Could Ontario really be better at primary care than the rest of Canada?

Does Canada really have a health care “system” that can be compared to other jurisdictions? No, not really. There is tremendous variability in how each province governs and runs their own systems. When reports and analyses by international organizations lump all the provinces together and run the numbers, the variability across the country is hidden.

This was brought into stark relief last week, by the Health Council of Canada’s recent report entitled, “How do Canadian Primary Care Physicians Rate the Health System?”  While Canada has improved since the last survey, the report said that the country as a whole ranks poorly when compared to international jurisdictions. These low lights were quickly picked up by the media outlets (here and here).

But most of the coverage missed one very simple and compelling point – Ontario does as well as or better than the rest of Canada (RoC) on all 29 measures.

Let us immediately say that we are not boosters or apologists for Ontario. Far from it.  One of us teaches a course at Rotman that focuses on what Ontario can learn from global trends. So we received the report with interest and began reading through it. We weren’t surprised to see that Canada did not perform well by international standards. However, our jaws dropped as we read the numbers and reached an inescapable conclusion: Ontario primary care doctors think much more highly of the Ontario health system than do their counterparts across the country. Ranking Ontario and the Rest of Canada (RoC) against nine international comparators, here are the average ranking by major topic for Ontario vs. RoC:

	Ontario
		Rest of Canada
General Perceptions Average Rank	4	8
Access to Care Average Rank	7	9
Coordination of Care Average Rank	6	9
Use of IT Average Rank	7	10
Practice Improvement and Incentives Average Rank	3	6
Overall Average Rank	6	9

* Where 1 is the best and 11 is the worst.

While Ontario’s overall rank of 6th is certainly still middle of the pack. It is well ahead of the really terrible results in the RoC. There are even some areas such as “practice improvement and incentives” where Ontario could be considered an international leader. This is decidedly different than the self-flagellation reporting that accompanies most Commonwealth Fund comparisons with Canada as a whole.Of course, it should be stated that these findings reflect the impressions of primary care physicians and are not necessarily an indication of system level quality and outcome measures. Nonetheless, the findings are intriguing.

First we determined the score for the RoC without Ontario’s inclusion:

(Sample size for Canada x the score for each measure) – (sample size for Ontario x the score for Ontario for each measure) / (sample size for RoC) Where the sample sizes are: Canada – 2124; Ontario – 488; and RoC – 1636 (calculated)

We then computed the rank for Ontario and the RoC against the 9 international comparators, Ontario, and the RoC (for 11 in total). We could not adjust for respondent variation at the individual question level. Policy wonks interested in primary care reform can click here if they’d like to review our analysis in detail.

Internationally (including the RoC), Ontario ranks first, second or third on six of 29 measures.  Here are the questions that Ontario ranks high on and its score:

• Physicians who say the quality of care has declined in the past three years (2^nd, lower is better)
• Physicians who say that they are satisfied or very satisfied with practicing medicine (3^rd)
• Physicians who say their practice shares after hours services with other practices or groups (3^rd)
• Physicians who coordinate care with social services or other community providers (3^rd)
• Physicians who receive extra financial support for providing enhanced preventative care (1^st)
• Physicians who receive extra financial support for making home visits (1^st)

On none of the 29 questions does the RoC rank in the top three. In fact, the RoC ranks in the bottom three on 16 of the 29 questions, whereas Ontario only ranks 9^th or worse five times.

Is there a methodological flaw that could have caused Ontario to leap ahead of the RoC?  Perhaps, but we could not spot it and invite readers to examine both the original report and our derivative analyses. Could there be an environmental bias in Ontario’s favour? We could see one bias: the CF/HCC survey was conducted between March and July 2012, a time when OMA negotiations had broken down and physicians were actively angry.  But if this bias impacted the results, one would have expected that Ontario physicians responding to the survey would have had a more negative attitude than their colleagues in the RoC.

If not methodology or environmental factors then is it possible that Ontario actually does have a much better primary care system than the rest of the country against international benchmarks? Over the past decade there have been extensive primary care reforms and a move to capitated Family Health Teams in Ontario. The argument that capitated payment systems have improved care has been strongly advanced by The CD Howe Institute in their paper, ”How to Pay Family Doctors: Why ‘Pay per Patient’ is Better Than Fee for Service”.  Blomqvist and Busby said:

“Today, most doctors in Canada are paid via fee for service, but some provinces, particularly Ontario, are expanding the use of a per patient payment system – commonly referred to as capitation – for family doctors.  Although Ontario’s experience in this regard has not been problem-free, our main conclusion is that other provinces should also make more use of capitation; in doing so they could draw on the lessons Ontario has learned.”

And:

“We strongly believe that other provinces should follow Ontario’s lead and learn from its mistakes to date – that a stricter and more consistent application of the capitation payment model would benefit all provincial health systems.”

Payment reform is only one part of the primary care reform that has been undertaken in Ontario. Others include inter-disciplinary care delivered by Family Health Teams, better compensation for home visits, financial incentives for prevention initiatives, an overall increase in pay for family doctors, and expansion of after-hours primary care. There have been mixed reports of the degree to which primary care reform has been successful.  The Auditor General has questioned the value for money spent. But interestingly, many of these initiatives appear to correpsond with the categories in which Ontario now performs well on internationally.

The results of the HCC/CF report are striking and worth talking about.  Either there is a major methodological flaw in the HCC/CF study (or our derivative analyses) or Ontario appears to have dramatically moved ahead of other provinces in primary care reform. Further study will be needed to see if payment models and/or other reforms in Ontario have indeed made such a major difference.