Quarterbacking healthcare: The central role of family doctors
How valuable is a quarterback to a sports team? Whether it be a Pat Mahomes or a Tom Brady completing big passes to star receivers, a capable quarterback is essential to a high achieving team. To a fan, the value of these players is unquestioned. Yet in health care, the central role family doctors play on a patient’s team often gets overlooked, even to the point of governments imposing cuts affecting family physicians’ ability to care for patients in the middle of a pandemic and investing instead in private surgical services.
In a world that often falls into the trap of focusing on short-term measurable deliverables, it is easy to miss out on primary care’s value. In the big picture of healthcare, however, the value of primary care is clear: longitudinal care focused on prevention increases patient-centred care and prevents fragmented specialist care.
Primary care has directly measurable benefits in financial savings through preventable hospital visits. In palliative care, we know that good community-based care can save up to $8,000 per hospitalisation. Addressing a knee replacement is usually a one-time cost but poorly managed chronic diseases can result in repeated admissions to hospital and cumulatively larger bills to the system.
Dr. Mayura Loganathan, a staff family physician at the Mount Sinai Hospital Academic Family Health Team who also leads its home-visit program, says his work reassures patients and prevents expensive emergency room visits. Many of his patients are homebound and unable to access care on time. If, for example, these patients catch pneumonia, he estimates a two- or three-day hospital stay can cost the system up to a couple thousand dollars. Instead, he says, when he sees his patients in their homes, he knows their baseline health, can catch pneumonias earlier and treat them with oral antibiotics that cost the system just over a hundred dollars in total. Like Loganathan, about 40 per cent of family doctors make house calls for homebound patients. These direct cost savings have the added benefit of preventing patients from facing the many difficulties of hospital admission.
“The biggest value is preventative medicine and the problem with preventative medicine is the public doesn’t see the value,” says Loganathan. He reasons, for example, that patients and their families may appreciate the interventions of cardiologists after heart attacks but do not give thought to the contributions of guideline-based primary care that successfully prevent heart attacks.
According to Dr. Liisa Jaakimainen, a family physician at Sunnybrook Academic Family Health Team who measures primary care performance using data electronic medical records (EMR), “primary care is comprehensive, it has continuity of care. And it’s patient centred. It’s got all these sorts of qualities that make it different from when you see a specialist. We know that having good continuity of care for people with certain chronic diseases improves their care.”
There is a large body of research supporting the effect of good primary care and continuity of care for patients, including receiving better evidence-based care such as cancer screening and diabetes care and reducing the number of hospitalizations.
According to Dr. Walter Wodchis, an associate professor at the Institute of Health Policy, Management and Evaluation at the University of Toronto, “It should be no surprise that we actually spend a lot of our money on a few people that are very sick.” According to his 2016 paper, 5 per cent of patients account for 65 per cent of total health care expenses. For patients representing the top 5 per cent of those costs, a third will remain at these high spending levels for multiple years since they are more likely to have more than one chronic condition.
Wodchis says that current guidelines do not address the complexity of caring for patients with multiple conditions. “For example, find a cardiovascular guideline that refers to how to manage someone’s arthritis or a depression guideline that helps you manage someone’s cancer.” While it might be ambitious to have guidelines for every possible comorbid disease combination, primary care providers already treat these patients regularly. Family physicians are trained to treat this wave of increasing patient complexity, thus it makes sense to invest more rather than less to support this possible future.
As a frontline physician, Loganathan says he can understand the difficulty in getting funding for better primary care and community social support. “It’s easier to get the public to vote when you tell them I’m going to add 10 more long-term care beds rather than saying I’m going to add a couple more resources that will prevent the need for those 10 long-term care beds,” he says.
According to Dr. Tara Kiran, an associate professor at the Department of Family and Community Medicine at the University of Toronto with a strong interest in primary care reform with a health equity lens, “One in six Ontarians still aren’t in a patient enrolment model and most of those patients are probably unattached: they may be seeing primary care physicians in the context of walk-in clinics and they are probably not benefiting from continuous comprehensive primary care.” She worries that for these patients, often immigrant-refugees in lower income neighbourhoods, as the quality of care is poorer.
Kiran adds that family doctors in Ontario continue to be restricted from entering team-based models of care such as Family Health Teams, where there is OHIP-covered access to mental health counselling, social work and dieticians. The inability of certain sectors of the population to access this care detracts from its value. Says Kiran, “I think that all Ontarians should have access to team-based care. It shouldn’t just be that you are lucky enough to have a family doctor who happens to be in a family health team.”
Currently, Ontario’s compensation models for family doctors are complex and range from full fee-for-service (FFS) and enhanced fee-for-service (Family Health Groups-FHGs) to blended capitation models (Family Health Teams-FHTs; Family Health Networks-FHNs; and Family Health Organizations- FHOs) where payment is a complicated derivation of a physician’s roster size and incentives for age, sex and other health outcomes. The latter three encourage doctors to enrol patients and provide extended afterhours care. Of those, only FHTs have access to funding for a team of multidisciplinary health providers (team-based care) for patients. While FHNs and FHOs can apply to become FHTs, the supply of FHTs has been restricted by the Ministry of Health in recent years.
Kiran says the goal should be 100 per cent enrolment for patients in team-based care models. Currently, however, according to Wodchis only “30 per cent of Ontario has access to a team-based care model; 70 per cent does not. It’s about reorganizing. It’s how do we deliver multi-disciplinary care to support primary care at the frontlines in the community around nursing for chronic disease management and access to specialists for things like mental health issues and complex medication regimens.”
Dr. Pauline Pariser has worked to address the challenge of community physicians accessing hospital and community services for their patients. Pariser helped develop the SCOPE program, or Seamless Care Optimizing the Patient Experience, in partnership with Toronto’s University Health Network (UHN), Women’s College Hospital (WCH) and the Toronto Central LHIN after noticing the disparity between available resources for local community physicians and those in team-based practices. After connecting her own practice to an FHT, Pariser discovered she had access to resources that had not been at her disposal in 20 years of community practice. SCOPE began with a quality improvement project at Toronto Western Hospital Emergency (TWH), affiliated with UHN, that tracked the high rate of patients community family doctors were sending to the emergency department. Applying a co-design model with these 50 community practices around TWH, Pariser translated their needs for connected care into the SCOPE program facilitating access to services such as dedicated system navigators, mental health support, and specialist phone and rapid in-person consultations
For a front-line physician like Loganathan, the “siloed” lack of communication between specialists and primary care physicians is especially tough for medically complex patients. He says coming up with a plan with relevant specialists, emergency room staff and interdisciplinary care providers has prevented unnecessary hospital visits for patients.
Dr. Danielle Martin, the Chief Medical Executive and Executive Vice President at Women’s College Hospital in Toronto (WCH) and a prominent advocate for public health care, says improving health care must involve leveraging the value of primary care. “Primary care, as many people have said, is really the patient’s medical home,” says Martin. “The value of primary care is that you accompany people through their journey in life through the high points and the low points and really try to be their anchor in the healthcare system.
“We know that health systems that have a strong focus on primary care have better outcomes at lower costs. It’s very easy for people to get lost in the rabbit holes of specialty care if they don’t have that anchor.”
Martin points to an example in the SCOPE program. For enrolled primary care providers, rather than maintaining slow communication channels such as faxed referrals, long waitlists or sending patients to the ER, if a family physician needs an internal medicine opinion on a patient or an urgent CT scan, the physician can call the relevant specialist at the hospital, get real-time advice and receive help in arranging for critical testing. By changing the traditional role of the family physician as a client of hospital services, she has helped design a system that avoids emergency department visits, hospital admissions, and yields high rates of satisfaction with patients and physicians.
Nonetheless, understanding the true importance of primary care will require more data collection and reporting. Jaakimainen notes that there has been a significant effort to standardize hospital level data but that has not extended to community or nursing care. She says one of the barriers is the fragmentation of data in community medicine, dispersed amongst of number of competing EMRs. Her research aims to use machine learning to analyze available administrative and billing data to measure health outcomes. Compared to the relative ease of financial institutions in accessing someone’s financial data, she says she is surprised by the lack of credible standardized data in community health care.
“Most of the encounters in the healthcare system are with family doctors and primary care providers. We just forget that and focus on emergency visits and MRIs and hospitalizations that no doubt are very costly and important,” says Jaakimainen, “but when you look at the system, people are seeing their family doctor the most and yet we don’t look at it. We criticize it sometimes but we don’t look at it very well and part of it is lack of data.”
Generously funding primary care and smart spending are not mutually exclusive strategies. For perspective, total health care expenditures were expected to reach $264 billion in 2019. In contrast, it is estimated that the Canadian economy loses $190 billion annually due to indirect income and production loss from chronic diseases. This represents 72 per cent of the total we spend annually on health care, a significant statistic given Canada’s historic underperformance in economic productivity per capita compared to countries like the United States.
Strong economies require healthy citizens who can contribute positively through labour or business creation. Without investing in primary care and strong social programs, we are, in a way, denying ourselves full capability of developing a strong competitive business market. Thus, when we arbitrarily cut primary care without analyzing its strengths, we risk damaging another pillar of our economy.
From family physicians who help coordinate patient care to specialists who treat specific conditions, we should all be working together as a team to keep patients thriving and at home. We should ensure that no patient is left out and offer care providers incentives and supports to tackle the difficult and complex medical issues we face in modern medicine. Through enhancing primary care with better data and collaboration, we can build a championship calibre healthcare system.
Most importantly, in recognizing the value of primary care, we are not simply arguing for increased physician pay but rather the importance of adequate funding to invest in a future where Canadians can have stable access to physician teams and receive the best care possible; and they deserve no less.