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FAQs 

Performance and Diligence Indicators Program 

(Last Updated February 16, 2010)

The Performance & Diligence Indicators Program is a new initiative designed to strengthen the use of leading clinical practices in primary care and enhance the way that family physicians are compensated. It is should lead to improved care and better outcomes for patients.  The program is voluntary and open to all family physicians in Alberta. 

As a new initiative, several questions are being asked about the program.  This document answers those questions.  It will be updated regularly and will change to reflect the focus of the program at the time.  Questions are posed in the following areas:

Participation in the program

If I participate in Phase I of the program, do I have to participate in Phase II?

Participation in the PDI Program is entirely voluntary, and while participation in Phase II is highly encouraged, it is not mandatory and physicians may withdraw from the PDI Program without penalty.

If physicians do not participate in Phase I of the program this year, can they enter Phase I next year?

Participation in the PDI Program for the 2010/2011 fiscal year is subject to availability of resources, and as a result, participation cannot be guaranteed at this time.  If the budget is available next year for Phase I, it is certain that both Phase I and Phase II requirements will need to be completed within the 2010/2011 fiscal year.

Can physicians who are working as a locum participate in the Performance & Diligence Indicators Program?

Locums may participate in the PDI Program if they (1) are the sole primary care provider for a group of patients, and (2) it is intended that there be a long-term relationship with the locum and the clinic.  Locums who are looking after another physician’s patients for the short term (i.e., while the physician is on maternity leave or extended vacation) are not eligible for participation in the PDI Program.  The PDI Program is designed to compensate family physicians who achieve targets on specific performance and/or diligence indicators that deliver substantive clinical value – the intent is to establish these indicators as longer term measures of patient care management. 

Can pediatricians participate in the Performance & Diligence Indicators Program?

Answer coming soon.

Do I need an Electronic Medical Record to participate in the Performance & Diligence Indicators Program?

No, you do not require an EMR.  However you are required to maintain your patient lists electronically (i.e. through a spreadsheet, word processing software, or an EMR).  Many physicians will find that their EMR is a very useful tool in maintaining your Validated Patient List, and measuring and reporting on indicators during future phases of the program, but it is not mandatory. 

 

Validating patient lists

Why is it important that we develop a VPL?

There are at least four very good reasons for developing a VPL:

  • Having a way to identify which patients you are actively caring for is the foundation for effective screening and disease management.  In this regard, establishing a VPL may be considered part of “diligence” in the program’s name.  More practically, however, if establishing a VPL identifies even a few patients who should be followed up with or whose care should be managed differently, it will improve patient care.
  • Evidence from other jurisdictions suggests that developing and maintaining a VPL will promote continuity of care.  Enhanced continuity of care is linked with better health outcomes for patients.
  • The VPL will be the denominator for some clinical indicators during Phase II of the program.
  • In recognition of the time and investment that is required on the part of physicians to establish their VPL, compensation of up to $7/patient will be provided over and above existing revenue from fee for service or alternate relationship plan. 

How is the draft patient list generated by Alberta Health & Wellness?

Alberta Health & Wellness applies an algorithm called the four-cut method against historical billing data (September 2006 – September 2009) to generate the list.  The four-cut method uses the following four steps in assigning a patient to a physician:

  1. Has seen only one physician
  2. Has seen predominantly one physician
  3. In the case of a tie, physician who performed a sentinel exam
  4. In the case of a tie and no sentinel exam, physician last seen by the patient.

Can we have a shared list in our clinic (i.e. I’m a part-time physician, and I share my patients with another part-time physician)? 

Shared VPLs are permitted, however in situations where two physicians share responsibility for managing patients on their list (i.e. due to job sharing) a single payment will be calculated for both physicians using pro-rata criteria.  This means that the physicians must divide their patient list between themselves and assign patients to only one physician – the manner in which patients are assigned is entirely at the physicians’ discretion – and reconcile this list against the AHW-generated list. 

The algorithm used by AHW to generate the patient list considers which physician was seen predominantly, as well as which physician performed a sentinel exam (03.04A).  In most instances this should prevent patients from appearing on both physicians’ lists.  With that said, the algorithm does have a degree of error and the physicians should still review the lists to ensure that patients appear on the most appropriate physician’s list.

How is a VPL divided amongst specialists in a clinic?

In cases where family physician(s) are providing specialized care to patients from another family practice, the patient list is divided at the discretion of the physicians involved.  Even if care is provided for a short term (i.e. 6 months for maternity patients), the physicians’ existing business arrangements for cost sharing, etc. can help determine how the patient list ought to be divided.

Why wouldn’t I make my VPL as big as possible?

Considering that compensation for Phase I of the program is calculated on a per-patient basis, it would be enticing to make the VPL as large as possible to maximize compensation during Phase I.  However, some indicators during Phase II will be based on the number of patients a physician has on their VPL.  In other words, the number of patients will form the “denominator” of some indicators.  During Phase II, having an accurate VPL will be beneficial as calculations for clinical indicators should be based on an accurate assessment of the number of patients for whom the physician is serving as the most responsible primary care physician.

How do I complete Level 1: physician confirmation?

Different clinics will have slightly different ways of conducting physician confirmation of patient lists.  In early November, an Implementation Guide will be produced that gives guidelines and examples for how physicians may choose to complete the confirmation.

What are my options for completing Level 2: patient confirmation?

Different clinics will have slightly different ways of conducting patient confirmation of patient lists.  In early November, an Implementation Guide will be produced that gives guidelines and examples for how physicians may choose to complete the confirmation.  However, options that would be considered eligible include:

  • In-person confirmations either during periodic health exams or during the development of a Complex Patient Care Plan.
  • Phoning patients directly to confirm the relationship.
  • Accessing summary reports from emergency departments (where patients are asked who their family physician is).

My patient list largely consists of frail elderly patients, and therefore changes quite regularly (and could be different after I submit it back to AHW).  What should I do?

The PDI Program understands that patient lists are dynamic, perhaps more so for family physicians caring for patients who are largely elderly.  For reporting purposes, we can only ask for a “snapshot in time” of what the patient list is on the day it is submitted. 

However, part of the intent for the PDI Program is also to ensure that physicians have a process in place within their clinic to keep the list up to date.  For most physicians, this will involve establishing a way to have patients directly confirm their belief that you are their most responsible primary care physician.  It is important to note that patient confirmation will not be required in situations where, in the professional judgment of the physician, there is potential that asking the patient to confirm a patient-physician relationship will adversely affect the patient.  This certainly may be the case for some frail, elderly patients.  However, when confirmation is not directly sought with a particular patient, rationale substantiating this decision must be documented.  In situations where physicians have not sought patient confirmation (for the reason described above) and have documented the rationale, they will be eligible to claim $3.50 per patient that is provided for “Level 2: Patient Confirmation”.

Some physicians have a pre-existing process for conducting patient confirmations, but that process did not actually capture the date on which the confirmation was last provided.  If you know the patient confirmation was provided after April 1, 2009 but cannot specify the exact date, can you still claim for Level 2: patient confirmation?

Yes, this is acceptable.  In this situation, physicians should enter April 1, 2009 in the VPL where it asks for the date that the patient last confirmed the patient-physician relationship.

Is parental confirmation going to be required for patients who are minors but can speak for themselves (e.g. 14-17 year olds)?

This may vary on a person-by-person basis and depending upon the relationship that physicians have with the patient.  Physicians will have discretion to determine whether direct patient confirmation or confirmation from a guardian is most appropriate.

Must all of the patients on my VPL provide confirmation that I am their primary care physician?

Level 1 (physician validation) must be completed for the entire AHW-generated patient list in to receive compensation in April 2010.  As it relates to Level 2 (patient confirmation), physicians will be compensated for the portion of their VPL that has provided such confirmation by March 15, 2010, meaning that the entire list does not have to provide patient confirmation during Phase I.  We anticipate requiring Level 2 confirmation for those physicians who continue on to Phase II in 2010.

With the above stated, it is still ideal for physicians to complete as many patient confirmations as possible before March 15, 2010.  We will be providing an Implementation Guide to participating physicians in early November that provides guidance on how to conduct patient confirmations.

If our office chooses to call patients directly to confirm the patient-physician relationship, what should we say?

It is understandable that an unsolicited call from their doctor would be cause for concern for some patients.  In an effort to avoid this, the following are examples of what physicians or their staff could say:

  • “This is Dr. [Name]’s office calling.  We are in the process of updating our office records, and wanted to confirm with you that Dr. [Name] is in fact your doctor.  This phone call has nothing to do with your health or whether Dr. [Name] will continue as your doctor.”
  • This is Dr. [Name]’s office calling.  We are trying to cut down on the wait time for our patients to see their own doctor.  To help us with that, could you please confirm who your family doctor is?”
  • “This is Dr. [Name]’s office calling.  We are trying to improve how well we screen our patients for chronic diseases.  To help us with that, could you please confirm who your family doctor is?”

Patient confirmation will not be required in situations where in the professional judgment of the physician there is potential that asking the patient to confirm a patient-physician relationship will adversely affect the patient.  However, when confirmation is not directly sought with a particular patient, rationale substantiating this decision must be documented and may be examined in the event of an audit.  In situations where physicians have not sought patient confirmation (for the reason described above) and have documented the rationale, they will be eligible to claim $3.50 per patient.

What should I do if I feel that asking patients to confirm the patient-physician relationship would adversely impact them?

Patient confirmation will not be required in situations where in the professional judgment of the physician there is potential that asking the patient to confirm a patient-physician relationship will adversely affect the patient.  However, when confirmation is not directly sought with a particular patient, rationale substantiating this decision must be documented and may be examined in the event of an audit.  In situations where physicians have not sought patient confirmation (for the reason described above) and have documented the rationale, they will be eligible to claim $3.50 per patient as part of Level 2: Patient Validation.

Can I add patients to my VPL if they do not appear on the draft list provided by Alberta Health & Wellness?

Yes, in fact there is a good chance that some physicians will have some patients that do not appear on the list provided by Alberta Health & Wellness.  Patient names should be removed if you are not their most-responsible primary care physician.  The opposite is also true – if you believe that you are the most responsible primary care physician for a given patient, they should be added to your list.
 
If a patient states that another physician is their family physician, do I have to remove them from my list?

Yes, if you approach a patient to confirm the patient-physician relationship and they state that another physician is their most-responsible primary care physician, you must remove the patient from your VPL.

Can the VPL include out-of-province students in situations where the physician is clearly the most responsible primary care physician for that student?

Physicians can continue to see out-of-province patients and be compensated through fee for service or their Alternate Relationship Plan, however the Performance & Diligence Indicators Program is limited to patients who hold a valid Alberta Health Care Insurance Card. Physicians should not include out-of-province patients in their VPL.

If I am a new family physician or am taking over a practice (i.e., due to a retirement or relocation of another physician), how do I establish my VPL?

If you are a new physician, or are acquiring another physician’s practice, you would establish your VPL in the same way.  However, given that you likely don’t have a large group of established patients for whom you are the primary care provider, your VPL will likely be quite small.  Participation in the PDI Program is entirely voluntary, and the decision to participate is entirely at your discretion.



How VPL data is used

Who will have access to patient names and how can this information be used?

By completing and signing the Patient List Request Form, the physician is granting Alberta Health and Wellness access to their historical billing data in order to generate a list of patients that the physician has seen over the past three years (specifically, from September 2006 to September 2009).  Only Alberta Health and Wellness staff will have access to this information and only for the purposes of generating an initial draft list of patients and then processing a payment when you re-submit the validated list.  This information will not be shared with your PCN or any other party. 

There is a standing Privacy Impact Assessment that applies to the procedure that is being used for Phase I of the Performance & Diligence Indicators Program.  In terms of future applications of this data, physicians will have to provide their consent in advance before patient data can be used or shared.  Depending upon the specific applications for data and procedures for data acquisition, analysis and reporting, an additional Privacy Impact Assessment may be required.  This will be determined as part of the planning around future phases of the program.

The PDI Program, nor the AMA, nor the Primary Care Initiative will have access to these patient lists.  Only the physician applying to the PDI Program and Alberta Health and Wellness will have access to patient lists.

As a physician, are there any restrictions for how I can use the VPL?

Physicians are the custodians of patient-identifiable data that is generated through the Performance & Diligence Indicators Program.  Within the limits of health information legislation, there are no restrictions for how you use the VPL.  In particular, the VPL can be used for internal quality improvement work such as that conducted through the Access Improvement Measures (AIM) Program.

 

Compensation and audits

If I participate in the program, how do I get paid?

Physicians who choose to participate will be asked to provide a Billing Arrangement Number to facilitate processing of the payment.  Those physicians who submit a VPL and description of their process for conducting patient validation that meets requirements will receive payment in April 2010.

Is there additional funding to be provided for Phase II? 

The Performance & Diligence Indicators Program is funded for $14.65M during the 2009-10 fiscal year and $22.48M in 2010-11.  Phase II of the program will build on Phase I by introducing clinical indicators.  Physicians who meet the requirements of Phase II will receive additional compensation, over and above the compensation that is linked to Phase I.   Exactly which clinical indicators will be introduced during Phase II and the amount of compensation that will be associated with Phase II requirements has not been finalized at this point in time.

How does compensation through the Performance & Diligence Indicators Program relate to fee for service billings or my Alternate Relationship Plan?

Compensation in Phase I is calculated the same way for all participating physicians, regardless of whether you practice in a fee for service environment or Alternate Relationship Plan (ARP) environment.   Compensation through the Performance & Diligence Indicators Program is over and above any revenue received through fee for service or through an ARP.

If we miss the deadline for providing Level 1 confirmation (i.e. March 15, 2010) but can meet this requirement before the reporting deadline in 2011, will we get paid in 2011?

Yes, physicians who enter Phase I of the program this year will be eligible to receive compensation if they satisfy Phase I requirements before the following year’s reporting deadline (likely in February 2011).  However, if you miss the March 2010 deadline, you will not receive any compensation until March 2011.

For patients who provide confirmation of the patient-physician relationship after March 15, 2010, when will we receive compensation?

A reporting deadline will be set for early in 2011 (likely in February 2011). Physicians who submit an updated VPL that includes patient confirmations received after March 15, 2010 will receive compensation in March 2011.

What circumstances would trigger an audit?

As with other programs that involve payment, random audits may be conducted at the discretion of Alberta Health & Wellness.  Other circumstances that may trigger an audit include:

  • Situations where it is found that patients appear on more than one physician’s VPL within a given clinic.
  • Situations where either no discrepancy or a significant discrepancy exists between the AHW-generated patient list and the VPL that is reported by the physician. 

It should be noted that PCIC understands and expects that some patients will appear on more than one physician’s VPL.  Except in situations where patients appear on more than one physician’s VPL within a given clinic, this will not be grounds for an audit.

 

Support that is available

What kinds of support will be available to help physicians and their staff?

There will be a number of resources available to physicians and their teams to support them through the validation process of Phase I, and the indicators measurement of Phase II. 

  • Website: The program website contains important information about key dates and timelines, contact information, as well as documentation available for download.  This website is updated on a regular basis and is one of the best places for current information on the PDI Program.  The website is: http://www.albertapci.ca/AboutPCI/PDI/Pages/default.aspx.
  • Teleconferences: Several teleconferences will be held for interested physicians and their teams, beginning with basic program information in September and shifting to discuss relevant issues within the program and to provide an open forum for asking questions.  Watch for additional teleconferences that will be scheduled in the November to February time period.
  • PDI “Help Desk”: The program has established a centralized help desk to provide telephone support to physicians and their teams, where they can speak with a facilitator trained in all aspects of the program.  It should be noted that this service does not provide on-site, in-clinic assistance.  The help desk can be contacted at: 1.866.714.5724 or by email at pdi@albertapci.ca.

 Who pays for the facilitator and other support?

The PDI Program recognizes that it is important to support physicians in implementing changes required to meet requirements of the program, and as such, offers free support in the form of a centralized Help Desk.  By calling 780.488.4350 or toll-free 1.866.714.5724, physicians and their staff will be able to speak with a specially trained facilitator at no charge.  There are no limitations in accessing this centralized Help Desk. 

Will my PCN support me?

Some PCNs will be in a position to support their individual physicians in participating in the PDI Program, while others will not be.  Some PCNs have either allocated funding specifically for the PDI Program, or are in a position to reallocate funds for it, while other PCNs do not have the financial flexibility to do so.

Relationship to other programs and initiatives

How does the Performance & Diligence Indicators Program relate to the Complex Patient Care Plan code (03.04.J)?

The Performance & Diligence Indicators Program is distinct from the development of Complex Patient Care Plans (CPCC).  With that said, however, developing a VPL may help to identify patients, some of whom may be candidates for development of a CPCC.  Also, the process of developing a CPCC provides an excellent opportunity for physicians to confirm patient-physician relationships with patients.

How is a VPL different from an AIM panel?

While the VPL has similarities to the AIM panel, there are some important differences, including:

  • Historically, AIM panels have been developed based on a 12, 18 or 24 month look back period.  The Performance & Diligence Indicators Program uses a 36 month look back period.  Going forward, the AIM program will also use a 36 month look back period.
  • AIM panels are limited to in-clinic visits and are used to match demand and capacity.  VPLs include in-clinic visits, but may also include patient visits to long-term care facilities.
  • While both programs share a “gold standard” of having patient lists validated by both physicians and patients, and having the lists kept up to date, the validation requirements are more stringent under the Performance & Diligence Indicators Program.



Important dates

What is the deadline for submitting my VPL?

The deadline for submitting a VPL for the 2009-10 fiscal year is March 15, 2010.  Reporting deadlines for next fiscal year will be established shortly.

 

How to get more information

How can I get more information?

To learn more about this initiative, please call 780.488-4350 or call 1.866.714.5724, email pdi@albertapci.ca, or visit http://www.albertapci.ca/AboutPCI/PDI/Pages/default.aspx.