Last week, the Ontario Medical Association and the Ontario government announced they had reached a tentative agreement that they hope will end their current dispute.
The tentative agreement, which will run until March of 2014, will affect doctors in a number of ways and also has implications for the wider health care system. In this article, we revisit some of the major themes Healthy Debate has reported on over the last year and a half, and examine how this tentative agreement will, or will not, address them.
Ontario has made substantial investments in primary care over the last decade in an attempt to improve quality and access, and also improved the recruitment and retention of family doctors. The return on these investments has been mixed.
These investments have significantly increased the number of Ontarians with a family doctor. Many more doctors are now working in team-based practices, and some of these teams now include a range of other health care providers, like dieticians and counselors. Morale has improved significantly among primary care providers, which experts say has improved both recruitment and retention of family doctors.
However, not all the new care models are performing as well as hoped. Some clinics do not provide the evening and weekend appointments required by their contracts, and many Ontarians cannot get a same or next day appointment with their family doctor. As a result, emergency room and walk-in clinic use is one of the highest among developed countries. There are also concerns that new capitation payment systems for family doctors (where doctors are paid per patient, rather than per service) do not encourage them to take on patients with complex medical needs, or encourage them to “de-roster” these patients and bill the government fee for service. In response to these concerns, the government delayed and then capped the entry of new family doctors into all enrolment models, which led to concerns that the spread of interdisciplinary care would be halted.
The tentative agreement will affect primary care in a number of ways.
Primary care groups will be required to provide more after hours care than in the previous agreement. The number of additional after hours requirements will vary according to the group’s size. While increasing the after hours requirement will likely improve evening and weekend access, the Auditor General identified a number of other barriers to patients accessing after hours services. Currently, it is not specified when physician groups must offer after hours services, so many clinics do not appear to offer services on Fridays or weekends. Also, some physician groups operate out of multiple locations, but the after hours service requirements need only be offered at one location, which may not be convenient for many of the enrolled patients. Additionally, compliance with the previous requirements was not monitored by the ministry. The new tentative agreement includes no language about monitoring and does not specify locations or days upon which after-hours services must be provided, which together may dull the impact of these new requirements.
Another key change is the introduction of an “acuity modifier”, which is meant to compensate family doctors who care for complex patients more fairly than under the current system. The precise size per patient of this modifier has not yet been determined, but according to the agreement there will be an interim modifier put in place while an acuity-adjusted capitation model is developed over the next two years. $40 million has been set aside to develop and implement this initiative – approximately 1% of the total budget for family doctors and general practitioners – so it is unclear at this point how big an impact this will have . As with other parts of the tentative agreement, the development of the acuity modifier is being delegated to a working group. It is yet to be seen whether an effective acuity-adjusted capitation model can be developed, and whether the $40 million that has been earmarked will be enough to implement it effectively. If an effective acuity modifier is not developed, some family doctors may continue to de-roster complex patients and bill fee for service, a practice that will continue to be allowed under the new tentative agreement.
An important element of the tentative agreement for patients is the expansion of resources for interdisciplinary health team provider resources to a wider array of primary care practices (such as dietitians and pharmacists). Currently, only community health centres and family health teams are able to offer their patients publicly funded, comprehensive interdisciplinary care, but under the new agreement other family physicians will also be eligible for these services. This signals an important commitment on behalf of both the government and doctors to continue to move towards an interdisciplinary, team-based approach to primary care. However, the agreement does not specify how much money is to be committed to this initiative, so it is unclear at this time whether it will be sufficient to provide access to interdisciplinary care to all Ontarians.
Through much of the 20th century, doctors have moved away from doing house calls, in part because of the shift towards more technologically sophisticated care and the ability to see more patients in the office than in homes. In recent years, there has been a renewed interest in house calls, because increasing numbers of chronically ill patients find it difficult to visit doctors’ offices. However, a number of barriers remain to increasing home visits. Under the current system, family doctors providing comprehensive, home-based primary care earn much less than what they could earn if they saw patients in their office. In the last election, the Liberal government pledged to commit $60 million to expanding house calls.
The tentative agreement stipulates that enhancements will be made to the existing bonuses for primary care doctors who provide home calls, and establishes a formula that takes into account the number of patients a doctor provides home services to (and the number of visits). However, the agreement does not establish criteria for ensuring that the resources for home visits are used for homebound, frail and medically complex patients, and not for less frail patients. The development of these criteria is to be delegated to a primary care working group.
Appropriateness of diagnostic tests
There is growing consensus among doctors and policy makers that steps must be taken to improve the appropriateness of diagnostic tests. Some tests can cause harm directly, while others can lead to unnecessary medical procedures, so it is important for the well-being of patients to reduce the amount of unnecessary diagnostic testing (while at the same time ensuring timely access to necessary tests). Policy makers are also eager to reduce testing that offers no clinical benefit in order to help control the growth of health care spending.
The tentative agreement includes a number of provisions to reduce unnecessary testing. The agreement will remove or restrict some specific tests, including folate, asparate amniotransferase, chloride, creatine kinase blood tests and thyroid scans. It will also adjust the frequency with which certain screening tests will be reimbursed, including screening for colon cancer and cervical cancer. Doctors will be encouraged not to order several tests for low risk patients, such as annual stress tests, pre-operative cardiac testing in people without heart disease, and routine pre-admission chest x-rays. The agreement also establishes that the Expert Panel on Appropriate Utilization of Diagnostic and Imaging Studies will continue its work, and a new working group with a distinct mandate will be established to address the appropriateness of a number of other tests and procedures, such as the use of blood glucose testing strips.
It is unclear how much of an impact the tentative agreement will have on the frequency of unnecessary testing. The specific tests slated for removal make up only a tiny fraction of tests performed in Ontario, while many ‘big ticket’ items, like the use of blood glucose testing strips, have been left to a future working group to address. Nor is it clear that the volume of activities identified in the agreement under “phase 2”, which range from prescription tracking mechanisms to practice patterns in cardiac services, are within the abilities of a working group to tackle effectively.
A recent pilot study in the Ottawa area has suggested that e-consultations (where specialists connect with family doctors or patients over the internet) hold promise for better communication among doctors, and shorter wait times and less travel for patients. E-consultations between patients and specialists could also be used to provide specialist consultation to remote communities, which would save patients both the trouble and expense of traveling to large centres to see specialists.
The tentative agreement includes a number of provisions for ramping up e-consultations across the province. A working group is to be established to evaluate existing pilot programs and develop recommendations for a provincial business and technology model. Fee codes are also to be established for e-consultations, beginning with dermatology and ophthalmology, with the intention of expanding these to other specialties over time.
The expansion of e-consultation is promising. However, successful provincial roll-out of these systems will require significant resources, and given the state of the e-health file in Ontario, it may be some time until Ontario’s family doctors are regularly consulting their specialist colleagues over the internet.
No caps on utilization of services
Although the agreement reduces most physician fees by 0.5% or more, there is no overall or individual cap on physician services. If the parts of the agreement that focus on decreasing unnecessary tests are effective, overall spending may decrease. However, physicians who are paid fee for service may respond to the cut in payment by providing a greater number of services, in which case expenditure will increase more than the government hopes.
The devil is in the details
The tentative agreement between the government and the OMA attempts to address many of the major problems facing Ontario’s health care system. However, much of the most important work has been delegated to working groups. The history of working groups delivering on promises and being able to tackle tough issues in Ontario is mixed. Time will tell whether the agreement will deliver on its promises.