Ontario wants to make it easier for patients to find a family doctor and to have access to same-day service. Those are laudable objectives and I strongly support them.
But based on my experience as both a physician and a consultant for primary care optimization, I see a major barrier to meeting these goals: the government doesn’t know enough about the services that doctors provide and the availability of doctors to their patients. As a result of the lack of information, the government can’t tell whether or not they can realistically expect family doctors to take on more patients, or how many patients truly have same-day service.
The problem begins with the information we use to measure physicians’ work. Canada’s provinces and territories rely on billing data, which includes surprisingly little information: doctor and patient identifiers, date, service fee and diagnosis. That’s not enough to get a clear picture of doctors’ work burden and patient services.
Worse, most provinces’ archaic billing systems have an additional failing: they only permit a single diagnosis for each encounter. That’s a major issue in primary care, where a visit might cover three distinct problems – for example, high blood pressure, knee pain and a urinary tract infection. Whichever diagnosis the doctor selects, the other two will go unrecorded, leading the databases to underestimate the work involved in all multi-problem encounters. Service fees such as those for smoking cessation counselling or after-hours premiums can help to more accurately capture doctors’ workload, but there are too few of these to make up for what’s missing.
Another way billing data fail to capture physician work effort is that it doesn’t include patient-doctor interactions that take place by phone and email because there are no fees payable for those exchanges. However, patients want to have the ability to phone and email their doctor and it can free up physicians’ time by reducing in-person appointments. That would allow doctors to provide additional patient services, which would help to meet government goals.
In other words, the government is using a system designed for billing purposes as a way to gather information, and the data systematically understates doctors’ activity. That can lead health system managers to believe that those of us presently working as family practitioners have more capacity to take on additional patients than we actually do.
When it comes to same-day or next-day appointments, my colleagues and I have always offered them. However, to demonstrate that we provide that level of service would require that the government be able to audit the date and time that every appointment slot gets filled. Though that’s something that’s technically feasible, the government has neither sought such information nor obligated physicians to use computer systems that can record and report appointment data.
Instead, health care researchers ask patients and doctors about appointment availability. While that seems sensible, it turns out that patients and doctors give different accounts: only 44% of patients surveyed for Health Quality Ontario’s annual “Measuring Up” report say they can get same or next day access, while Ontario doctors told Commonwealth Fund researchers that 66% of them provide such service.
Perhaps doctors are overstating their availability or maybe patients are failing to distinguish between access and convenience (see this excellent piece on that subject by one of my office colleagues). Regardless, it’s hard to plan solutions when the source information is so inconsistent.
Fortunately, most of the missing data on doctors’ work activity and availability can be addressed by feasible changes to government and physician office information systems:
- Allow billing claims to include multiple diagnoses with a single service fee, as well as the time of day of the service
- Create fee codes for phone and email encounters so that we can track all patient services
- Mandate appointment software that records when a slot is booked by a patient
If we take these steps, we’ll gain a far better understanding of the actual work that family doctors do, which in turn will inform us on how to match physician supply to patient demand. With that new knowledge in hand, we can move forward to successfully plan ways to assure that everyone has a family doctor and that their doctor is readily accessible.