“The Hunger Games” in Ontario Primary Care
Primary care for every Ontarian—sounds like a simple and laudable goal for our state-run single payer system. In fact, it’s what we used to have in Ontario decades ago before government efforts to curtail costs, restrict access, and limit models of primary care such as Family Health Teams, Community Health Centres, and even fee-for-service practices. Blaming family doctors for the rising costs of care hasn’t been helpful and neither have attempts to obliterate fee-for-service family medicine seen to be “turnstile” medicine by academic consultants. As a result of decades of provincial “management”, we now have “The Hunger Games” of Primary Care where 2.5 million Ontarians are without access to a family doctor, and this is estimated to rise to 4.4 million by 2026.
The talk to the hand approach by successive governments has resulted in municipalities and health care institutions competing against each other for family doctors. Hospitals are extracting family physicians from the community to act as hospitalists to help with alternate level of care patients waiting for long-term care and to help manage complex patients needing elective surgeries. The possibility of hospitals providing better pay, pension and benefits is obviously an attraction for physicians. It is a typical “follow the money” result.
The hospital’s gain is the community’s loss; that is unless the perspective taken is this is just evidence of more coordinated care and collaboration. The reality is that aspects of the health care system are inextricably connected. Adjusting one area has an effect in other areas or like a balloon-squeezing one area causes another area to bloat. The level of coordination is organic and increasingly so in a system with growing complexity. Efforts to manage and coordinate care are creating more costly administration and growth in bureaucracies—tax dollars diverted from direct patient care, even though this may be what representative organizations and some physicians are calling for.
Meanwhile, communities across Ontario are attempting to recruit and retain primary care doctors. A variety of financial perks such as money upfront is being offered with some success. Other approaches to shore up family medicine in Ontario are being floated out. Recently Dr. Jane Philpott and associates are trumpeting primary care teams for Ontario as though they are a novel concept. She proposes something “radical” for primary care whereby people moving into a new neighbourhood would automatically be assigned to a clinic with family doctors, nurses, pharmacists, and social workers- teams of approximately 30 providers would make up a team to provide care to several thousand patients.
The team approach is hardly radical but the assignment of a patient to a specific set of care providers without choice is likely to be problematic. Rationing of care in our supposedly equity-driven health care system has resulted in people going for years without being able to access primary care. That’s not equitable, universal, or accountable as champions of our single payer health care now describe it. Despite promoting the primary care home concept as a way to address what the OurCare study identified as important to Canadians (the largest-ever pan-Canadian conversation about primary care), including wanting primary care to be universal and accountable, the 250 new primary-care teams or “health homes” would be allocated to certain municipalities based on areas of “greatest need”.
The devil is always in the details. Let’s unpack this “radical” idea.
The creation of 250 teams is estimated to take five years and would require funding of an additional $2 billion dollars per year. Whether these 250 potential new teams could be funded when predecessor health team applications were not approved is simply a troublesome question left out of the discussion. It’s about the money. It always has been and will continue to be.
Family doctors make up a large proportion of the overall doctor pool in Ontario. Under the current context, the more physicians there are, the more patients are seen and the more the Ontario Health Insurance Plan is billed along with related diagnostic costs and treatment costs. Improved access to care means additional costs to our single payer health care system that the government routinely attempts to budget and control. As funding increases for health care, it takes away from funding for other sectors unless the budget deficits grow along with the debt meaning greater pain for taxpayers. And offsetting benefit from growth in GDP isn’t happening anytime soon.
It is perverse that in the name of equity, access to care is restricted by a single payer system held up as a national treasure while patients die on wait lists and fail to access what is the core of our health care system, primary care.
Here is another consideration. The significant number of family physicians in Ontario has a strange effect on the bargaining process between the Ontario Medical Association and the Ministry of Health regarding funding for physicians. Currently there is a process of arbitration to deal with the dispute between Ontario’s doctors and government, but it appears that the ruling is delayed. While it is possible that there could be a decision this September, it would only be a first step to sorting out improved remuneration for family physicians—a process that could take years, conveniently for government as it can push the arbitration amounts out to future budgets.
If the arbitrated decision does emerge this September, it may be an indication that an election is on the horizon even though actual funds to family physicians could take years to materialize. This should not be seen as any kind of immediate relief for primary care but rather another exercise in dragging out the necessary spending and enhancing election optics.
Importantly, we need to ask who it is that will decide the criteria that will be used to establish “need”. There is potential for unintended consequences. No doubt these new primary-care teams are at risk of becoming part of political gamesmanship particularly around election time as various political ridings are in play. Will political need become the driving force for the location of these health homes? Almost certainly. There are politics in state-run health care delivery and while this is nothing new, it is growing increasingly concerning as various municipalities must fall in line or risk losing opportunity for primary care for their citizens.
Rationing has been the government approach for decades. Ontarians should not suddenly expect that to change now. There are budgets to meet. How would improved access be funded in the future as other social needs becoming more pressing with an aging population, growing homelessness, and the addiction crisis compete for government attention and dollars. Perhaps the 250 proposed teams are supposed to solve all that but there are many competing and urgent issues that are complex and requiring funding too.
In this vein, a new primary care clinic is offering team-based care in Kingston, the Midtown Kingston Health Home previously called The Periwinkle Health Home and driven by Dr. Jane Philpott. It has taken two years and $4.1 million investment from the Ontario Government to plan and launch it. Sadly, gone are the days when family physicians would gather their expertise together, create a group practice, hire staff and nurses, appoint an IT lead-physician and open their office to the community—all accomplished without millions of dollars from government in upfront investment and without costly years of planning.
But it’s a new era and one in which a patient can’t just walk in and join the team practice. Patients must first be attached to Health Care Connect so that the large volume of people registered there can be cleared from that specific backlog. Perhaps Health Care Connect has finally found its mojo after fifteen years of mainly being a repository for patients waiting for care and a diversion for patients calling their MPPs to complain about having no family doctor. As the director of clinical services with Kingston Community Health Centres is reported to have said:
“It’s a bit of a sad state in the world of primary care these days, where people have been going without for so long. I think this is where we have our work cut out for us.”
Indeed.
But there are solutions beyond growing the administrative costs and having communities compete for primary care physicians. The College of Family Physicians of Canada (CFPC) has identified new compensation structures in other provinces with elements that have potential to improve the attractiveness of family practice and to retain current physicians. For example:
in British Columbia physicians receive equal time payment for direct and indirect care, and administrative tasks as well as being compensated for the complexity of longitudinal care
in Saskatchewan, dedicated funds are provided to develop family physician-led ideas for improving access to team-based care
in Nova Scotia there are premiums for additional tasks and for working non-traditional hours
in Manitoba, physicians will be able to add $3.50 to in-person visits to help offset the overhead costs up to $42,000 per year
The CFPC encourages other provincial governments to follow suit.
Improved compensation mechanisms for Ontario’s family physicians and recognition by government of their value as the backbone of the health care system is the necessary step forward to address the millions of Ontarians without access to primary care. Other ministers of health in Canada have demonstrated sincerity in their actions to improve access to primary care physicians rather than using diversionary tactics. They are doing so without entertaining “radical” notions.
It’s time the Ontario government appreciated its family physicians and moved on from “The Hunger Games” approach. It doesn’t have to be this way.
Dr. Merrilee Fullerton will be publishing a book that will provide an account of her experience of the early pandemic years as Ontario’s Minister of Long-Term Care, this article was originally published on her substack.