Sick patients continue to face challenges in accessing primary care
Improving access to primary care has been a key priority of the Ontario Ministry of Health and Long-Term Care for the past decade.
The number of Ontarians who have a regular family doctor has increased dramatically.
However, patients who are chronically ill continue to have problems accessing primary care.
More family doctors and more rostered patients
The 2003 Ontario Liberal Party platform promised better access to family doctors and nurse practitioners. To achieve this objective, the government provided additional funding for family doctor training and also created new group practice structures and compensation models for family doctors. These new models included substantial financial incentives for doctors to take on new patients.
The Ontario Medical Association reported last November that more than two million Ontarians have been newly rostered with a family doctor – meaning that both the family doctor and the patient have agreed to enter into an ongoing relationship – since 2003. Rostering means that a patient is formally registered with a family doctor or primary care practice.
However, does rostering two million Ontarians mean that those who most need a primary care now have access to care when they need it?
Challenges accessing primary care
One senior health care decision maker who wished to remain anonymous told healthydebate.ca that Ontario currently has “financial incentives in place to roster patients… but limited incentives and accountability to improve access to urgent care within primary care practices.”
In September 2011, healthydebate.ca covered the issue of timely access to primary care. One feature of the new primary care models is that they are structured to encourage doctors to provide timely access to patients for urgent concerns. When doctors work within a Family Health Team, for example, they are required to provide access to patients to their practice by offering extended hours and telephone availability. However, these systems are not always implemented in a manner that adequately meets patient needs.
Health Quality Ontario recently reported that less than half of Ontarians are able to see their family doctor on the same or next day when they are sick. Canada ranked near the bottom in a survey of fourteen countries for the ability to get a same or next day appointment when sick. For this and other reasons, many patients continue to visit walk-in clinics or emergency departments when their needs might be met by their regular family doctor. Other patients don’t have a family doctor at all.
New patients and Health Care Connect
The Ontario government launched Health Care Connect in February 2009 to help patients find a primary care provider. Patients call Health Care Connect, which is based at their local Community Care Access Center, to register with the program. A “nurse connector” asks for the patient’s health information and helps the patient find a primary care provider. Primary care providers who agree to accept patients through Health Care Connect receive a one time incentive fee to enroll these patients – $200 for most patients and $850 for patients who are deemed by Health Care Connect to be “complex and vulnerable.”
According to the Health Care Connect website, over 140,000 patients have registered with the program since its launch. Over 90,000 of these patients have been “referred” to primary care providers through the program – meaning that a family doctor has agreed to accept the patient. However, there is significant variation across Ontario in terms of referral rates. In some regions more than 90% of patients who register are referred. In Toronto for example, only about one-third of patients are successfully referred to a family doctor.
Patients with chronic medical problems continue to face challenges
More than 7,000 of the patients referred to family doctors by Health Care Connect have been deemed to be “complex and vulnerable.” Joanne Greco, Director of Client Services with the Toronto Central Community Care Access Centre says that complex and vulnerable patients are given priority within the Health Care Connect program and that “when the program was created there was a desire to make sure that those with the greatest needs are matched before those who can wait.” Health Care Connect reports that 78% of registered high needs patients to the program have been referred to a primary care provider.
What is less clear however is whether patients who are “referred” by Health Care Connect build lasting relationships with their new family doctors. Lynn Wilson, chair of the Department of Family Medicine at the University of Toronto says that she is concerned about the effectiveness of Health Care Connect in improving access to care for more complex, difficult to serve patients. Wilson says “while tremendous strides have been made in rostering patients, now we need to make sure that the hard to serve patients have adequate access to primary care.”
Compounding the problem is that many vulnerable patients, such as those with dementia or severe mental illness, are simply unable to navigate the Health Care Connect process without substantial help from someone else.
Shifting the focus to patients who need help the most
Rick Glazier, a family doctor and researcher at St. Michael’s Hospital noted in a Journal of the American Medical Association article that the new compensation models in Ontario have in some cases provided “strong incentives to drop precisely those patients with higher health needs and complex care.” Not only are family doctors penalized when their patients visit walk-in clinics, they also receive the same monthly payment for a healthy patient who visits once a year as they do for a complex patient who needs to be seen every week.
Jan Kasperski, CEO of the Ontario College of Family Physicians argues that “family doctors need to be reassured that accepting hard to place patients into their practice will not be overwhelming.” Kasperski also notes that many difficult to place patients are living with mental health and addiction issues. She warns that focusing on rostering patients with high needs can overwhelm doctors, particularly new graduates who are often those accepting new patients, saying that “if all new graduates are getting is a high intensity, high resource population, they will drown” and that some doctors will respond by closing their practice to new patients. Danielle Martin, a family doctor at Women’s College Hospital in Toronto disagrees, saying, that “while complex patients can be difficult to manage … people go to medical school to learn how to take care of sick people.”