“Ontario is open for business!” At least that’s what our provincial government tells us as our health-care system teeters on the brink of collapse. Hospitals are burdened with high volumes and family physicians (FP) are tirelessly managing more complex cases amid overwhelming administrative burdens.
I’m a comprehensive FP in a small rural town and have witnessed our health-care system deteriorate over time. The statistics are eye-opening. As of September 2022, more than 2 million Ontarians did not have an FP; Statistics Canada reported that in 2019, 4.6 million Canadians did not have a family physician; Canada ranks 23rd out of 32 Organization for Economic Cooperation and Development countries in the doctor-to-population ratio; Ontario has the second-lowest density of family doctors in Canada; the COVID-19 pandemic sped up family doctors’ retirements and exodus.
For our economy to grow, Ontarians must be healthy. While we promise to increase medical school enrolment, family physicians are leaving the profession now. The crisis is worsening. Health care’s front door, primary care, must be fixed if Ontario truly is to be open for business.
Proposals on how to address the FP shortage are varied. Non-physician medical professionals state they can fill the gap by expanding their scope. Corporations push to privatize health care. FPs ask for more health-care funds to be directed to primary care and boost team-based care based on the community’s needs.
So, let’s take a look at three ideas proposed to address the FP shortage using an evidence-based approach.
Idea 1: Expand the scopes of health-care professionals
Pros: Nurses, pharmacists and midwives would like to expand their scope and be paid to address the doctor shortage. They offer short-term cost savings, accessibility and patient satisfaction. One systematic review compared the cost-effectiveness of advanced practice nurses (APN) with physician-led care and found that some care like diabetes costs less per visit.
Cons: The evidence that non-physicians bring cost savings, improve quality of care or increase access is weak. Proponents simplify the problem to be a human health resource issue without addressing other systemic issues. For instance, while a systematic global review on the cost effectiveness of APN compared to physician-led care for chronic diseases found that APNs can reduce costs, the overall results are inconclusive. The review excluded diagnoses and demographics that FPs routinely see, like children, acute issues and patients with multimorbidity. It found increased costs for diagnoses, investigations and referrals. This review was based on small-sampled studies, so it’s hard to generalize for all of Ontario. Unfortunately, there are no similar systematic reviews of cost effectiveness or quality of care for pharmacists and midwives in primary care.
Bottom line: In our town, an APN opened a private practice and charged patients more than the government pays doctors to run their clinics. It would be preferable to have a government-funded APN join our practice, a team-based clinic, to support the whole community regardless of what patients can afford to pay for their health-care needs.
Interprofessional health-care providers (IHPs) are vital in team-based primary care. Teams have shown to reduce hospital admissions and prevent hospitalizations. Population health outcomes improve when IHPs and FPs collaborate.
While team-based care should be funded by governments, it needs community members’ active involvement to serve their needs best. For example, patients in my town have different needs than those in, say, Manitoulin Island. Community members can decide the composition of team-based care – RNs, nurse practitioners (NP)s, pharmacists, dieticians, psychologists and physiotherapists can all be part of the team. Design reform is challenging, though. Jargon created by policymakers and non-frontline workers has increased primary care’s complexity, though we have seen promise in grassroots-made primary care teams.
We know the impact primary care physicians have on patient, community and health-care system levels. More rigorous research on long-term health outcomes from care by non-physicians’ is needed.
For our economy to grow, Ontarians must be healthy.
Idea 2: Health-care privatization
Pros: For-profit entities say they can lower wait times and improve access and health-care sustainability. Singapore has a mixed privatization system whereby patients pay above a claim limit and make mandatory salary contributions. The government covers the cost for low-income groups. Public hospital admissions are based on medical conditions, not subsidy status, to decrease disparities. Furthermore, the costs of services are based on the patient’s ability to pay. The health-care market is tightly controlled with full government oversight.
Cons: Privatization without sufficient oversight does not solve doctor shortages and can worsen them where care is needed most. A systematic review that examined 37 health indices over 30 years in 188 countries found that more private services created less equity, worsened universal health care and showed no long-term improvement in health outcomes. The authors stated that health-care sustainability is not an issue of public versus private funding.
Another systematic review over two decades found similar poorer quality and access issues. For-profit entities were found to avoid underserviced areas and to use more non-physicians to increase profits. The U.S., with its for-profit medical care, still has a shortage of 180,000 doctors.
Bottomline: Further risk-benefit analysis is needed before we move any closer to privatized health-care services. Strict government oversight is required. Successful health-care markets have user payments based on affordability. Even in mixed privatized health-care systems, the government still must incentivize health-care practitioners to practice in underserviced areas.
The reality is that a $1 billion investment is needed in Ontario’s primary care. I practice rural comprehensive medicine but trained in a Family Health Team (FHT). During training, IHPs like pharmacists counselled patients on polypharmacy, social workers provided mental health support and therapy, NPs followed-up prenatal visits and patients had access to physiotherapists for rehabilitation – all funded by the government. In contrast, patients in our clinic do not have access to this. Community physicians have to pay for all their clinic costs, including wages for nursing, receptionists, etc. Medical students have shared with me their concerns about practicing comprehensive medicine in the community due to insufficient FP remuneration compared to specialists working in hospitals.
Another issue with capitation-based remuneration I’ve seen is insufficient accountability for access to quality of care, especially for patients with complex chronic conditions like schizophrenia. Scandinavian countries have 95 per cent of marginalized patients enrolled in their primary care models and have contracts of what patients can expect from FPs and vice versa. Incentives are needed to lead patients’ medical homes and practice comprehensive medicine to attract and retain FPs as this type of care improves patient outcomes the most. Some FPs have moved to other Canadian provinces due to primary care reforms, including remunerating non-clinical work. Other incentives could be government-paid overhead for FPs. For health-care reforms to succeed, they should account for physician autonomy and other health policy carrots.
Therefore, Ontario needs to prioritize longitudinal neighbourhood-based care, focusing on marginalized patients’ access to primary care. There is robust evidence for investing in a team-based model, funding FPs through “blended capitation.” Team-based clinics have skilled IHPs, and address provider satisfaction. However, policymakers choose short-term “visible” investments like hospital-based care.
Idea 3: Smarter spending: redistributing health-care funds
Pros: FPs ask for strengthening team-based care to provide equitable, ethical and efficient use of resources and to allay administrative burden. One additional FP per 10,000 patient population decreases mortality by 6 per cent. FP-led team-based approaches provide patients with a medical home in their neighbourhood for increased access. A systemic review by the Commonwealth Fund analyzed performance measures like equity and health outcomes of top-performing countries. A bottom-up solution was found to provide high-quality services and decrease barriers for equity-deserving populations. Norway focuses its funding on underserviced areas while enjoying the highest doctor-per-person ratio. Its spending on health care is similar to Canada’s at 10 per cent of gross domestic product.
Cons: Primary care is disproportionately female compared to other specialties and gender pay gap studies have found systemic biases early in medical training. Specialties that have a higher proportion of male physicians have been resistant to pay redistribution. For redistribution of government health-care funding to physicians, some have proposed anti-oppression training, challenging the hidden curriculum and updating the relative value of fee codes. Moreover, there is no country in the world that has solved the doctor maldistribution in rural areas.
Bottomline: Expanding existing team-based approaches to all communities may attract and retain FPs. Relevant stakeholders need to have a say in health-care reform.
Final thoughts
Of the three ideas, the third is the most viable and sustainable solution. Shifting resource allocation toward primary care is needed as it bears the burden on health-care delivery. It has the most robust, long-term evidence and involves community members for solutions. Having an FP has been shown to have lower hospitalizations, improve health outcomes for all patients and has long-term cost-effectiveness. Privatization alone has yet to show improved care or how to solve the doctor shortage, while FP-led primary care teams divert patient volumes away from costlier hospital-based services. There is no question that health care’s front door is primary care; investing in fixing the door will allow Ontario to be truly open for business. Isn’t it about time?
