In our family medicine practice, we regularly ask patients to give us feedback on how we’re doing. They tell us, over and over, that one of the things they like best about our practice is the teamwork – how much they love their doctor but also their social worker, or nurse, or dietitian. And how well they work together.
Our patients are lucky. Our team is lucky. Most Ontarians today have a family doctor but only 1 in 4 Ontarians has access to a primary care team that integrates other health professionals. About 250,000 Ontarians belong to a Community Health Centre (CHC) and about 3 million belong to a Family Health Team like the one we practice in. Community Health Centres have been around a long time and have had a focus on serving marginalized populations. Family Health Teams were introduced just ten years ago in an effort to improve access and primary care for all Ontarians.
But a decade after they were introduced, only a portion of Ontarians can access Family Health Teams. And what’s more worrying, certain groups seem less likely to belong to one. Research has found that patients living in urban areas, new immigrants, and those who are sicker are less likely to be a patient at a Family Health Team.
Why is access to Family Health Teams so unequal? The reasons are complex but to some degree it comes down to money. Physician groups can only apply to become a Family Health Team if they agree to change how they get paid. Instead of getting a fee per patient visit, they must agree to switch to salary or capitation payment. In capitation, physicians get a set fee per patient per year, regardless of the number of visits, with the amount varying based on the patient’s age and sex. In some jurisdictions, capitation payments also take into account patients’ medical complexity or social vulnerability. But, in Ontario, the capitation formula only adjusts for age and sex.
That means that a doctor paid by capitation in Ontario gets the same annual amount to look after a healthy 20 year old male who only comes to the doctor once a year as they would to look after a 20 year old male with type 1 diabetes and depression who needs to be seen monthly. Not surprisingly, doctors with sicker patients are less likely to want to get paid by capitation in Ontario – and so less likely to become a Family Health Team.
To make things more complicated, Ontario physicians paid by capitation are also eligible to earn bonuses. One of these bonuses, the Access Bonus, pays physicians up to $50,000 more in a year if their patients don’t see physicians practicing in another clinic.
As it turns out, switching to a capitation model was attractive for many rural and small town physicians because they easily qualified for the Access Bonus. Their patients often didn’t have any walk-in clinics to go to. But, many urban physicians knew they would never qualify for the Access Bonus – not because they didn’t try to see their own patients, but because many of their patients would go to walk-in clinics because they were more convenient. This means that Family Health Teams are less likely to care for groups that live primarily in urban areas, like recent immigrants or people who are homeless or underhoused.
So we end up with an inequitable system. Many Ontarians with the greatest needs for team-based primary care are least likely to have access. Some call this the inverse care law.
Getting out of this mess will be difficult, but we suggest two potential first steps. One is changing the capitation “formula” so that it accounts for a patient’s medical complexity or social vulnerability. Another is modifying or eliminating the Access Bonus. But instead of moving in this direction, the government has restricted entry of physicians into capitation models and therefore also Family Health Teams, perpetuating and potentially exacerbating current inequities.
Many organizations in the U.S. are trying to shift family doctors from fee-for-service payment to capitation. They should be mindful when they design their payment systems that they improve equity and not make it worse.
We get paid through capitation and we like the flexibility it gives us. It means we can spend more time with patients when we need to and also have an incentive to provide care by phone or email. But ironically, we know that in our current system, we would make more money if we served healthier patients. That kind of incentive is just wrong.
Our team at St. Michael’s has unique relationships with the hospital and university that has made becoming a Family Health Team financially practicable – despite our urban setting and our mission to serve the sick and the poor. Other physicians (and their patients) aren’t as lucky.
We love working in a Family Health Team. We know our patients benefit from the excellent team that can help them with everything from medication side effects to how to eat healthier to how to decrease their household debt. All Ontarians deserve the same.