You and your family doctor

What happened to the health care crisis? It used to be public issue number one, but now weird weather and other inconvenient climatic truths have bumped health care to second place in our national preoccupations. However, that doesn’t mean it has gone away. At the level of primary care – the basic relationship between you and your family doctor – profound changes are underway.

“They will, in fact, influence the very way we practice medicine,” says Dr. Barbara Watts, a family practitioner in north Caledon.

Most of us, at least those of us with family doctors, have already dutifully enrolled in the plan. (Remember the form you signed on a recent visit last year.) But according to Watts, many patients have only a vague idea about what they’ve agreed to. That’s because the major thrust of the changes is still to come.

Diagnosis

Part of the problem with understanding our health-care system is its mind-numbing complexity. What we do understand is that costs are escalating, that wait times are growing, that emergency rooms are overloaded, and that there just aren’t enough doctors to go around.

Bob Baynham, CEO of Headwaters Health Care Centre in Orangeville, sums up the simple principle behind our national approach to health-care delivery: “In an ideal world family physicians are the gatekeepers to the medical system and every citizen should have a family doctor.”

But in the Headwaters region, an estimated 25,000 to 30,000 people, about a quarter of the population, are without a family doctor – and that is not a problem exclusive to us. Across southern Ontario, more than 100 regions are designated as under-serviced.

It is this basic problem that the province’s restructuring plan aims to correct. Will it work?

Prescription

In 2001 the Mike Harris government rolled out the concept of Family Health Networks (FHNs or “fins” as they’re called).

With some $250 million in funding, the idea was to encourage family doctors to band together in groups to provide more after-hours care – to take pressure off emergency rooms; and to concentrate more on prevention – to take pressure off the health-care budget – and to make people feel better, too.

The doctors would work together to provide extended office hours and to cover one another on holidays. Patients would also be able to call their FHN’s telephone advisory service staffed by a registered nurse who, if necessary, could call a doctor.

The FHNs would encourage doctors to spend more time on preventive care by changing their payment structure. Instead of fee-for-service, by which doctors are paid for every particular service they provide, they would be paid by “capitation,” that is, by the number of patients in their practice, their “roster,” regardless of how often they see any one individual.

The primary criticism of the fee-for-service model is that it seems to give doctors the incentive to recommend as many services as they can to as many patients as they can, and to keep them coming back.

Further, it can encourage doctors to focus solely on acute care – to spot the immediate problem and fix it – rather than on preventive care. Your doctor may tell you not to smoke, not to eat junk food, get more exercise and avoid stress, but your doctor doesn’t get paid for that, nor for having detailed discussions about your medical history, psychology, family relationships and social circumstances that could be influencing your health.

The capitation model is designed to give doctors an incentive to enlarge their rosters by signing on new patients, thereby alleviating the doctor shortage.

The theory is that with doctors being paid a set amount per patient per year, whether they see the patient or not, they’ll be encouraged to minimize visits and to enlarge their roster – and their incomes. The goal is to shift their focus from “How many patients can I see in one day?” to “How can I keep this person healthy so they don’t need to see me as often?”

To compensate for the fact that some patients – the elderly and the very young – require more health care, there are premiums built into the payment model to ensure doctors do not skim off only healthy patients and stint on services to others.

Other premiums on top of the basic per-patient fee are also built into the system. Doctors are rewarded, for example, if they take on new patients, treat serious mental health issues, provide after-hours service and deliver palliative care. They also receive bonuses if certain percentages of their patients avail themselves of preventive services, such as colorectal screening, flu shots, pap smears, mammograms and immunizations (for toddlers).

The government is also pushing – again through financial incentives – the use of electronic medical records as a way to improve the sharing of and access to patient information.

Despite the fanfare and the money, family doctors were reluctant to leap on board with the FHN concept. According to Watt, that was partly due to the medical community’s longstanding distrust of their political paymasters and their often seemingly fickle approach to health policies.

In fact, the FHN concept was modified slightly in 2003 with the introduction of Family Health Groups (FHGs or “figs”), which allowed for more traditional fee-for-service-type billing, prompting some doctors to participate.

But the big push came in 2005 when the new McGuinty government introduced a further refinement, the Family Health Teams (FHTs or, yes, “fits”). With $600 million in funding, it more than doubled the Harris investment. Its intention was to create 150 Family Health Teams by 2007/8 that would serve 2.5 million patients.

The fundamental elements remained: collaborative groups of doctors, after-hours coverage, per-patient funding and a whole series of bonuses, incentives and premiums that aimed to achieve various government priorities, chief of which was prevention.

The government has also removed the cap on earnings doctors can charge to OHIP. The health ministry projects that the bonus and incentive programs will raise the average annual income of family doctors by about 24 per cent, to about $277,000 from about $223,000, making them among the highest paid doctors in their category in Canada.

Another important innovation of the FHTs was to broaden the team concept beyond family doctors to include other categories of health-care providers, such as dietitians, mental health workers, nurse practitioners and other specialists.

The thinking was: doctors don’t have to do everything themselves. If they have access to more support, they can see more people without compromising quality.

How? By referral. That is, by taking a more “holistic” or integrated approach, the family doctor could call on other expertise to help get at the root causes of ill health, such as poor nutrition, smoking and psychological problems, and to better manage chronic conditions, such as diabetes and cardiovascular disease.

Hence the introduction of Allied Health Professionals (AHPs). The Family Health Teams can include AHPs who are paid by the Ministry of Health but are employees of the FHT.

By referring patients to these auxiliary resources, doctors should be able to focus more on education and health promotion – and on meeting targets the province has set for preventive measures, such as pap smears and mammograms.

According to Barbara Watts, the most important change for patients is that the services provided by the auxiliary personnel will be new and covered by OHIP. This, she says, is particularly beneficial in the case of mental health services, which traditionally have been hard to come by.

The FHTs may also help alleviate pressure on hospital emergency rooms.

Bob Baynham points out that the total number of visitors to Emergency is actually levelling off. “But the people we are seeing are sicker.” That is, the hospital is receiving more people with serious chronic diseases who, with a little help, might avoid visiting the hospital.

“There are great tools out there to manage chronic diseases,” Baynham says. “We just need to learn how to use them.”

Progress

In this region, Family Health Teams have been approved for Orangeville, Shelburne and Erin, as well as in nearby Alliston, Georgetown and Brampton. Most are still in the start-up phase.

For example, the Dufferin Area FHT, based in Orangeville, had its business plan approved by the Ministry of Health in late 2006, but it is still negotiating funding for costs associated with renovating and running the facilities required to house the proposed forty or so AHPs. (These include three registered nurses, five nurse practitioners, five mental health workers, two registered dietitians, a certified diabetic educator, a health promotion worker, a respiratory therapist, a clinical pharmacist, and even a part-time psychiatrist.)

Other FHTs are in the same situation. Eric Stern, chair of the Erin-based East Wellington FHT, says they need funding to expand existing facilities in order to house the two nurse practitioners, two registered nurses, half-time dietitian, half-time mental health worker and various other health professionals they plan to hire.

“The funding has to come through,” Barbara Watts says, “otherwise the whole thing is an exercise in public relations.”

Already the slowness of implementation has led critics such as the Coalition of Family Physicians of Ontario to wonder whether FHT actually means “Fictitious Health Teams.”

However, in Shelburne, Mel Lloyd Family Health Centre is already offering three nights a week of after-hours care. It has two nurse practitioners and three registered nurses assisting the two family doctors on staff, freeing them up to see more patients.

Dr. Nadine French, one of the doctors at the centre, is particularly excited that it has just been approved for a new diabetes education program which will allow them to hire a dietitian and an additional RN.

“This is big news,” she says, because this program will be open to patients who are not on their roster, which broadens the impact of the program’s benefits to the wider community.

Second opinion

For all the government’s ballyhoo about primary-care reform, and the capitation model in particular, not all doctors are signing on to the team concept.

Dr. Peter Cole is one of the holdouts. He has chosen to remain an independent practitioner. He feels that the new incentives and bonuses will drain funds from other resources to pay doctors for what they should have been doing all along, providing comprehensive care to their patients.

And he’s not keen on the team concept either. At 62, he says, “I have my own style of practice.” That includes offering his patients a more holistic approach, sometimes referring them to naturopaths, homeopaths and other providers of alternative medicine, including his wife, Ila Sisson. She is a registered nurse who runs a natural healing practice out of their home-based office north of Orangeville. Together they hold health promotion workshops.

(The government does offer a special comprehensive-care model for solo practitioners that is similar to the FHT concept, but does not require joining a team.)

Cole, who eschews a white coat (“I don’t own one.”) in favour if his trademark plaid shirt and who commutes to the hospital by motorcycle, might be dismissed as a loner or a “fringe” player. His resumé says otherwise.

Following a few years in private practice he pursued a fellowship in epidemiology and public health, then became director of Toronto’s family planning program. His administrative career eventually led to the position of Medical Officer of Health, first for Halton, and then for Peel. He left the latter position in 1999, after more than fifteen years, “tired of the politics” which he felt “wasted my energies” and ready to concentrate on family practice where he felt he could “make some real difference to people’s health.”

Ironically, Cole was one of the people responsible for developing the reforms that are now being implemented. More than thirty years ago, as an employee of the health ministry, he helped develop a capitation pilot program in Sault Ste. Marie.

In the ’70s, he was also involved with Community Health Centres, which also used an integrated approach to multidisciplinary care. The government was slow to take up the concept at the time. They were “nervous,” says Cole, because of the big budgets required to run them. However, the model has now been developed extensively in inner-city neighbourhoods where people otherwise tend not to have family doctors.

Doctors employed at those community centres are paid a straight salary. And it’s that payment model that Cole would prefer to see province-wide. He says both fee-for-service and capitation put doctors in a “conflict of interest.” Capitation, Cole suggests, simply transfers the problems with fee-for-service to a new model. That is, doctors are prone to get “greedy” and sign up more patients than they can handle.

“Good prevention takes time,” he says. But if doctors are paid according to the number of patients they roster, “there is a powerful incentive to expand their practice too far.” And patients on crowded rosters don’t get the kind of care they should. They can’t. Their doctors are too busy.

Cole bases those concerns on his own experience in Orangeville’s After Hours Clinic. There he sees many patients who are rostered with other doctors – patients who, according to the new model, should seek out their own doctors for after-hours care. But, he says, “They tell me it takes two to three weeks to get an appointment.”

Whereas his practice has 1,500 to 1,800 active patients, he knows of doctors who are signing up well in excess of 3,000.

He is also concerned that once the FHT programs are fully functional, the government will have an excuse to drain away resources from existing community-based services, especially in the area of mental health. Where, he asks, will all those additional AHPs come from?

The victims, he points out, will be people without a family doctor because the new FHTs will provide services only to the patients on their roster. That means stranded or orphaned patients could end up with even less access to care.

However, Lynn Lowe of the Dufferin Area FHT insists that the programs offered by the FHT are meant “to augment, not replace programs currently offered.” Nor is it the intention to replace staff in the hospital who currently run community-oriented programs.

Prognosis

Ontario’s primary care reforms may seem radical, but Barbara Watts says other countries have taken their reforms much further.

In Britain, for example, taking a test or having a needle or attending a workshop isn’t enough. It’s the actual health outcomes that are measured.

“If you’re a diabetic,” Watts says, “and your blood sugar is controlled within a certain level and a certain number of your patients achieve that, you get a bonus.”

“It’s really pushing it,” she says. “It’s kind of suggesting – I don’t know – I should go to your home and make sure you don’t eat that chocolate bar.”

It’s an open question, then, whether the current reforms will lead to improved health “outcomes” for us all. And whether family doctors will begin to take a more integrated and preventive approach to patient care.

Dr. Barbara Watts is optimistic. And despite his reservations, Dr. Peter Cole acknowledges the proof will be in the pudding. Still, it will be a good while yet before the results in terms of the overall health of the population can be measured. And whether anyone gets left behind.