In the last decade, efforts to improve access to primary care in Ontario have led to major changes to how family doctors practice and are paid.
A recent report suggests that these newer models of primary care are not meeting the needs of vulnerable populations, and that Community Health Centres (an older model of care) do a better job.
However, Community Health Centres are expensive, and are designed to provide more intensive services to a relatively small population.
For several decades now, a small number of family doctors have been working with other primary care providers and health promotion services in Community Health Centres (CHC). CHCs pay doctors a salary rather than fee-for-service, and are governed by community boards. CHCs were referred to as “the best kept secret in health care” in a recent Toronto Star article. However, CHCs are intended to serve a very small fraction of Ontarians.
A recent report from the Institute for Clinical Evaluative Sciences compared CHCs with other ways of delivering primary care in Ontario, such as Family Health Teams. The report suggests that CHCs are providing better care to sicker people. However, some experts caution against interpreting the results without considering the different model of care, and higher costs, of CHCs.
New models of primary care practice
In 2002 almost 10% of Ontarians lacked a primary care provider, and less than 20% of family doctors were accepting new patients. Lack of access to good primary care can lead to poor management of chronic diseases, fragmented care through walk in clinics and overburdened emergency departments. Evidence suggests that a strong primary care system results in better health.
Motivated by the lack of access to primary care, Ontario has shifted from a system where most family doctors were practicing on their own or in small groups and paid through fee for service, to group practices intended to improve the comprehensiveness and quality of care. In the past decade, more than two thirds of Ontario’s family doctors have joined these new models of care, which serve over 8 million Ontarians. Around 3 million Ontarians receive primary care from other models, or from solo family practices.
These reforms have been accompanied by substantive investments. Payments for primary care in Ontario increased by 32% from 2006 to 2010. Family doctors received $3.7 billion in payments in 2010, constituting about 1 of every 12 public dollars spent on health care in Ontario.
However, a recently released report found that patients enrolled in these newer models had higher than expected emergency department visits. Rick Glazier, a family doctor and lead researcher for this report says that Ontario has “spent a lot of money, with the main goal of improving access, and more people now have doctors, but no other measures of access [such as emergency department visits, use of walk in clinics, or same or next day access] have improved.”
One explanation for this may be that enrolled patients do not have access to after hours care through these models. While required to provide after hour care to enrolled patients according to their contracts with the Ministry of Health and Long-Term Care, a 2011 Auditor General report found that only 41% of Family Health Networks, 60% of Family Health Organizations and 74% of Family Health Groups were providing after hours services.
Community Health Centres
In contrast to some of the models introduced in the past decade, CHCs have been providing comprehensive primary care since the 1970s. Ontario’s 73 CHCs emphasize health promotion and disease prevention by providing services like counseling, cooking and home work clubs alongside primary care.
CHCs are governed by community boards which identify priority populations, such as newcomers, low-income seniors and Aboriginal Ontarians. CHCs are predominantly in urban areas and are carefully located in certain geographic settings to meet this objective. Meb Rashid, a Toronto family doctor who has practiced at a number of CHCs describes the CHC model, particularly in urban areas, as “high intensity, lower volume practices which are targeted at serving populations who are underserved, or have difficulties accessing health care services.”
The features of some of the different primary care models are summarized in the table below.
Community Health Centre
Family Health Group
Family Health Organization
|Number of patients in 2008/09 – 2009/10||Almost 110,000 clients(0.9% of Ontarians)||Almost 4 million patients(33.3% of Ontarians)||Over 2 million patients(18.9% of Ontarians)|
|Doctors paid by||Salary||Blended fee for service||Blended capitation|
|Reports to||Community-ledboard of governors,
Local Health Integration Network
|Self governing||Self governing|
|After hours requirements?||Yes||Yes||Yes|
|Table adapted from ICES Report Comparison of Primary Care Models in Ontario, 2012.|
Comparing and evaluating models of primary care
The report found that CHCs are more likely to serve the most vulnerable populations – people who are more likely to be newcomers to Canada, have a high burden of mental illness and chronic diseases, and lower incomes – than other models of care. These people have tended to be more frequent users of emergency departments. However, the report found that CHC patients had considerably lower than expected rates of emergency department visits. The ratio of observed/expected emergency department visits per person was 0.79 at CHCs, compared to 1.25 at Family Health Networks, 1.06 at Family Health Organizations and 0.86 at Family Health Groups.
The report also found that the newer models of primary care – such as Family Health Teams, Family Health Organizations and Family Health Networks – tended to serve patients from higher income neighborhoods with better health status. Doctors in these models are paid a set fee per year for each patient enrolled in the practice. Rick Glazier says that these models lack the financial incentives needed to enroll higher needs patients noting that “Ontario is virtually alone in not recognizing the need to level the playing field by paying doctors more to enroll sick and disadvantaged patients in their practices.”
Are there lessons for newer models of primary care from Community Health Centres?
A spokesperson from the Ministry of Health and Long-Term Care told healthydebate.ca that there is a Ministry of Health and Ontario Medical Association working group focused on examining potential adjustments to the capitation formula. This working group discussed including other ‘complexity modifiers’, beyond age and sex, to capitation payments to family doctors.
Ontario has invested billions in an attempt to improve access to primary care. However ,there is still room for improvement, particularly around improving timely access to primary care as well as access for Ontario’s most vulnerable people.
While the CHCs show good outcomes, they are a more costly model of primary care. Patients at CHCs have longer appointment times, and the number of patients in each CHC primary care practice is significantly smaller than other family practice models in Ontario.
Glazier says that it is “costly to look after incredibly needy, disadvantaged populations in a very community focused way.” Adrianna Tetley, executive director of the Association of Ontario Health Centres says that the CHCs welcome more research on the cost effectiveness of the CHC model of primary care. Tetley urges researchers to “look beyond costs at the practice level and move to examine the use of health care system resources” such as emergency departments and prescription medications. Tetley argues that when considering system costs of CHC patients there is “an upfront investment, with money saved down the road.”
Brian Hutchison, Professor of Family Medicine at McMaster University says “this is a very complex picture and there aren’t any simple lessons to draw from this.”