What the rest of the country can learn from Ontario’s family doctor payment model

Allan Carpenter walks into the doctor’s office and gets to work.

The 65-year-old patient and his longtime doctor Gordon Arbess have a lot to talk about, even though they see each other for check-ups every two weeks.

Mr. Carpenter’s back and hip are so sore he fears he will end up in a wheelchair. He is looking forward to all of his medical appointments, including an upcoming visit to an orthopedic surgeon. He has been HIV-positive since the late 1980s and recently beat throat cancer.

“We have a team of people trying to help you,” Dr. Arbess says, soothing his patient’s nerves, “and I know how much you got out of it. But I know that some days it’s hard for you to get to those appointments. I understand. I hear you.”

For Canadians without a family doctor, the idea of ​​having a physician guide – a “captain of my ship,” as Mr. Carpenter calls Dr. Arbess – is appealing in itself. But Mr. Carpenter is blessed with more than one captain. He has a whole crew.

His clinic east of downtown Toronto is part of the Academic Family Health Team at St. Michael’s Hospital, a five-site organization with more than 200 staff, including nurses, dietitians, pharmacists and social workers, as well as office staff to support approximately 80 physicians. and 36 resident physicians.

This model, which Ontario calls the family health team, is widely regarded by health system experts as the best way to provide primary care, especially for patients like Mr. Carpenter who suffer from multiple complex health conditions. Family physicians also favor the team approach because it helps them avoid burnout by sharing the workload. The Canadian Medical Association has appointed “developing team-based care” as one of its key recommendations to address the country’s health care crisis.

Despite this, Ontario has not opened a new Family Health Team in a decade, partly because of the cost.

And from 2015 until last spring, the provincial government barred physicians from joining the most popular physician payment model that underpinned Family Health Teams, unless they replaced a departing physician or are willing to shingle in a high-needs area.

The decision of the former Ontario Liberal government to rein in its signature primary care reforms offers lessons for other provinces that are moving away from the old paradigm of single physicians working on a fee-for-service basis in offices they own or rent themselves. British Columbia has just announced a new approach to paying family physiciansand Alberta expects new deal reached with doctors in September will lead to more family physicians joining a model that includes physician compensation in team clinics to enroll patients for greater continuity of care.

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According to the province’s former deputy minister of health, the most important lesson of Ontario’s primary care reforms is this: if a government wants to change the way it pays family doctors and pay them more, he must put clear and enforceable rules in his medical services agreement.

“There was a big mistake made in 2008,” Robert Bell said, “and the mistake was that we didn’t put accountability in place.”

Ontario began to overhaul its primary care system in the early 2000s. The new models paid family physicians working in groups primarily for the number of patients they enrolled in their practice, which deviated from the traditional fee-for-service approach where physicians were paid for each discrete episode of care they provided.

Alternative models mixed capitation payments — which are annual payments to doctors for each patient on their list — and fee-for-service to varying degrees. The approach was meant to encourage long-term relationships with patients and give doctors time to provide comprehensive care to older, sicker patients who might have four or five health issues to discuss in a single visit.

Doctors had to join one of the new payment models, the most popular of which is called a Family Health Organization, or FHO, if they wanted to be part of a Family Health Team, or FHT. The particularity of the FHTs was that the provincial government paid the salaries of the dietitians, pharmacists, social workers and other health professionals who completed the team.

There are currently 181 Family Health Teams in Ontario, the last of which opened in 2012.

In many ways, the reforms have succeeded. Physicians flocked to the new patient registration models, resulting in a 43% increase between 2006-2007 and 2015-2016 in the number of Ontarians who reported having a family doctor.

Patient care has also improved, said Tara Kiran, a primary care researcher at the University of Toronto and a physician at the family health team where Allan Carpenter is a patient. She and her research colleagues found that ESF patients received better monitoring of diabetes and visited the emergency department less often than patients in unmanned practices, although emergency department use increased for both groups over time.

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So why the break? In reports published in 2011 and 2016the Auditor General of Ontario suggested that the Ministry of Health was not getting its money’s worth in the new payment models.

According to the Auditor General, OSF physicians earned an average of $420,600 in gross income in 2014-2015, significantly more than the $237,100 that physicians would have earned, on average, under the traditional model of fee-for-service.

The Auditor General found that in 2014-2015, each doctor in an FHO worked an average of 3.4 days per week and that 60% of family health organizations did not meet the number of night or weekend hours. end required by the ministry.

Dr Bell, former president of the University Health Network in Toronto who served as deputy minister from 2014 to 2018, said while he believes the model is best for patients, the Liberal government he worked for decided to restrict access to the FHO structure because he could not get the Ontario Medical Association to agree at the bargaining table on clear accountability measures.

“If you’re going to be in this reasonably lucrative model,” he said, “you have to be in your office. You can’t let people go to the ER because they can’t see you. This was the real reason why the FHO model enrollment was discontinued.

The Ontario Medical Association (OMA), which represents doctors in the province, has long disputed the auditor general’s findings, saying they failed to take into account the scope of work of family physicians. The reports “missed the mark,” said OMA president Rose Zacharias. And when it comes to accountability, she added, “it’s built in and built into how we operate as professionals.”

Either way, Ontario’s decision in 2015 to restrict access to more lucrative capitation payment models had immediate consequences, said Imaan Bayoumi, a family physician and director of the Center for Primary Care from Queen’s University.

She and her colleagues analyzed Ontario Health Insurance Plan (OHIP) billing data over a 10-year period to determine the proportion of Ontario patients “tethered” to a regular primary care provider, a method more reliable than patient surveys. “At a high level, what we’ve seen is that there was a rapid increase in the proportion of patients being tethered between 2008 and 2014,” she said. “Most importantly, after the province restricted access to new models of care, there were no more attachment gains.”

Dr Kiran said the restriction was “terrible” news for family medicine residents in Ontario, the vast majority of whom were trained in family health teams and then found limited opportunities to practice in a setting. interprofessional after obtaining their permit. According to the national service that matches medical graduates with training programs, the share of Ontario graduates who named family medicine as their first choice of residency has fallen from a high of 37.1% in 2015 to about 30%. in each of the past four years. .

This spring, the OMA and Premier Doug Ford’s Progressive Conservative government reached a new deal that reopens the FHO model so that 720 new doctors can enter each year, down from as few as 122 in fiscal year 2015. -2016, when entry was limited to regions that had a great need for doctors.

Both parties agreed to insert language into the agreement indicating that the FHOs will ensure that patients with urgent illnesses are seen the same or next day. They also agreed to establish a working group that will determine how to adjust capitation models so that physicians are better paid for enrolling complex patients; currently, capitation rates are tied to the patient’s age and gender.

Mr. Carpenter hopes that more patients can join him in enjoying team-based care. He said he knew where he would be without Dr. Arbess and his healthcare team: “In a quiet yard, under some grass.”