How can we improve doctor and patient accountability in Ontario?

To get better quality, timely health care, patients and providers must continue to find ways to make a patient’s regular family doctor the customary first option for non-emergency care needs. As it stands, both parties could be doing more to strengthen the patient-doctor relationship, and financial incentives on providers alone likely won’t be sufficient.

Because regular family doctors know a lot about the nature or their patients’ problems and they can treat these problems more effectively than providers with little knowledge of a patient’s medical history ; by overseeing the drugs their patients use and the services they receive from labs and specialists, they can reduce wasteful duplication and ensure a more cost-effective use of public resources.

In recent decades, many Ontarians did not have a regular family doctor and struggled to access timely care. But over the last decade, with considerable public costs, some progress has been made to reduce the access problem. Ontario has reformed primary care to pay doctors more on a per-patient basis (capitation) – paying doctors a lump sum amount based on the number of patients under their care – and less via a fee for each service provided. Meanwhile, reforms emphasized patient enrollment with a family doctor or group of doctors. From 2003 to 2012, over 2.1 million Ontarians who had no family doctor were enrolled in a primary care model.

While enrollment figures suggest access to primary care has improved, high numbers of walk-in clinic and emergency department visits suggest gaps remain. However, it’s important to note that the size of these gaps are hard to determine, because these data do not account for those patients who might be visiting walk-in clinics out of convenience, rather than seeing the family doctor with whom they are enrolled (who might have been available to see them on that day).

In Ontario, when patients enroll with a family doctor, or group of doctors, they sign a written agreement to turn to these doctors, in the first instance, when they need basic care. If these enrolled patients visit outside providers, their regular doctors incur a financial penalty (a reduction in the “access bonus”). But many enrolled patients still seek care from other providers. Last year alone there were over 1.7 million visits by enrolled patients with other physicians, for services that their regular family doctor may have been able to provide in a timely manner.

The progress in ensuring access to care is likely best illustrated in survey results. In the most recent round of Commonwealth Fund results, Ontario physicians reported that roughly 60 percent of their patients were able to get same or next day care on request (the national average was 47 percent, in the United Kingdom it was 86 percent). Ontario docs also reported that 67 percent of practices have an arrangement where patients can see a doctor or nurse if needed when the practice is closed (versus 46 percent nationwide and 95 percent in the UK). And roughly 60 percent of Ontario practices shared after-hours services with other practices or groups (44 percent was the national average in Canada and 61 percent was the response in the UK).

While survey results indicate that Ontario is performing much better on primary care access measures relative to other Canadian provinces, we could be doing much better.

What does the UK do so well? For starters, UK doctors provide more advanced-access scheduling opportunities, some online appointment scheduling services, and are obliged to offer after-hours care as well as weekly walk-in hours. And walk-in clinics in the UK are organized to function primarily as complements to family practices whereby most services provided are minor in nature and clinics are largely staffed with nurses.

But primary care in the UK also has extremely high numbers of patients on their capitated rosters, allow doctors the opportunity to run parallel private practices, and charge patients fees out of pocket when they visit outside doctors for services that could have otherwise been performed by their enrolling physician. In fact, most other countries where the per-patient payment models are used require patients to seek out their primary doctor in the first instance. For example, health maintenance organizations, which are common in the US, steer patients to seek out the services of providers on the organization’s list. These policies are blunt, controversial, yet effective levers to encourage patients to get most services from their regular family doctors.

With nearly 2 million visits to outside physicians in Ontario last year – enrolled patients who seek out care elsewhere – there clearly is room for strengthening the relationship between patients and their primary-care doctors under new payment models. Patient data show that most outside use occurs on weekdays; is common among younger patients; occurs when a patient’s primary doctor was in his or her office; and, tends to be at outside doctor’s offices that were long distances from a patient’s home. Although the long distances travelled to visit an outside doctor seem puzzling, what’s likely happening in the data is that many patients are seeking care closer to their place of work or their school. Saddled with busy lives – and jobs that limit their free time – patients are sometimes seeking care by reducing the private costs of travel and time, without necessarily paying attention to their enrollment agreements. Patient convenience still plays a part in Ontario’s primary care system.

The data do not show if patients who sought outside care tried to get same or next-day access to their regular doctor but were unsuccessful. However, it’s fair to conclude that many of them simply wanted to save their time and resources by visiting the local walk-in clinic nearby. The key lesson for policymakers is that financial reductions in payments to doctors – a key part of the current payment model (the access bonus) – is insufficient as a means of promoting the family doctor-patient relationship.

Both parties must do more. Enrolling physicians should make great efforts to show available after-hours care, and perhaps offer a block of hours when their office is available on a walk-in basis, like in the UK. We could also consider making the services available at walk-in clinics more complementary – meaning staffed mainly by nurses and intended only for minor health needs – to those offered by family practices, something which could also be driving the strong UK access results. Another option would be for the government to impose a maximum amount of time within which a patient must be seen. The government could also track access to care and after-hours availability, for example.

To the extent that patients might be ill-informed about their enrollment agreements, doctors should clarify to patients that, upon signing the enrollment agreement, they are agreeing to only seek care from another provider as a last resort.

A bolder proposal would ask patients with a pattern of frequent outside use to pay a nominal charge if they visit outside providers for basic services. Patients who work long distances from home could be permitted one or two outside visits per year before charges begin. Or better, such a charge could be contingent upon their regular doctor’s ability to provide an appointment within 24 hours of a request. Patients with regular outside use patterns can also be encouraged to enroll with family doctor closer to their place of work or be notified when a space becomes available.

Ontarians value a high level of patient flexibility and convenience. But frequent visits to outside doctors weaken the family doctor-patient relationship and lead to wasted public resources and multiple treatments.