Physician Service Agreement yet again leaves the most vulnerable in the shadows

There is a minimal degree of “advantage” that is required to access primary and preventative care services in Ontario – for example, a fixed address or a valid OHIP card. Preventative screening tools such as the Fecal immunochemical test (FIT) require a home address and most labs need a valid, and often, physical copy of an OHIP card before any blood can be drawn and interpreted.

But what happens to those who are underhoused or those whose personal struggles are so overwhelming that safeguarding identification such as a valid OHIP card is impossible? Surely, they too deserve equitable access to a health-care system whose foundations are built on principles of social and distributive justice. But somewhere along the line, we’ve managed to create barriers to health care that have caused us to deviate from Tommy Douglas’ vision. The recently ratified Physicians Services Agreement in Ontario has made those barriers that much more insurmountable – leaving those most vulnerable in society further disengaged from primary and preventative care. 

Last year marked 50 years since Julian Tudor Hart, a British General Practitioner, published his landmark paper in the Lancet entitled, The Inverse Care Law:

“The availability of good medical care tends to vary with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.”

‘To the extent that health care becomes a commodity it becomes distributed just like champagne.’

Despite a privileged upbringing, Hart spent his career caring for those most deprived in the Welsh Valleys of the United Kingdom. He quickly noted that the disadvantaged needing more health care received less than those needing less of it. 

“… to the extent that health care becomes a commodity it becomes distributed just like champagne. That is, rich people get lots of it. Poor people don’t get any of it.”

Fast forward 50 years and the Inverse Care law is still relevant in Ontario in 2022.

Many Ontarians attending clinics for addiction services lack the required advantage to fully access primary and preventative care services they so desperately require. Many live on social and disability insurance and struggle with poverty for basic needs. Those able to work often have precarious employment earning minimal wage. Most have deep-rooted scars from stigmatizing health-care experiences that make fostering trusting relationships with medical professionals a challenge. Those brave enough to seek out primary care are often turned away from family health-care models because of financial penalties and disincentives to health-care practitioners should they enrol patients attending addiction clinics.

The same, however, is not true for enrolled “non-addiction” patients who may need medical specialty care or, surprisingly, other family medicine-based ones such as HIV care, low-risk obstetrics, palliative care or sports and exercise medicine. Furthermore, many addiction patients continue to be turned away from primary care providers because of regulatory bodies’ oversight of prescribed controlled medications.

These current market-day forces are rooted in social injustice and promote disengagement and exclusion for a population most in need of health care. Providing primary and preventative care services to patients where they are seeking addiction treatment is a model of care that has potential.

Skilled primary-care addiction physicians, many of whom also work in other family health models of care, are key to narrowing this chasm. Addiction medicine is family medicine. Undiagnosed conditions such as diabetes, hypothyroidism, hypertension, migraine disorder, COPD, hepatitis C, HIV, anxiety and depression are common conditions whose symptoms are quelled by illicit substance use. Even the most widely accepted and practiced addiction medicine strategies will fail time and time again if physical and mental health ailments are not properly diagnosed and treated.

This is the model of care that we have diligently worked for years to create in an inner-city addiction medicine clinic. Our pharmacies are busy filling prescriptions not only for buprenorphine and methadone, but also antihypertensives, hypoglycemics, puffers and curative hepatitis C treatments. Counselling includes trigger avoidance and motivational enhancement strategies, but also dietary discussions regarding glycemic index, DASH diet and immunizations.

Patients, no longer silenced by intimidation and stigma, find themselves confident and empowered to take control of their own health-care needs in a setting in which they feel most comfortable. Alas, a model of care of which Hart would be proud. 

We cannot blame the poor response on physicians when they are given less than a week to cast their vote.

On March 27, 2022, the Physicians Service Agreement was ratified. What’s more, it was ratified by a disappointing 28 per cent physician participation rate. But we cannot blame the poor response on physicians when they are given less than a week to cast their vote on a 60-page agreement, at a time when physician burnout is at an all-time high and many are contemplating retiring or leaving the profession completely.

The details of the Physician Service Agreement directly threaten this collocated model of primary and addiction care. Those primary care physicians enrolled in family health models of care will now be limited and subject to individual financial caps in providing services to patients outside of their family health team or organization. Those providers will have to either abandon their rostered patients in family practice clinics and provide care in addiction settings alone or forego providing primary and preventative care in addiction settings where the need is greatest.

In both scenarios, addiction patients are disserved. Family medicine specialists will either stop providing primary and preventative care to patients in addiction settings or will have to leave the very locations where they continue to hone their craft, engage in research and quality improvement and teach medical learners.

And while most physicians’ lives will remain unchanged with the 4 per cent raise as outlined in the PSA, the impact of further primary care disengagement in a population already marginalized and in greatest need is distressing and deplorable.

Clearly, those responsible for creating the current PSA are not familiar with Hart’s Inverse Care Law.

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Neal Belluzzo


Neal Belluzzo is an assistant professor in the Department of Family and Community Medicine at the University of Toronto. He has a special interest in inner city health and is currently completing his MPH at the Dalla Lana School of Public Health.

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