Making doctors responsible for the patients in their geographical area. Offering primary care after-hours and on the weekends. And pushing away from solo practitioners and towards interprofessional care.
Those proposals were all in the recently released “Patient Care Groups: A new model of population based primary health care for Ontario,” led by McMaster University’s David Price and nurse practitioner Elizabeth Baker. The report suggests a fundamental shift in how primary care is delivered, calling for a model where doctors would serve everyone in a geographic area and be organized under Patient Care Groups.
The Ministry of Health and Long-Term Care asked the expert advisory committee that created the report to address a number of issues. They were asked to propose a system that would offer everyone in Ontario access to a primary care provider, an interprofessional team and care in the evenings and on the weekends. And they were tasked with integrating primary care into the health care system.
The team soon realized that they would have to make sweeping changes, says Price. “It became clear to us that nobody had really articulated a coherent vision for primary care and primary health care,” he says. “I think where we have failed in our work in primary care is that we’ve tried to create initiatives that address a single aspect, but don’t touch the broader system.”
Groups like the Ontario Medical Association say the team should have consulted primary care providers more thoroughly and that Patient Care Groups are an additional layer of bureaucracy Ontario can’t afford. Others, like the Ontario College of Family Physicians and the Association of Ontario Health Centres, are anxious for details about exactly how it would be implemented.
Deputy Minister of Health Bob Bell offered the first insights on that last week, when he spoke about what the province was interested in from the report – and what they wouldn’t be acting on – in the College of Family Physicians of Canada’s Family Medicine Forum.
Here’s what we know so far about the report and what the government is planning to implement.
The Price-Baker Report’s suggestions
Getting in to see a doctor should be as easy as enrolling a child in a school, says the report. It proposes that patients within a certain area be automatically eligible to register with one of the family doctors or nurse practitioners serving it.
That would offer all Ontarians access to a primary care provider. “It staggers me that we say it’s unacceptable for a child to move into a district and not get schooling and yet in a first world country we say it’s acceptable for a citizen to move into an area and not get primary care,” says Price.
That doesn’t mean people would lose their current family doctor: Those who already have a care provider would be able to stay with them. And people who prefer a doctor near their work, or need specialized care – like geriatric physicians – could choose primary care providers from outside their catchment area.
The government seems to be embracing that concept. In his speech, Bell said they’re “very interested in the concept of geographic-based, risk-adjusted, population-based primary care,” under a model “that would say, ‘everyone who wants access to a primary care provider within this geographic region should have that.’”
The report suggests that access be coordinated by Patient Care Groups (PCGs). The PCG teams would be made up of an executive director, clinical lead, care coordinator and patient representative. The roles could be taken on by existing organizations, such as Family Health Teams and would report to the Local Health Integration Networks (LHINs).
The LHINs, in turn, would help do the health human resources planning and needs assessments of the communities, disseminate best practices and contract resources such as information technology.
Bell said primary care would be led by local “thought leaders in the community and by administrative resources, probably from the LHINs.”
The PCGs would also coordinate care and assess quality standards. Like hospitals, they would have accountability agreements that would make them responsible for hitting health indicators at both the patient and population levels. Those goals would be created by the ministry of health, with the input of Health Quality Ontario, the LHIN and Public Health and could be tailored to the specific area.
They would also ensure patients have access to after-hours and weekend care – Bell suggested offering primary care until 8 p.m. – as well as a certain number of same- or next-day appointments.
All group practices would be required to provide after-hours and weekend care. Solo practitioners would also have to offer after-hours care, but how they do it would be up to them: perhaps by partnering together with other practitioners, using a shared electronic medical record system, and rotating after-hours shifts, or by working with urgent care centres. It could also be coordinated through walk-in clinics or emergency departments, an option that would be especially useful in rural areas.
Beyond offering more access, the PCGs would also help integrate primary care with other parts of the health-care system, such as hospitals or long-term care. And it would allow them to share best practices with each other. “[Primary care providers] are still siloed, not just among categories of providers, but even within ourselves,” says Baker. “One family health team down the street could be completely different than another.”
Finally, the report suggested the PCGs be funded on a per-capita basis, adjusted for patient needs. They would then contract the care in the area to doctors and nurse practitioners – and could decide “which provider payment mechanisms are most appropriate.” (Price clarified in an interview that the committee’s “direction and conversation was that physician compensation was the purview of the OMA and the Ministry of health.”)
That’s one area that doesn’t seem ready for reform – especially in the midst of the heated fee negotiations between the Ontario government and the OMA. “The one thing I can tell you is that David recommended a different system of funding for physician compensation within the patient care groups, [and] we can’t go there. We simply can’t,” said Bell, saying the government “would not dream” of changing the funding for primary care without working with the OMA.
Where Ontario stands on primary care
As a result of the primary care reforms in Ontario over the past decade, the number of adults in the province who have access to a primary care provider has risen from 92% in 2006 to 94% in 2015. Northern Ontarians have lower rates, at 88%, as do recent immigrants, at 86%.
One of the most significant changes over that time was encouraging doctors to move away from working independently and towards group care. Now, nearly four million Ontarians now have access to interprofessional care, with over three-quarters of that coming from family health teams.
But thanks to limited monitoring and enforcement, promised after-hours and weekend care hasn’t materialized, with walk-in clinics and emergency rooms often filling the gaps. In the 2104 Commonwealth Fund health policy report, which surveyed older adults, 51% of those surveyed said it was difficult to get after-hours or weekend care without going to the emergency department – placing Canada last out of 11 countries. That puts unnecessary strain on our emergency departments, with 1 in 5 of the visits there being for an illness that could be treated by a primary care provider.
The family health teams are also less likely to serve newcomers to the province, those who are in low-income neighbourhoods and people with comorbidities.
“It’s really clear to us that we’ve developed an inequity in our system,” says Price. “There are those citizens who have access to interprofessional care providers and those that don’t. There are those who have access to a family practice system that provides evenings and weekend coverage and those that don’t. There are those that have access to coverage when their family doctors are on holiday and many that don’t.”
Boon or bureaucracy? The reaction to the report
When the Baker-Price report came out, some argued that Patient Care Groups would be an additional administration burden the province couldn’t afford. “The report talks about what we think looks like another layer of bureaucracy, at a time when health care resources are limited,” says Ontario Medical Association president Mike Toth. “We wonder where the resources are going to come from to fund this.”
Adrianna Tetley, CEO of the Association of Ontario Health Centres, agrees. “We don’t need another layer. That was the biggest reaction of all of our members,” she says.
The PCGs are in fact a layer of administration – and that’s just what’s needed, because there is none now, argues Price. “We would never accept that a hospital wouldn’t have some level of bureaucracy. If you had a hospital where the ORs, specialists, food services were all working independently, imagine what kind of a hospital would you have? That’s precisely what we have in primary care.”
Tetley does agree with the fundamental principle of the report, however, saying it is time for primary care to be offered in a more structured way than wherever a doctor decides to hang their shingle. “Designing the primary care system based on the needs of the people, rather than the needs of the providers, is really a critical piece.” She also thinks the accountability measures are “absolutely overdue. Anybody who gets any health care dollars needs to be held accountable for those dollars,” she says.
Many more expressed their concerns about how, exactly, this would be implemented. Price says that’s outside of the report’s scope. “This is a concept document,” he says. “We were trying to set an overall vision and an aspirational goal of where we felt we could get to in three years.”
Groups like the Ontario College of Family Physicians are anxiously awaiting the details. “Part of what we’re hearing from membership is that there’s some desire to have a clearer sense of direction,” says Sarah-Lynn Newbery, president-elect of the OCFP and one of the members of the report’s expert advisory committee. “People are really hungry to understand what the vision is for primary care and what the specifics of that vision are: the extent to which population based care will be developed, the ways interprofessional providers can be accessed by patients whose physicians do not currently work in teams and what accountability for performance metrics will really mean.”
The government is creating a unified plan, looking at the Price-Baker Report and the Donner report on home care, among others, said Health Minister Eric Hoskins in a speech earlier this month. He spoke of the LHINs playing a greater role, as part of the goal to have more local governance. He also talked about the importance of integration.
“There is perhaps no more important quality of a health care system that puts patients first than the quality of being integrated,” he said. “That goes for our system of primary care… and our home and community care system as well.”
Implementing the Baker-Price report may be challenging. Robert Cushman, former CEO of the Champlain LHIN and ex-Medical Officer of Health for Ottawa, describes it as “more stick than carrot,” and says it will be difficult to push through existing stakeholders. The OMA dispute will only make that process harder. “The timing couldn’t be worse,” he says.
Yet he’s optimistic about the possibility. “I subscribe to the notion that if you’re going to build a health care system, you have to build it from the bottom up – primary care has to be really strong,” he says. “Giving it a rock-solid foundation, the way this does, has the potential to make a big difference.”