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More Ontarians should have access to team-based primary care


In our family medicine practice, we regularly ask patients to give us feedback on how we’re doing. They tell us, over and over, that one of the things they like best about our practice is the teamwork – how much they love their doctor but also their social worker, or nurse, or dietitian. And how well they work together.

Our patients are lucky.  Our team is lucky. Most Ontarians today have a family doctor but only 1 in 4 Ontarians has access to a primary care team that integrates other health professionals. About 250,000 Ontarians belong to a Community Health Centre (CHC) and about 3 million belong to a Family Health Team like the one we practice in. Community Health Centres have been around a long time and have had a focus on serving marginalized populations. Family Health Teams were introduced just ten years ago in an effort to improve access and primary care for all Ontarians.

But a decade after they were introduced, only a portion of Ontarians can access Family Health Teams. And what’s more worrying, certain groups seem less likely to belong to one. Research has found that patients living in urban areas, new immigrants, and those who are sicker are less likely to be a patient at a Family Health Team.

Why is access to Family Health Teams so unequal? The reasons are complex but to some degree it comes down to money. Physician groups can only apply to become a Family Health Team if they agree to change how they get paid. Instead of getting a fee per patient visit, they must agree to switch to salary or capitation payment. In capitation, physicians get a set fee per patient per year, regardless of the number of visits, with the amount varying based on the patient’s age and sex. In some jurisdictions, capitation payments also take into account patients’ medical complexity or social vulnerability. But, in Ontario, the capitation formula only adjusts for age and sex.

That means that a doctor paid by capitation in Ontario gets the same annual amount to look after a healthy 20 year old male who only comes to the doctor once a year as they would to look after a 20 year old male with type 1 diabetes and depression who needs to be seen monthly. Not surprisingly, doctors with sicker patients are less likely to want to get paid by capitation in Ontario – and so less likely to become a Family Health Team.

To make things more complicated, Ontario physicians paid by capitation are also eligible to earn bonuses. One of these bonuses, the Access Bonus, pays physicians up to $50,000 more in a year if their patients don’t see physicians practicing in another clinic.

As it turns out, switching to a capitation model was attractive for many rural and small town physicians because they easily qualified for the Access Bonus. Their patients often didn’t have any walk-in clinics to go to. But, many urban physicians knew they would never qualify for the Access Bonus – not because they didn’t try to see their own patients, but because many of their patients would go to walk-in clinics because they were more convenient. This means that Family Health Teams are less likely to care for groups that live primarily in urban areas, like recent immigrants or people who are homeless or underhoused.

So we end up with an inequitable system. Many Ontarians with the greatest needs for team-based primary care are least likely to have access. Some call this the inverse care law.

Getting out of this mess will be difficult, but we suggest two potential first steps. One is changing the capitation “formula” so that it accounts for a patient’s medical complexity or social vulnerability. Another is modifying or eliminating the Access Bonus. But instead of moving in this direction, the government has restricted entry of physicians into capitation models and therefore also Family Health Teams, perpetuating and potentially exacerbating current inequities.

Many organizations in the U.S. are trying to shift family doctors from fee-for-service payment to capitation. They should be mindful when they design their payment systems that they improve equity and not make it worse.

We get paid through capitation and we like the flexibility it gives us. It means we can spend more time with patients when we need to and also have an incentive to provide care by phone or email. But ironically, we know that in our current system, we would make more money if we served healthier patients. That kind of incentive is just wrong.

Our team at St. Michael’s has unique relationships with the hospital and university that has made becoming a Family Health Team financially practicable – despite our urban setting and our mission to serve the sick and the poor. Other physicians (and their patients) aren’t as lucky.

We love working in a Family Health Team. We know our patients benefit from the excellent team that can help them with everything from medication side effects to how to eat healthier to how to decrease their household debt.  All Ontarians deserve the same.

Tara Kiran and Rick Glazier are family doctors at the St. Michael’s Hospital Family Health Team.

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11 comments

  1. Mario Elia

    Thanks for the article, Tara and Rick, important points made.

    Interesting that MDs holding onto the CCM and FHG models are likely in urban centres, likely because of the risk associated with the Access Bonus. Do you have any suggested solutions for alternatives to the urban Access Bonus, while still ensuring that MDs actually provide timely access. In light of primary care reform coming, I hope that we can find a system that both attracts fee-for-service doctors to a capitation model (rather than force them to the model, and assuming the ministry eventually scraps Managed FHO entry) while still having some sort of punitive measure for those that provide poor access.

    • Tara

      Great question and a tricky issue. I personally think we should be measuring patient’s experience of access at every primary care practice and consider publicly reporting this data as a non-financial incentive to practices to improve access.

    • Vera

      Great idea, then I get no health care. I cannot get a primary care doctor as I was kicked out for refusing cancer screening – informed consent my a.s.s, not for women there isn’t. The walk-in will still treat my migraine without requiring a pap test. We have no private options in this country and in Ontario doctors can and do refuse to take you on as a patient if you are seen as “non compliant for screening”, no exceptions. It’s their way or the highway. The walk-in I go to, has more respectful doctors. We have no private options in Ontario either so without the walk-in I would have to use street drugs to treat the migraines I guess.

  2. Scott Wooder

    I have been in a capitated practice, working with a team since 1989. I agree that there are enormous benefits to this model.
    The underlying premise of the article is that patients cannot join Family Health Teams because their family physicians won’t leave Fee For Service based models for capitation based models.
    In January 2015. the Government severely limited the ability of physicians to enter capitation. This was one of nine focused cuts designed to save money.
    There has been a moritorium in new Family Health Teams for several years. This is again a cost saving measure.
    I do agree that a capitation rate that takes into account more than just the age and sex of a patient would be fairer for providers and more importantly better for patients.
    No change to the model will allow more capitation based practices or more Family Health Teams in the near future.

    • Vera

      I was kicked out of the so-called family health team for refusing a pap test as a requirement to get migraine medication. Fee for service is cheaper and I get more respectful treatment and am allowed “informed consent”, something denied to me by those “teams”, using a walk-in clinic in downtown Toronto. They don’t tell me they won’t treat headaches without doing a quick pap test first. Time to bring on two-tier so we have a “Harley Street” choice when you refuse to treat us.

  3. Dr. Nicole Nitti

    it has been frustrating to watch efforts to spread inter-professional primary health care across the province be impeded by poorly thought out strategies that leave behind the people who need it most. I think it is important to note that Community Health Centers are mandated to focus on complex and high needs patients and to engage with communities in a very different way then most other primary care models. Being a straight salary model for physicians with a roster size that is based on a SAMI score (a measure of complexity) and mandatory activities such as chart audits, cancer screening reporting and quality improvement plans creates a very different practice environment. CHCs are not talked about enough in discussions on primary health care transformation even though solutions proposed to fix our broken and segmented system often sound a lot like what CHCs have been doing for years. Is there a role for expanding on and improving the work already being done in the Community Health Center sector?

  4. Aurelia Cotta

    I am in a FHT, and as I have said many times, I love my family doctor, because she and I have a strong relationship, and I’m a complex patient, and it’s got nothing to do with her FHT. Transferring around to other staff when she is off can be a bit of a nightmare, unless it’s one of the other long time GPs who knows me. (my EMR record is probably a terabyte size.)

    There is a nurse, but I only see her once a year for a flu shot. And one of the other offices in her group, has a social worker. The social worker unintentionally creates a problem because the govt assumes she can do every kind of therapy and deal with all sorts of psych patients. Well, she’s good, but not trained in 10 different techniques thanks. My surgeon tried to refer me to a psychiatrist in her hospital, and it became a bureaucratic mess because I was “already covered” for mental health by my FHT, and had to see the social worker first. *smh*

    The FHT keep evening hours, and weekends, rotated around among the GPs, but except for Winter, they often don’t have patients, because the other office locations are not convenient to go to after work. (My doc’s office is closer to my house, but when I started seeing her, she was closer to my work. Over 20+ years, she and I both moved.) Other reasons for going to walk-ins? Well, maybe your kid doesn’t have a fever until 8pm, or maybe they have a horrendous rash, and you can’t wait. Even then only ERs can remove foreign objects or do stitches, or x-rays, or check you if you have post-op problems or questions, or draw blood. But some ERs are terrible, and some are great. So again, I may not go to my local ER, I might go to an ER with a “built-in walk-in clinic” and get routed to it, without even knowing.

    Also? These days, people often work far away from where they live, and if you are sick during the day, you are likely to go to the place nearest work. After work or weekends, you go to the closest place to home. On vacation with the Family up north? You’ll drop in at a walk-in near your hotel, not drive 500km back home to see your FHT Doc.

    This is the biggest issue with catchments and capitation and trying to figure out how to pay Docs and where patients go—it’s not the 1950’s anymore. Women work outside the home, sometimes far from home. They pick OB/gyn doctors and then daycares based on where they work, not where they live. I know people who pay for private schools or lie about school catchments because it fits their commute. Same for doctors.

    Same for specialists and hospitals. Doctors aren’t interchangeable and patients aren’t widgets. I might get referred to a certain psychiatrist for a specific therapy method, or a cardiologist who specializes in my heart issue. They may not live anywhere near me, or be located near my job—but my GP might have a good medical reason to send me to someone out of my “catchment”.

    Yet, the Doctor gets punished financially when the patient does the most logical thing, and goes to a walk-in nearby, instead of an ER. Or the patient has to wait even longer for proper care because they have to see the FHT “therapist” first before a referral.

    Seriously, why can’t my budgetary dollars follow me? Why am I “assigned” to anyplace. Or worst of all, why does my great doctor get paid so little for seeing me and doing round the clock care yet get punished if she tells me on the phone to go to a walk-in, because it’s 7:30 and I’ll never get there in time. (God forbid we are practical and efficient.)

    Why can’t patients do what is most practical for them? And medically best for them–without it causing a giant paperwork mess?

  5. Farah Ahmad

    Thank you for sharing your truly ‘unbiased facts’ and voicing the need to identify and implement innovative strategies to improve equity in access to team based primary care, especially FHTs. This model holds a lot of potential for patients with chronic conditions and/or access challenges. Yet, patient agency seems to have fallen through cracks in the conceptualization of model – ironic given that the system is supposed to be patient-centered. Moving forward….meaningful engagement (not tokenistic) of patients in developing the system-level solutions may help us to avoid such unintended consequences.

  6. Rob C

    I am a Family Doctor treating thousands of immigrants and it seems impossible to join or create a Family Health Team. This seems reserved for the privileged old stock Canadians. Why is it that the existing doctors not commit themselves to a higher percent of immigrant patients?

    • Gerry Goldlist

      re:
      “I am a Family Doctor treating thousands of immigrants and it seems impossible to join or create a Family Health Team. This seems reserved for the privileged old stock Canadians. Why is it that the existing doctors not commit themselves to a higher percent of immigrant patients?”

      Why did you have to make this a race thing: “reserved for the privileged old stock Canadians”? There are people of all classes, races, religion etc who need of doctors.

      Maybe existing doctors do not commit themselves to a higher percent of immigrant patients because their practices are full or they choose to work in an area where there are few immigrants.

      As a physician who worked my whole career in North York, I have patients who have lived in Toronto for their whole lives and patients from the different waves of immigrants that have come to Toronto over the last 40 years. My first immigrants were those fleeing Rene Levesque in Quebec, then South Africans, then Hong Kong before it went back to Communist China. Iran after the Ayatollah took over, Sri Lanka, Middle East and any other trouble spot in the World.

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