The next challenges for primary care in Ontario
Over the last year, reports have suggested some of Ontario’s new primary care models, which are significantly more expensive than older practice models, have had limited success in improving access and quality.
In response, the Ministry of Health and Long Term Care is conducting a review of these models, and had recently instituted a temporary freeze on the hiring of new physicians for group practices.
This review, along with a current lack of plans to create new Family Health Teams (one of the new primary care models), raises questions about how best to realize benefits of significant investments made in primary care and to continue the important progress that has been made.
Over more than a decade, Ontario has made significant changes to its primary care system in order to improve quality and access, while also improving the recruitment and retention of family doctors. Where in the past family doctors often practiced alone or in very small groups, more than two thirds now practice in some kind of group model and millions of Ontarians participate in these models. Also, while most family doctors used to be paid for each service they provided to patients, many are now primarily paid based on the number of patients enrolled in their practice (known as capitation).
Among several goals, group practice models were intended to improve access to primary care during evenings and weekends and to encourage physicians to accept new patients.
Group models were also designed to address the shrinking number of family doctors providing comprehensive primary care. When the models were introduced, morale was low, burnout was high, and the number of medical graduates going into family medicine was on the decline. David Tannenbaum, president of the Ontario College of Family Physicians believes these efforts have been largely successful, saying “there’s a sense in primary care that things have gotten much better… career satisfaction is much higher and we are bringing top-quality docs into family medicine.”
Ontario’s 200 Family Health Teams
Ontario created several new group models of primary care delivery. Among the highest profile was the implementation of 200 Family Health Teams across the province. Many of these were located in teaching centres. In Family Health Teams, family doctors work together with government funded nurse practitioners, dieticians, psychologists and others to provide more comprehensive care than any of them could provide on their own.
Despite hopes among the primary care community that Family Health Teams would become the standard in Ontario, the government originally planned to create only 200 for the whole province. According to Angie Heydon, executive director of the Association of Family Health Teams of Ontario, Family Health Teams currently serve just over 2.8 million Ontarians, about 21% of the population.
All of these changes to Ontario’s primary care system involved a large financial investment. Primary care payments to physicians increased by 32% from 2006 to 2010. In 2010, payments to family doctors accounted for $3.7 billion; roughly 1 out of every 12 dollars spent by the Ministry of Health and Long-Term Care. This increase was intended, in part, to address long-standing inequity in payment between family doctors and other physicians in Ontario.
Bumps in the road
While Ontario’s new group practice models, especially Family Health Teams, have been hailed as a success, reports from researchers and Ontario’s Auditor General suggest there remains significant room for improvement.
Recent studies from the Institute for Clinical Evaluative Sciences report that while more Ontarians now have a family doctor, many still cannot see their doctor in a timely way. As a result, these models do not appear to have had a significant impact on walk-in clinic or emergency room visits.
It also appears that while many more Ontarians now have a family doctor, Family Health Teams have tended to enroll healthier and wealthier patients. This has raised concerns that those who could benefit the most from the interdisciplinary care provided by Family Health Teams are not accessing it. The exact cause is not known, but it is likely due in part to the current capitation payment system, which adjusts financial compensation for the age and sex of patients, but not other factors that affect medical complexity.
Ontario’s Auditor General has also raised concerns about accountability, having found that many new group practices were not providing the evening and weekend services required in their contracts. Also of concern to the Auditor was the lack of ongoing analysis of whether the significantly higher cost of group practices over traditional fee for service are justified by superior outcomes.
The Auditor General made a number of recommendations to the Ministry of Health and Long Term Care, including regular analyses of patient enrollment in group practices and ongoing review to ensure group practices provide after hours services.
Primary care models under review
In response to the Auditor General’s report, the Ministry of Health and Long Term Care began to review group practice models this past summer.
During the first part of this review, the Ministry froze new applications for group practices with capitated payment systems, except in cases where group practices needed to replace a doctor who was retiring. This freeze led to some confusion within the medical community, particularly among new doctors who found themselves working on fee-for-service and worried they would not be able join the type of group practices they had been trained to work in.
The review is ongoing, but some details have been released by the ministry.
At the beginning of October the Ministry lifted the freeze on approving new hiring for existing group practices, and announced that it would now approve a maximum of 25 applications a month, down from 50 prior to the freeze (replacements for retiring physicians will not count against this cap). This limit of 25 now applies to all of the new group models (the limit of 50 applied only to capitated models). These approvals will now be based on a scoring system, meant to ensure new group practice spots go to communities with the greatest need for new doctors.
Zita Astravas, a spokesperson for Ontario’s Minister of Health and Long-Term Care, Deb Matthews says “the scoring system will be based on a number of factors, including the number of people in a region registered with Health Care Connect and the number of doctors per capita in each region.” The Ministry also plans to work with the LHINs to identify communities with the greatest need.
While all the details of this new scoring system are not yet known, and may change after public consultation, its current emphasis on underserved communities could go a long way to improve access to primary care. The government also looks to other primary care models like Community Health Centres and Nurse Practitioner Led Clinics to help meet the needs of underserviced communities.
Other details of the review have not yet been released, including how the Ministry plans to improve required access to evening and weekend services as well as the availability of same-day and next-day appointments.
No plans for more Family Health Teams
While the Ministry has lifted the hiring freeze for existing captitated group practices, it has no current intention of creating any new Family Health Teams. “The government committed to create 200 Family Health Teams and it has done that,” says Astravas, “now we’re just looking to expand them.”
The plan to create only 200 Family Health Teams raises concerns about potential inequities within Ontario’s health care system. Patients enrolled with these models have access to services from health care professionals, such as dieticians and psychologists, not usually covered by the public system, while the rest of Ontarians must continue to pay for these services themselves.
The cap on new Family Health Teams is also a cause of concern for some primary care groups. Heydon believes the government should not be restricting the number of Family Health Teams. Rather, she argues “we need to make interdisciplinary care the standard.”
Tannenbaum agrees. “The model of care, of inter-professional team-based collaborative practice is the future of family medicine and primary care,” he says. While he acknowledges that “that Family Health Teams are an expensive model,” he says “what we’re seeing with this team-based model is that family doctors feel like they provide better care… that they have the resources to manage complex chronic diseases in the community.”
Which way forward?
More than a decade of change in primary care has meant a more stable practice environment for family doctors, millions of people participating in the new models and an entrenchment of the appreciation for team based care.
It is clear, however, that not all of the goals of primary care reform have been achieved. The challenges for the next decade of reform will be to increase after hours and same-day access for participating patients, improved health care outcomes and achieve equitable access for all.