Every day, more than 150,000 Ontarians visit a family doctor. Some visit because they feel unwell. Others come for a preventive checkup. Many more come because they have a health condition like diabetes, high blood pressure or depression.
Family doctors listen, examine, diagnose, counsel, write prescriptions, order tests and, in some cases, refer to specialist colleagues for advice. They play a key role co-ordinating care between different health professionals and social services.
Over the last decade, provincial governments in Canada have invested in improving primary care —funding interprofessional teams, encouraging group practices and networks and introducing new ways of paying doctors. But now, some of these improvements are under threat.
In Ontario, the government and medical association have entered arbitration for a new physician services contract. This week, they are discussing how family doctors should be paid. The results could have reverberations across the country.
All told, the government is proposing more than a 30 per cent pay cut for doctors working in new primary-care models that together care for more than 5.5 million patients.
Just as worrying as these blunt cuts are recommendations that will undo new primary-care models and progress in improving care for people living in Ontario.
New models offer better patient care
The new primary-care models were introduced in Ontario in the early 2000s. In the new models, physicians and patients sign enrolment agreements that formalize the doctor-patient relationship. Physicians work together in groups and share responsibility for after-hours care.
In some cases, the new models include funding for non-physician health professionals. In all cases, the new models have shifted physician remuneration away from the traditional pay-by-the-visit system to a blended payment that includes a fixed amount per patient per year based on patient age and sex.
These models are based on international research that found family doctors provide the best care when they have a clear “roster” of patients, are supported by a team and are paid in a way that allows them flexibility in the time they spend with patients and how they follow up.
Our research suggests that patients in these new models who have chronic conditions like diabetes are more likely to get recommended care.
The new models have also helped attract new graduates to choose family medicine as a speciality, countering shortages and low morale. Remember how many Ontarians couldn’t find a family doctor in the 1990s and early 2000s?
I have been lucky to work in one of these new models. Our team has used the flexibility to change the way we work. We care for 45,000 patients at six clinics in downtown Toronto. We share an electronic medical record, offer evening and weekend clinics, share care with non-physician team members, proactively contact patients overdue for screening and respond to patient requests by phone or email.
Three out of four of our patients say it’s easy to get care from us in the evening or over the weekend. Three out of four say they receive an appointment the same or next day when they are sick and need care.
These numbers are much better than they used to be, much better than the provincial and national average and many of those who wait have told us they would prefer to wait — they want to see the physician they know rather than see a covering doctor the same day.
Mandatory quotas, less flexibility
All of these improvements in patient care would be under threat if the arbitrator accepts the government’s proposal.
There would be mandatory quotas for in-person visits. This of course would leave less time to communicate with patients via e-mail or phone or speak with colleagues about patients. And it would mean less flexibility to spend more time with the patients who need it.
We would face large financial penalties if our patients see a family doctor who is not part of our team. For example, every time a patient goes to a walk-in clinic or sees a family doctor providing psychotherapy, we would get dinged the cost of that visit — with no limit.
Many of our patients choose to go to a walk-in clinic because it’s convenient. They work near our downtown clinic but live in the suburbs. Or they have a physical disability and the walk-in clinic is in their building.
Practices like ours would face a tough choice. We could take patients who see outside family doctors off our “roster” — but these patients often need us most.
Or we could abandon the new primary care model — our new way of working and the improvements we’ve made — and go the back to the pay-by-the-visit model that virtually all the experts agree incentivizes volume not quality.
A less attractive career
Pay cuts together with less flexibility would also mean fewer medical students choosing family medicine as a career — and ultimately, fewer family doctors.
The status quo is not perfect. We can do more to ensure all Ontarians have access to a new model of care and restructure financial incentives to encourage doctors to care for those with the greatest needs. We also need to address concerns that some family doctors are using the flexibility of the new models to reduce their hours.
But the status quo is a vast improvement from a decade ago.
Let’s not go back in time. Let’s invest more in primary care, not less.