House calls and Ontario’s election
In the run up to the Ontario election, the Liberal party has promised $60 million to support physician house calls.
The number of doctors who make house calls has declined markedly over the past fifty years, and only a small proportion of Ontario family doctors currently provide ongoing care to patients in their homes.
What might $60 million achieve, and what are the other parties’ positions on supporting house calls?
Most people are generally healthy – they see a doctor a few times per year at most, and have no chronic medical problems. Most healthy Ontarians have a family doctor, and when they do fall ill they have no difficulty in attending an appointment. But some of the people who need health care the most – those who are elderly, frail and have several chronic medical problems – find it impossible to get to their family doctor’s office. Some of these people call 911 whenever they need help. Others rely on their home care providers, usually a personal support worker or a nurse but rarely a physician. This creates the ironic situation in which most healthy Ontarians can easily receive care from family doctors, while many frail housebound seniors rely on health care providers with much less training.
Some evidence suggests that when older patients receive care from a team that includes a doctor that makes house calls, they are less likely to be hospitalized or admitted to a nursing home. Perhaps most importantly, older people might be better able to maintain their independence and quality of life if physician house calls were more common. However, for a variety of reasons, few doctors make house calls regularly. To learn more about why this is, click here.
The arithmetic of health care
Hospital costs increase as we get older, and the average cost of hospitalization for someone aged 80 years and above is nearly $10,000. Long-term care costs about $200 per day for a basic room, ($150 paid for by the government, and $50 paid for by the patient), or about $55,000 per year paid for by the government. On the other hand, the average cost per year for Ontarians who receive home care is about $4000. With 88% of Ontarians prefering to receive care at home, this approach is clearly patient-centered. Caring for people at home may also be cheaper.
The Liberal plan for house calls
In advance of the upcoming Ontario provincial election, the Liberal party has pledged to fund home visits by a physician or nurse to patients who cannot access their family doctor’s office because of mobility issues or severe illness. The Liberals platform includes $60 million put towards funding regular, scheduled house calls by doctors and nurses as well as a province-wide telehealth home care network that patients can access online, or use to speak directly with a nurse or doctor, all from their homes.
If all of the $60 million goes to doctors, the government might be able to pay for almost a million more house calls each year, since the fee for a daytime house call is approximately $65. The Toronto Star recently reported that Ontario doctors billed the Ontario Health Insurance Plan (OHIP) for 484,600 house calls in 2010, so a million more house calls would be a dramatic increase. But just because the money is offered to doctors doesn’t mean that more will start doing more home visits. Phil Ellison, a family doctor in Toronto who frequently makes house calls says that “in the time that it takes to do one house call, you can see at least three patients in the office” and that some doctors “do house calls after hours, or on weekends, which expands work days.”
One alternative to adding house calls to busy practices is to have teams that are dedicated to providing home-based care. A Toronto-based program called House Calls does just this. The House Calls budget of $480,000 per year pays for a team of health care providers and administrators, with affiliated doctors billing the OHIP directly. House Calls serve around 250 frail elderly patients each year. Its staff believes the program pays for itself, by keeping people out of hospitals and nursing homes. Mark Nowaczynski, the medical director of House Calls claims that the program has avoided costly hospital visits, and early admission to long-term care. Nowaczynski “estimates that for every dollar the government is spending on our program [House Calls], we’re saving the health care system somewhere between five to ten dollars.” He does note, however, that the cost savings estimates are anecdotal, but that there are plans underway to study the cost effectiveness of this program.
Can the Liberal commitment of $60 million replicate the purported success of this small program? If the $60 million was spent on programs like House Calls, 100 or more similar teams across the province could be created. Again, however, the question of whether doctors will be keen to participate remains unknown.
Deb Matthews, the Liberal Minister of Health and Long-Term Care and candidate for re-election in the riding of London North Centre, said that no decisions have been made as to how the $60 million will be spent if the Liberals are re-elected. She did note that “in different parts of the province, the model will look different” and stated that the commitment is focused on “keeping people out of long-term care.” Matthews acknowledged that there are barriers to increasing house calls, adding that “we want to fairly compensate doctors for doing house calls” and that the pledge is not a promise to all seniors for house calls, but rather only to those who have serious difficulties leaving their homes for a doctor’s appointment.
The New Democratic and Conservative views
France Gelinas, the NDP health critic and candidate for re-election in the Northern Ontario riding of Nickel Belt says that “this is an urban-centric promise that leaves so many Ontarians out.” Gelinas says that “this program cannot be equitably delivered to all Ontarians” especially those who live in rural or Northern communities where there is already a shortage of physicians and other health care providers. Gelinas proposes that interdisciplinary teams can help meet the demand for care at home by ensuring that “the right care is given by the right person at the right place.” Nowaczynski says that providing house calls in rural and remote areas “is tricky because of distances, and obviously doctors can work more effectively if they can visit a cluster of patients.”
Christine Elliott, the Progressive Conservative health critic and candidate for re-election in Whitby-Oshawa says keeping seniors at home for as long as possible “is about more than just doctors house calls” and includes “many other health care professionals involved in care.” Elliott also suggests that the pledge is shortsighted in meeting the demands of the aging population, suggesting that “the Aging At Home Strategy launched several years ago really hasn’t been resourced properly” and while “there is no question that home care delivered properly is preferable from a cost and satisfaction point of view” there is “a need for a range of services, including more long-term care beds, because some peoples’ physical needs cannot be managed at home.”
What will the future bring?
When Ontarians go to the polls on October 6, it seems that one of the issues that will be decided is the future of house calls in Ontario. Although the details of how the $60 million pledged by the Liberals will be spent remain unclear, the promise of increased funding to house calls was touted by many as a step in the right direction. While the NDP and Conservatives election platforms both commit to strengthening home care, they make no mention of house calls, and both party’s health critics have raised concerns about the Liberal proposal.
Nowaczynski, who focuses his medical practice exclusively on providing home-based primary care, believes Ontario needs many more doctors like him who are prepared to spend a large portion of their time taking care of older adults in their own homes. He says that “the right incentives to home-based care have been lacking but creating the right inducements can lead to a “whole lot of doctors doing a little bit of house calls” as part of their regular practice.