Study questions whether Ontario's primary health care reforms serve the sick and poor

Ontario has invested millions of dollars into the healthcare system in response to a serious doctor shortage. But despite improvements in primary care, a study out of the Institute for Clinical Evaluative Sciences (ICES) has found Ontario's chronically sick and poor are the least likely to benefit from the investments. In response to a serious doctor shortage, Ontario has undertaken major investments in new models of care provided by family doctors and other health workers. The first two models that were widely available to Ontario's doctors, the Family Health Network (FHN) and the Family Health Group (FHG) both have after-hours care requirements and incentives for a host of services including prevention, mental health care, smoking cessation and enhanced management of chronic diseases. The major difference between these models is that FHN doctors are paid mostly through an annual payment per registered patient, based on a person's age and sex, called a capitation payment. Under this system, the doctor gets paid regardless of how many visits the patient makes. FHG doctors continue to be paid mostly through enhanced fee-for-service, a system that pays only when patients make a visit to a doctor.

Compared with doctors who are paid per visit, doctors who are paid standard annual fees (FHN or the capitation group) had:

• Enrolled healthier patients
• Enrolled 30 per cent fewer new patients who didn't previously have family doctors
• Provided 32 per cent less after-hours care

In addition, their patients had a 20 per cent higher rate of emergency department visits.

"As far as we could tell, this situation was present before the doctors joined their groups and didn't change as a result of capitation. This means that the capitation model attracted doctors with these kinds of practices. Both of the new models enrolled patients who were wealthier than average in their communities. While the capitation model provides an alternative to fee-for-service practice, its incentives may need to be altered so that its benefits can be made available to all Ontarians," says Dr. Rick Glazier, ICES Scientist and lead researcher.

The study looked at 4,060 doctors with nearly 3 million patients between September, 2005 and August, 2006.

Author affiliations: ICES (Glazier, Klein-Geltink, Kopp, Sibley); St. Michael's Hospital Centre for Research on Inner City Health and Department of Family and Community Medicine (Glazier), the University of Toronto Department of Family and Community Medicine (Glazier) and Dalla Lana School of Public Health (Glazier), Ontario.

The study "A population-based evaluation of large-scale primary care reform models" is in the May 25, 2009 issue of CMAJ.

Source: Institute for Clinical Evaluative Sciences