed to determine Care xiv indicates that about 38% of
gest that the theoretical argument whether an intervention has the diag- Ontario hospitals are using stan-
for evidence-based management is nostic or therapeutic benefit it claims dardized protocols for the diagnosis
ironclad — decisions made on the to have, and whether it is more effec- and treatment of common clinical
basis of a preponderance of evi- tive than other interventions.xi conditions and procedures.
dence, particularly within one’s own Provided that physicians are aware In Ontario, in the 2008-2009 fis-
company, will be better decisions of the potential for decision bias, cal year, $11.7 million was paid in
and will help organizations thrive.ix practice guidelines can enhance the incentives by the Ministry of Health
Evidence-based medicine can physician’s clinical and diagnostic and Long-Term Care to about 3,900
enhance, but it cannot replace, the skills and improve patient care. For physicians who followed diabetes
clinician or diagnostician’s expertise physician specialists, they can also management protocols, essentially
and experience. There is a complex improve the extent to which the cor- an evidence-based best practice strat-

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egy, for their diabetic patients.14 Over (AHSC AFP) provides for accountabil- care is crucial for effective functioning,
the last several years, Ontario has ity in the domains of clinical services, good patient care, and patient safety.
begun to use incentive payments to academic activities, leadership, and The OMA Policy on Interpro-
direct physicians’ efforts toward par- innovation. Participating physicians fessional Care addresses the issues
ticular patient populations and have an appointment at a university, and specifies the necessary features
improve their care; the diabetes strat- have medical staff appointments at a for successful interprofessional care. It
egy is one example of this.15 hospital with hospital privileges, are is available online (
Evidence-based guidelines can be members of a hospital department, pcomm/omr/sep/07maintoc.htm).
a means for physicians to be more and are AFP Practice Plan members. Because of their relevance to account-
accountable to themselves, to their The governing agreements are among ability, several of the principles of the
patients, and to the profession. They the Ministry, the physician organiza- interprofessional care policy are reit-
do have the potential to open the tion, the university, the hospital, and erated in the accountability principles
profession to third-party account- the Ontario Medical Association. at the end of this document.
ability when government or private In the 2008 agreement, perfor-
insurers can enforce practice guide- mance measures include total OHIP Ministry of Health and Long-Term
lines by linking them to physicians’ billings, patient service volumes,
incomes, such as is done in pay-for- number of medical students, and
Care Emergency Department
performance models in the United number of full-time equivalents Pay-for-Results Program
Kingdom and the United States. (FTEs). After the first funding year, the In 2008, the Ministry of Health and
One way to resolve this potential Ministry may penalize participating Long-Term Care announced the
conflict between physician autonomy physicians in any specialty group at an implementation of a new hospital
and use of clinical practice guidelines AHSC if they provide less than 90% emergency department pay-for-
is for the profession to take the lead in of clinical services set out in the results program under the Ontario
developing evidence-based guide- accountability template.16 Thus, this Wait Time Strategy. Twenty-three
lines. In that way, they give up some agreement includes the accountabil- hospitals with high-volume emer-
individual autonomy for science that ity aspects of review of performance gency rooms and lengthy ER wait
they as a profession endorse.xv for meeting volume objectives and times were designated to receive a
consequences for not meeting those one-time performance improvement
objectives. However, neither account- funding initiative intended to reduce
Ontario Initiatives ability provisions nor penalties are at emergency department length-of-
There are a variety of initiatives the individual physician level. stay and improve satisfaction.
underway in Ontario. Academic Funding is dependent on reducing
physicians have led the way with Interprofessional Care Teams wait times for higher-acuity patients,
payment plans that include account- reducing the number of patients with
ability mechanisms. The Ministry of Interprofessional care is a multidisci- wait times greater than 24 hours, and
Health and Long-Term Care is pro- plinary, team-based approach to ensuring that wait times for lower-
viding incentives for physicians to practice, with health-care profession- acuity patients do not worsen. Par-
follow evidence-based guidelines, als interacting to solve common ticipating hospitals are also required
and for hospitals to reduce the length issues. Successful interprofessional to regularly track patient satisfaction
of emergency department stays. care provides mechanisms for ongo- and monitor quality of care. The
ing communication among care- Ministry expects to expand the pro-
Academic Health Science Centres givers, optimizes participation in gram in 2009-2010.xvii
clinical decision-making within and
Alternate Funding Plan across disciplines, and fosters respect
The 2004 Memorandum of Agree- for the contributions of all profes-
Accountability Provisions in
ment between the OMA and the sionals within the group.xvi Other Jurisdictions
Ministry of Health and Long-Term Many Ontario physicians partici- Programs in other provinces and
Care required the establishment of an pate in interprofessional care. Ontario other countries have addressed
Accountability Expert Panel to de- physicians have a variety of arrange- accountability in various ways —
velop a framework for the measure- ments — formal interprofessional through policy documents, legisla-
ment, accountability and reporting of teams, groups of physicians sharing tion, and demonstration projects.
deliverables and a methodology for services of other health-care provi-
evaluating requests for additions to ders, or more informal liaisons be- Quebec Public Health Act
the complement of physicians at each tween physicians and community
Academic Health Science Centre. resources. Regardless, within those Quebec’s Public Health Act 17 is in-
The Academic Health Science groups, clearly delineated account- tended to ensure that physicians are
Centres Alternate Funding Plan ability for various aspects of patient accountable to the Quebec Ministry

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of Health and Social Services. Under purchasing agreements between the data, usually accomplished through
the Act, physicians are required to Commonwealth and the states with information technology systems that
report to the public health authori- regard to free public treatment in include electronic medical records.
ties unusual clinical manifestations hospitals. In its recent report,xix the As of 2006, more than half of all
due to vaccination, and to report Australian National Health and American state Medicaid programs
intoxications, infections, and dis- Hospitals Reform Commission sug- were operating one or more pay-for-
eases that are on a regulated list. gests a new division of accountabil- performance programs. Most Ameri-
Physicians must treat individuals ity between the federal government can Medicaid pay-for-performance
with contagious diseases or infec- and the states. The federal govern- programs use standardized clinical
tions, or direct them to treatment; ment would be accountable for pri- performance measures related to pre-
physicians are also required to mary care, aged care, prevention, ventive and primary care and to treat-
report to authorities those individu- and the health of Indigenous peo- ment and management of chronic
als suffering from such diseases or ples. The states would be account- diseases. Measures are maintained
infections who refuse treatment or able for public hospitals, mental centrally by the National Committee
examination. To ensure account- health, maternal and child health for Quality Assurance. They are
ability under the Act, physicians fail- services, and public health services. directed toward such health issues as
ing to make such reports or notices Performance measures would cross asthma, hypertension, cancer, cardio-
are subject to a fine. the entire health system, including vascular disease, childhood immu-
Quebec has recently appointed a general practitioners, as well as hos- nizations, chronic obstructive
Health and Welfare Commissioner, pitals and other health services. pulmonary disease, depression, dia-
who is responsible for assessing the The Australian system is quite betes, osteoporosis, and smoking.xxi
results achieved by the health and different from the Canadian one, Some programs use structural mea-
social services system, and for report- however, in that a large portion of sures related to a specific status or
ing to the public about the govern- Australians have both public and activity, such as adoption of informa-
ment’s efforts to address major private health care. All Australians tion technology, wait times, or hours
issues.18 Under the Public Health Act, pay a 1.5% tax on income for health of operation.
the Ministry may require physicians care, but about 40% take out private Many of the initiatives in the Amer-
to provide aggregate data to assist health coverage, which entitles them ican Medicaid programs have been
with its ongoing surveillance of the to a specialist of their choice and remarkably successful in improving
health status of the population. treatment in a private hospital.xx care. Probably the most notable is the
change in the percentage of patients
Alberta Bone and Joint Health Pay-for-Performance Programs who had suffered a heart attack and
were prescribed beta-blockers,xxii an
Institute Other counties, most notably the increase from 62% in 1996 to 96% in
The Alberta Bone and Joint Health United States and the United King- 2005. There are some exceptions,
Institute has built a model of carexviii dom, have moved extensively into however. The quality of care for
based on the principles of evidence- pay-for-performance systems as an patients suffering from mental illness
based prevention, diagnosis and treat- alternative to fee-for-service. Pay-for- has not improved since 1999, as mea-
ment, guaranteed access, continuous performance systems assume that by sured by follow-up after hospitaliza-
evaluation, and patient-centred care. rewarding physicians for quality of tion. Patients with some complex
The Institute considers optimizing care, rather than paying for the num- illnesses or comorbidities present
access, quality, and cost to be key ac- ber of services provided, patient challenges to physicians treating
countability dimensions. Patients are health and the health-care system them, and may not be amenable to
assigned case managers at intake. can be improved. Quality of care is standardized solutions.
There are standardized care paths and measured either by outcome or
standards of access and quality. The process measures. The Ontario dia-
system has almost immediate feed- betes incentive is an example of a
Corporate Strategies Adopted
back of access, quality, and cost data. process measure. Outcome measures by the Health-Care System
In recognition of the important role of are related more clearly to patient In the corporate world, performance
patients to their own health, the Insti- health status, but are also more diffi- review has typically been assessed in
tute requires patients to sign a “care con- cult to measure, particularly in the terms of number of sales or amount
tract” to participate in their own care. prevention arena. of profit. Reward to those who meet
The best systems will probably use their performance accountability
Australian Reforms process measures that are demon- requirements is characterized by in-
strably tied to improved outcomes. creased salaries and stock options, as
Historically, the Australian Health Pay-for-performance systems require well as other perquisites. These are
Care Agreements (AHCAs) were the ability to collect and aggregate valuable and motivating incentives

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in situations where employee perfor- at The Ottawa Hospital, palliative Ontario Hospital Report Research
mance increases profitability. How- care components will be function- Collaborative
ever, those performance measures ally integrated into the critical care In Ontario, the Hospital Report Re-
and rewards do not represent an ap- units. At Norfolk General Hospital, search Collaborative (HRRC)19 has
propriate means of measuring or recommendations will enable published reports on the perfor-
rewarding physician performance. improved scheduling and use of mance of Ontario hospitals for about
Nevertheless, some aspects of cor- resources in the OR and in ambula- 10 years.20 The HRRC uses a balanced
porate practice do transfer to parts of tory care. xxvi These are ways to scorecard of indicators for measures
the health-care system. A few Ameri- attempt to improve the quality of of hospital performance. Individual
can hospitals are attempting to services — in the corporate world reports cover acute care, emergency
address safety issues using Toyota’s and in health care. They increase department care, complex continuing
production system, called kaizen, individual responsibility for im- care, rehabilitation and mental
which focuses on continuous use of proved processes. health.
problem-solving techniques to When improved processes are The HRRC is funded by the On-
improve processes and increase tied to consequences, they represent tario Hospital Association and the
safety. By using the Toyota model, accountability mechanisms. The Ontario Ministry of Health and Long-
the health-care system is looking to Toyota example is a process model Term Care. The reports indicate that
the corporate world for solutions. that is probably most applicable to the primary audience is intended to
In the Toyota system, there are small units in the health-care sys- be hospital boards of directors, senior
detailed specifications of how work is tem, such as exemplified by the hos- managers, and Local Health Inte-
to be done before it is performed; that pital units engaged by Ministry gration Networks, and that the infor-
is coupled with testing work as it is coaching teams. mation is intended for strategic
done. The specification is somewhat planning and priority setting.
analogous to a temporary best prac- Public Reporting and The information seems to be use-
tice until a new problem is discov- ful; for example, the 2007 acute care
ered, at which time the problem is Physician Profiling report indicates that there is improve-
analyzed experimentally and re- Many jurisdictions have introduced ment from 2006 to 2007 in the ex-
solved.xxiii The focus is on continuous public reporting of health quality istence of formal procedures for
learning, improvement, and innova- measures as a means of demonstrat- removing patients from wait lists and
tion for all staff — managers and line ing public accountability and trans- in measures of patient safety.
workers alike — using the scientific parency, improving the quality of
method.xxiv health care, and containing health- College of Physicians and Surgeons
In some American hospitals, im- care costs. Physician profiles are also of Ontario
plementation of this system to im- intended as a means of increasing The College of Physicians and Sur-
prove processing has lead to accountability and improving qual- geons of Ontario publishes on its
reduction in infection rates and med- ity, often through physician self- website summaries of the decisions
ication errors. The idea is to empower management of change. They may of the Discipline Committee, by
staff to examine and change current be publicly reported. Although month and year, along with the
processes in a systematic way and to physician profiling and public names of the physicians and sum-
continue to use those learned strate- reporting has increased over the past maries of the decisions.21
gies to improve processes. Toyota’s couple of decades, particularly with
production system engages workers American health-care plans, assess- Health Quality Councils
to become more accountable for the ments of their validity and useful- Ontario, Saskatchewan, Alberta, and
efficiency of production; it is one of ness suggest caution. New Brunswick have legislated health
the main factors that has led Toyota quality councils that report annually
to be such a profitable corporation. Public Reporting to government on the quality and
A similar focus on examination of performance of their health systems.
processes has been used with suc- Public reporting of data on clinical Reports are available online.22
cess in some Ontario hospitals with performance is fairly common in
coaching teams organized by the the United States, but it is relatively California Pay-for-Performance System
Ministry of Health and Long-Term new in Ontario. There are conflict- In California, public reporting of
Care. The goal of the coaching teams ing reports about its impact on clini- physician group performance is a key
is to help hospitals develop their cal care. For illustrative purposes, a part of the pay-for-performance pro-
own problem-solving capacity and, few examples of public reporting are gram. xxvii Each medical group gets a
like the Toyota system, learn to im- provided below. Most are at the sys- summary rating for meeting national
prove their own systems and pro- tem level, rather than at the individ- standards of care. The rating is based
cesses continuously.xxv For example, ual level or group physician level. on the average score across 13 mea-

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OMA Policy on Accountability

sures.23 These reports are available on managed care plans, hospital trusts, cian and the department chief, that
the Internet 24 by county, physician and regions, is larger than that on the assessments be mandatory, and
group within a given county, and by health-care providers, and the results that all physicians be assessed on a
measure for each group. They are also are more positive. Nevertheless, the rotational basis every three years to
available in print in public libraries interpretation of the meaning of the five years. It also recommends that all
and major drug store chains. Ratings differences in terms of patient out- information collected be confidential
are provided on a four-point scale. An comes is controversial.26 between the physician and the chief,
individual can look up results for any One effect of public reporting and not available to hospital admin-
physician group on any of the mea- may be to focus public attention and istrators or boards of
sures. This public reporting provides government funds on particular
the opportunity for patients to make areas. When this occurs, the result Alberta Physician Achievement Review
their provider decisions based on may be neglect in other areas, possi- The Alberta Physician Achievement
information provided in the online bly of equal importance, and in- Review (PAR) process was man-
assessment. equities in the system. dated by law in 1999. 27 It provides
for review by patients, medical col-
Wisconsin Collaborative for Health-Care Physician Profiling leagues, co-workers, and by physi-
Quality cians themselves, with each group
This collaborative, established in Physician profiles, also called physi- assessing on some dimensions.
2003, is physician-led. In 2007, it cian report cards or score cards, con- Physicians are assessed by their
included 28 physician groups, hos- tain evaluative information about medical colleagues on clinical com-
pitals, and health plans that re- the physician’s clinical performance. petency, psychosocial management
ported data for more than 50% of Evaluative information in the pro- of patients, patient interaction, and
Wisconsin’s physicians. Its goal is to file may be restricted to the physi- professional self-management. They
improve the quality and cost-effec- cian, shared with regulatory bodies, are assessed by co-workers on patient
tiveness of health care. It reports or made public. interaction, co-worker collegiality,
comparative measures of perfor- The collection and reporting of and co-worker communication. Pa-
mance in ambulatory and hospital these data varies widely in sophisti- tients assess on patient interaction,
settings using data submitted volun- cation — some are comprehensive, telephone communication, patient
tarily by provider organizations. As controlled evaluations; others per- information, personal communica-
well as achieving public reporting of mit the public to post any evalua- tion, office staff, physical office, and
primary care sites, it has a model for tion. Public reporting of individual appointments. Physicians assess
translating evidence-based medicine physician data has the potential to themselves on all attributes of all
into community practice. A variety result in refusal of care to complex dimensions.
of aggregate data are provided on- patients who may lower scores. The All Alberta physicians are required
line25 by topic at the physician group, evidence concerning this practice is to have a review every five years, with
hospital, or health-care plan level. inconclusive. about 1,000 physicians reviewed per
year. Each physician asks eight physi-
Assessments of Public Reporting Council of Academic Hospitals of Ontario cian colleagues, eight non-physician
A recent survey of 18 experts in the 360-Degree Physician Performance Review co-workers, and 25 patients to com-
U.S. health-care system about public The Council of Academic Hospitals plete a questionnaire. Data are ana-
reporting of health-care performance of Ontario (CAHO) has recently lyzed by an independent body with
indicated concerns over measure- released its plan for a 360-degree results provided to physicians in a
ment and interpretation, including physician performance review. It is manner that they can compare their
data quality, validity, reliability, modelled after the Alberta Physician self-ratings with those of patients,
accuracy, and risk adjustment. Achievement Review process de- colleagues, co-workers, and with
Respondents also suggested the need scribed below. provincial norms. Those scoring in
to involve stakeholders in the design The review process would apply to the top and bottom 10% are flagged
of indicators.xxviii physicians in Ontario’s 25 academic for attention and review by the
A Canadian review of the litera- hospitals. Like the Alberta program, College of Physicians and Surgeons
ture on performance reportsxxix indi- it would provide for review by of Alberta.28 However, PAR informa-
cates that they have little effect on patients, peers, consultants, and tion is strictly for educational pur-
consumer knowledge, attitudes or other clinicians. The plan suggests poses and cannot be used in any
behaviour, but that consumers who linking the 360-degree performance advertising, disciplinary action, or
do use the reports to make change evaluation with quantitative indica- legal process.xxxi The PAR website pro-
find the data useful. tors, such as length of stay, infection vides a variety of sources for practice
The research on the effects on rate, and mortality. It recommends improvement and education for
group providers, such as hospitals, that results be shared with the physi- Alberta physicians.29

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OMA Policy on Accountability ance with various clinical guide- atively small set of conditions that is an international lines. It is being used in the U.S. in are delivered by only a few special-
online forum that permits users to national and regional health plans. ties.xxxvii
rate their physicians on a five-point Measures of quality of performance
scale on the dimensions of staff, are developed by using claims data-
punctuality, helpfulness, and knowl- bases to extract information about
Risk Adjustment and Risk
edge.30 Scores are summed and physi- the degree of compliance with vari- Sharing
cians rated overall as good, average, ous clinical guidelines. Performance All reimbursement systems have
or poor. Individual scores, com- can be assessed in terms of relative financial incentives and risk. How-
ments, and summary scores are avail- compliance rate or as satisfying an ever, compared to American models,
able to the public and to physicians. absolute compliance rate standard. where much of the health-care sys-
The anonymous information pre- Similarly, cost-efficiency measures tem is administered on a for-profit
sented at RateMD is unsubstantiated can be calculated and physicians basis, Ontario physicians assume rel-
and open to abuse by disgruntled compared, within specialty, on rela- atively little financial risk. Never-
patients or unknown others. Approx- tive cost-efficiency performance.xxxiv theless, in some models, there is
imately 16,000 Ontario physicians modest risk. In Ontario, physicians
have been rated. Assessment of Physician Profiles in capitated models, such as Family
The research on the effects of perfor- Health Networks (FHNs) and Family
New York State Cardiac Mortality Rates mance reports on health-care pro- Health Organizations (FHOs), paid
In New York State, cardiac bypass viders, mainly physicians, shows on a per-patient basis, are subject to
mortality rates are published by hos- mixed results, with many papers cit- negation of their access bonus 32 by
pital and by surgeon. Whether publi- ing the same cardiac mortality re- the amount of outside use. Thus, if an
cation results in physicians refusing porting and analyses described enrolled patient sees another phy-
high-risk patients has been ques- above for New York State. sician, who then charges OHIP for
tioned. One survey of physicians A small survey in Ottawa indi- services, this reduces the original
indicated that physicians thought cated that family physicians were physician’s total access bonus by the
that public reporting does result in receptive to performance assessment amount of outside use.
high-risk patients being refused ser- feedback and found it useful, but
vice, specifically because of the had reservations about such infor- Risk Adjustment
State’s public reporting require- mation being shared with patients.
ments. However, another report that When asked to rank their account- Risk adjustment is the use of infor-
analyzed the data showed no evi- ability to patients, professional bod- mation to calculate the expected
dence of systematic bias against ies, peers, funding bodies, and annual health-care costs of individu-
operating on high-risk patients.xxxiii others (self, specialists, family and als and to subsidize those costs.
friends), patients were ranked first There are methods of adjusting capi-
Massachusetts Online Physician Profiles by all respondents.xxxv tated models for risk: reinsurance,
Massachusetts physician profiles 31 A 1998 American assessment of and various risk adjustment models,
provide access to information about data use by primary care physicians, are two primary methods.
the education, training, and experi- pediatricians, and internists, from Reinsurance is individual stop-
ence of all physicians. That includes profiles for improving patient care, loss coverage that provides that the
their publications, malpractice claims indicated that about one-quarter physician is responsible for the
paid, hospital discipline, criminal found profiles useful or very useful, health-care costs of an individual
convictions, and disciplinary actions. and another 40% found them mod- only up to a certain dollar threshold
However, there is no clinical evalua- erately useful. Over half used them over a given time. It is used in the
tive information provided. to change patient care practices U.S. to protect physicians paid by
often, always, or sometimes. But, capitation, especially those in small
Episode-Based Physician Profiling almost half never, or rarely, used groups, from losses due to catastro-
The newest approach to physician them to change patient care.xxxvi phic illnesses or events.
profiling is episode-based. An epi- Assessment of the episode-based Risk adjustment models include
sode of care refers to a period during method of physician performance demographic models based on char-
which a disease process is present measurement indicates that, because acteristics such as age and sex, func-
and is being managed, diagnosed of the variation in detail and com- tional health models that measure
and treated by health-care providers. prehensiveness of claims data, it ability to perform daily living tasks
To assess the quality of physician offers opportunities for misidentifi- or that assess previous health-care
performance, the method uses cation of low-performing and high- spending, and clinical indicator
claims databases to extract informa- performing physicians. Moreover, models that use diagnostic informa-
tion related to the degree of compli- clinical criteria are available for a rel- tion from claims or encounter data.

7 Ontario Medical Review •July/August 2009 Ontario Medical Review •July/August 2009 23
OMA Policy on Accountability

Another strategy to reduce physi- Risk Sharing A common response to these de-
cian financial risk is to use what are Some American risk-sharing models mands has been the use of evidence-
called “carve-outs.” With this method, include not only primary care and based medicine. In Ontario, this is
services, conditions or populations specialist physician services, but also linked to incentives for particular
are carved out of the capitation pay- inpatient hospital services and phar- diseases or populations which, of
ment and reimbursed on a fee-for-ser- maceuticals. Generally, as the scope themselves, are not accountability
vice basis. xxxviii “Case rates” for of provided services increases, finan- mechanisms. In the U.K. and many
procedures that have predictable cial risk increases. American systems, evidence-based
lengths of treatment, or “episode of In the U.S., some capitated systems medicine is used as the basis for pay-
care rates” for services for a single have failed because of an insufficient for-performance models of care.
episode for a patient, are both types number of patients and/or an insuffi- Physician profiles are another
of carve-outs. cient number of providers to share means of attempting to increase the
In Ontario, capitated payment the risk.xlii If risk is distributed across a quality of health care, whether for the
models use both risk adjustment large patient population, the effect of sole use of the physician, or as public
and carve-outs. Rates for physicians a few extremely high-cost cases is information. Efforts to make systems
are risk adjusted for patient age and ameliorated. In Ontario, physicians transparent as well as accountable are
sex; extra fees, payments, incentives in capitated models have the option shown by public reporting of health-
and bonuses are carved out for par- of having capitation payments made care quality at the provincial, group
ticular patient populations and for to the individual physicians or to the practice, or individual physician level.
specific health-care services. Risk group. Rather than using incentives to
adjustment is also used in Israel, The American trend appears to be improve quality, some governments
Europe and the United States. away from risk-sharing models, or to have legislated changes designed to
The Israeli and European health- limitation of their scope, although increase the accountability of phy-
care systems are quite different from Medicaid-managed care plans may sicians. Alberta’s Physician Achieve-
those in Canada or the U.S. In the be an exception.xliii Poor utilization ment Review program, and Quebec’s
Israeli health-care system, for exam- management, rising medical costs, public health services legislation, are
ple, four non-profit sickness funds inadequate capitation increases, and examples.
contract with providers to provide financial failures among medical Regardless of whether it is within
medical care; citizens must choose groups have led American physicians pay-for-performance models, there is
from one of the four funds. Risk and hospitals to rebel against the increased emphasis on measuring
adjustment is based on age, gender, amount of risk they were assuming.xliv,xlv the performance of physicians. This
and region. Five “severe diseases” Many American models have is shown in the Ontario Academic
are carved out and paid separately. structural arrangements that include Health Science Centres Alternate
Health insurance is mandatory for four or five layers of contracts from Funding Plan, the CAHO 360-Degree
all citizens, and the funds are obliged health maintenance organizations Physician Performance Review, the
to accept all applicants.xxxix (HMOs) through physician-hospital proposed Australian reforms, and in
Similar systems that have a com- organizations (PHOs), through indi- the Wisconsin Collaborative.
petitive market for sickness funds exist vidual practice association (IPAs) via For Ontario physicians, account-
in Belgium, Germany, the Neth- a medical group to the physician, so ability must be a reciprocal process
erlands, and Switzerland. In these it is difficult to determine how much between them and their patients, the
countries, all citizens have a guaran- risk is assumed by the individual College of Physicians and Surgeons
teed choice of sickness funds that physician.xlvi Moreover, U.S. models of Ontario, the Ministry of Health
either provide them with medical care are not directly comparable to and Long-Term Care, and hospitals.33
or purchase care for them, although Ontario models as payments origi- Physicians cannot be held account-
the number of funds in a country nate with for-profit organizations, able for achieving specified outcomes
varies from four in Israel to 275 in and the scope of services is greater. or following particular clinical guide-
Germany. All countries have methods lines if the necessary resources are
of risk adjustment, including age, not available to support them.
gender, urbanization, disability,
Summary The Ontario Medical Association’s
income, historical costs, social status, The past few years have shown in- principles of accountability for
family composition, and chronic ill- creased demand for accountability physicians and their partners in the
ness. The addition of some of the and transparency in health care, in health-care system are stated below.
health-based risk adjusters after the other public sectors, and in the cor-
plans had been in existence for a year porate world. In health care, these Physician–Patient Accountability
or two im-proved the systems. In demands are directed toward two
some countries, special risk-sharing goals: improving the quality of
arrangements are made for outliers.xi,xli health care and reducing its cost. The OMA believes that optimal pa-

24 Ontario Medical Review •July/August 2009 Ontario Medical Review •July/August 2009 8
OMA Policy on Accountability

tient care is achieved when accoun- safety can be addressed in a timely ing pay-for-performance plans, are
tability for health-care outcomes is fashion. accountable to the Ministry for the
shared between physicians and their The OMA believes that the phy- accountability provisions in those
patients. This is most readily accom- sician, having greater breadth of plans, including agreed-upon mon-
plished when their relationship is char- training and larger scope of practice, etary consequences if those provi-
acterized by mutual respect and trust. should be the clinical lead in inter- sions are not met.42
In the best circumstances, physi- professional teams.
cians enable patients to join them in Physician–Hospital Accountability
a decision process that considers Physician–College of Physicians
potential risks. Physicians are legally
bound to obtain consent from pa-
and Surgeons Accountability The OMA believes that optimal
tients or their agents for treatment. Principles patient care is achieved in hospitals
Patients or their agents are entitled to Each physician is accountable to the when physicians and hospital ad-
refuse treatment.34 Physicians are eth- College of Physicians and Surgeons ministrators strive toward the com-
ically and legally bound to adhere to of Ontario for his or her standards of mon goals of optimal patient care
the prevailing standard of care.35 practice, standards of professional and safety. Active physician partic-
Physicians are legally bound to ethics, standards of knowledge and ipation in the decision-making
report to the medical officer of health skill, conduct, and continuing med- processes of the hospital will facilitate
if they are of the opinion that a ical education.39 the achievement of these goals.
patient has a reportable disease.36 The College regulates its mem- Physicians have an ethical re-
Patients are entitled to be informed bers in accordance with the law, and sponsibility to their hospital patients
of all aspects of their health care. This develops, establishes and maintains to advocate for hospital resources to
includes the right of a patient to dis- standards of qualification, standards meet their health-care needs.
closure of harm that may have oc- of practice, standards of professional Issues around resource availabil-
curred to him or her in the course of ethics, standards of knowledge and ity and service delivery levels are
receiving health care.37 skill, and programs to promote con- linked integrally. Hospital decisions
Physicians are required to take tinuing competence.40 As the College to reduce, restrict, or remove funding
steps that are reasonable in the cir- is the regulator for the profession, it or other resources can be expected to
cumstances to ensure that patients’ should exercise its authority in a result in a change in physician ser-
personal health information is pro- responsible manner. vice levels.
tected against theft, loss, and unau- Hospitals are responsible for pro-
thorized use or disclosure.38 Physician–Ministry of Health and viding physicians with privileges
To improve patient care, the OMA with the resources necessary for them
encourages physicians to participate
Long-Term Care Accountability to treat patients effectively and in a
in the development of clinical prac- Principles timely manner according to the privi-
tice guidelines that are evidence- As a steward of public funds, the leges granted. This includes such
based. Physicians may choose to use Ministry of Health and Long-Term resources as professional and support
clinical practice guidelines as a tool to Care is accountable to the public for staff, operating room time, on-call
supplement their clinical judgment funding decisions, including pay- scheduling, equipment, bed space,
and enhance their clinical skills. ments to physicians for their ser- anesthesia services, and outreach ser-
vices. The OMA is mindful of this vices. Further, hospitals are responsi-
Physician–Interprofessional Care responsibility. ble for making changes in resource
In accordance with the CMA availability in discussion with the
Team Members Accountability Code of Ethics41, physicians should medical staff; such decisions must
Principles use health-care resources prudently. not be imposed unilaterally.
The principles cited below are taken Physicians must retain autonomy As the decisions made by physi-
from the OMA Policy on Interpro- in medical decision-making. Neither cians impact the financial resources
fessional Care. Because of the im- the Ministry nor any other body of the hospital, physicians should
portance of clearly delineated may usurp this authority. consider the impact of their decisions
accountability for effective team Physicians who receive incentive on hospital resources, although their
functioning, patient care and patient payments for meeting set goals for primary duty and responsibility lie
safety in interprofessional team specific patient populations or ser- with the patient.
models, they are reiterated here. vices are accountable to the Ministry Physicians are accountable to the
In health-care teams, a formal to demonstrate that these services hospital’s board of trustees through
process for conflict resolution should have been provided. the medical advisory committee for
be in place so that issues regarding Physicians who participate in the quality of the professional services
scopes of practice, roles, and patient alternative payment plans, includ- they provide within the hospital.

9 Ontario Medical Review •July/August 2009 Ontario Medical Review •July/August 2009 25
OMA Policy on Accountability

Physicians and the hospitals in gration (Ministry of Health and concept, there seems to be a
which they serve their patients may Long-Term Care, Strategic Ad- consensus that evidence-based
have individualized agreements that visory Committee and LHIN management makes for better
specify the services that physicians Collaborative, Memorandum decisions.
will perform, and the resources that from Ron Sapsford, Deputy Min- 9. Psychologists Daniel Kahneman
hospitals will provide to them. ister, and Bill MacLeod, LHINs, and Amos Tversky published
Because of the interdependence of 2009, Feb 24. extensively on heuristics and
some specialists, such as surgeons 5. The Alberta Bone and Joint biases in decision-making. Kah-
and anesthetists, some agreements Health Institute has a care con- neman won the Nobel Prize in
may have contingencies that pro- tract for patients undergoing economics in 2002, partly for this
vide for exceptions due to the condi- joint replacement (Frank C, Dick work.
tions of another specialist. D, Smith D, Wasylak T, Gooch K 10. CMA guidelines are at http://
& Zernicke R. The Alberta Bone
Permission and Citation and Joint Health Institute: creat- British guidelines are online at
The contents of this publication may ing sustainable accountability (Both accessed:
be reproduced in whole or in part through collaboration, relevant 2008 Mar 12).
provided the intended use is for non- measurement and timely feed- 11. Online at
commercial purposes and full ack- back. Healthcare Papers. 2006;7 aryMainMenuCategories/qual-
nowledgment is given to the Ontario (1):34-9). Similarly, several pain ity_safety.aspx. (Accessed: 2009
Medical Association. clinics in California have trilat- Mar 9)
eral opioid contracts between 12. Online at
Ontario Medical Association. OMA the specialist, the patient, and sed: 2009 Mar 9).
Policy on Accountability in the the patient’s primary care physi- 13. Evidence-based practice informa-
Health-Care Sector. Ont Med Rev cian (Fishman S, Mahajan G, tion is online at http://hiru.
2009 July/Aug: 17-29. Jung SW, & Wilsey, B. The trilat-
eral opioid contract: bridging the (McMaster);
ISBN: 0919047726 pain clinic and the primary care (University of Ottawa); www.
© Ontario Medical Association, 2009 physician through the opioid of
contract. Journal of Pain and Alberta) (All accessed: 2009 Mar 9).
Author Symptom Management; 24(3): 14. OMA Economics Department.
This paper was prepared by Aura 335-342. Available from http:// Data are for the third year the
Hanna, PhD, a senior policy analyst in download. journals.elsevier- incentive was available.
the OMA Health Policy Department. 15. This is not pay-for-performance;
3924/PIIS0885392402004864. in pay-for-performance models,
Footnotes pdf. Accessed: 2009 Mar 24.) review is required and incentives
1. The ways in which physicians 6. For example, in West Virginia, are contingent on performance.
are currently accountable was pediatric patients may have lower In Ontario, physicians are paid
detailed in an OMA Board back- levels of drug entitlements be- for participation.
ground paper, published in the cause of the behaviours of their 16. Prior to funds being withheld,
March 2008 Ontario Medical parents. the Ministry of Health and Long-
Review, and available online at 7. Sackett D, Rosenberg W, Gray Term Care will meet with the J, Haynes R, & Richardson S governance organization to
omr/mar/08maintoc.htm (1999). Evidence-based medi- explore potential extenuating
(Accessed: 2008 April 14). cine: what it is and what it isn’t. circumstances.
2. Commitment to the Future of Medi- British Medical Journal, 312, 71- 17. Quebec. Public Health Act, R.S.Q.
care Act, 2004, S.O.2004, c. 5. 72. Online at 2001, Chap.S-2.2. Online at
3. Local Health System Integration cgi/content/full/312/7023/71 www2.publicationsduquebec.go
Act, S.O. 2006, c. 4, s. 18. The (Accessed: 2008 Mar 4).
accountability agreements are 8. The authors of this article are on ge.php?type=2&file=/S_2_2/S2_2
posted online at http://www. faculty at Stanford University, _A.html. Pfeffer with the Graduate School 18. Quebec. An Act Respecting the
tion/lhin/lhin_aa.html. of Business, and Sutton with the Health and Welfare Commis-
4. One of the goals of the LHIN Engineering School. Their book sioner, R.S.Q., C-32.1.1. Online
Collaborative, announced recent- on evidence-based management at: www2.publicationsduque-
ly, is to engage the health service has been discussed and debated
provider community to ensure in the management literature. telecharge.php?type=2&file=/C_
collaborative and successful inte- Although there are critics of the 32_1_1/C32_1_1_A.html.

26 Ontario Medical Review •July/August 2009 Ontario Medical Review •July/August 2009 10
OMA Policy on Accountability

19. The Hospital Report Research Achievement Review program is patient to disclosure of harm that
Collaborative was superseded in available on the website of the may have occurred to him or her
2008 by the Health System Per- College of Physicians and Sur- in the course of receiving health
formance Research Network. geons of Alberta at www.cpsa. care” (College of Physicians and
20. These are available online at Surgeons of Ontario, 2003). (Accessed: 2008 Sept 4). Disclosure of harm. Toronto:
21. Online at 29. Online at http://www.par-pro- CPSO. Available online at www.
=1444. htm (Accessed: 2009 Mar 9). htm).
22. The Ontario Health Quality 30. Online at 38. Personal Health Information
Council reports are online at (Accessed: 2008 Sept 4). Protection Act, 2004, S.O. 2004,, 31.Online at http://profiles.mass c. 3, Sched. A, s.12(1).
Alberta’s are at 39. Physicians should be aware that
index.php?id=%2097, Saskatche- Profile-Find-Doctor.asp this document provides an over-
wan’s are at www.hqc. (Accessed: 2008 Sept 9). view, not a detailed account of all
tal.jsp?LFqKTVQ7W8BD+4vt8v 32. For physicians in Family Health the ways that they are account-
meKjBIzBf0QfLQkUwK4QBZaJv Networks, the access bonus is an able to the College. The role of
0Z63bjKY3KIzOVcA+lmY4 (All additional 20.65% over the capita- the College, its authority and
accessed: 2008 Sept 10). Being tion payment, and for physicians powers are set out in the Regu-
new, New Brunswick’s health in Family Health Organizations, lated Health Professions Act
council has not yet reported. Infor- it is 18.50%. (RHPA), the Health Professions
mation is available at www. 33. A background paper on physi- Procedural Code (Sched. 2 of the cian accountability is available RHPA) and its regulations (O.
health_council/health_council-e. in the March 2008 Ontario Medi- Reg 39/02, 107/96, and 59/94)
pdf. Accessed: 2008 Nov 18. cal Review, and available online and the Medicine Act and its reg-
23. These are: asthma medicine, at pcomm/ ulations (O. Reg. 114/94, 856/
breast and cervical cancer screen- omr/mar/08maintoc.htm 93, and 865/93 (all available
ing, child immunizations, chla- (Accessed: 2008 Apr 14). online by typing in the name of
mydia screening, testing and 34. Health Care Consent Act, S.O. the relevant Act at www.e-laws.
controlling blood sugar and cho- 1996, Chap.2, Sch. A.
lesterol for diabetes patients, 35. The 2004 Code of Ethics of the eStatutes&reset=yes&menu=bro
testing kidney function for dia- Canadian Medical Association wse&lang=en (Accessed: 2009
betes patients, testing and con- states that the fundamental re- Mar 12).
trolling cholesterol, testing sponsibility of a physician is, 40. Regulated Health Professions Act,
children with upper respiratory “Consider first the well-being of R.S.O., 1991, c.18, Sched. 2.
infections. Online at www.opa. the patient” (Canadian Medical Available online at Association. CMA Code of Ethics.
groupabout.aspx (Accessed: 2004. Ottawa: Canadian Medical a741833c -4193- 4cf7-b90c-
2008 Aug 14). Association). Available online at 99cd8260849c/1/frame/?search
24. Available online at http://www. =browseStatutes&context= ci_id/2419/la_id/1.htm). The (Accessed: 2008 Dec 17).
25. Online at report- regulations under the Medicine 41. Canadian Medical Association
ing/(Accessed: 2008 Sept 10). Act also require that physicians (1868). CMA Code of Ethics
26. See Lindenauer P, Remus D, “maintain the standard of practice (updated 2004). Available online
Roman S, Rothberg M, Benjamin of the profession” and that they at
E, Ma A, & Bratzler D (2007). not practice in a “disgraceful, dis- PolicyPDF/PD04-06.pdf
Public reporting and pay for per- honourable, unprofessional” or (Accessed: 2008 Oct 9).
formance in hospital quality “unbecoming” manner. (Medicine 42. One of the alternate funding
improvement. New England J. of Act, R.R.O. 856/93, s.1 ss.1 (2, 33, plans is with the Academic Health
Medicine, 356(5), 486-496 and 34). Science Centres.
responses to that article by 36. Health Protection and Promotion
Mullen & Bradley, Mansi, & Act, R.S.O. 1990, c.H.7, s.25. References
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