Allan Carpenter shuffles into the doctor’s office and gets down to business.
The 65-year-old patient and his long-time physician, Gordon Arbess, have plenty to talk about, even though they see each other for a check-up every second week.
Mr. Carpenter’s back and hip are so sore he worries he’ll end up in a wheelchair. He is anxious about getting to all his medical appointments, including a coming visit with an orthopedic specialist. He’s had HIV since the late 1980s, and he recently beat throat cancer.
“We do have a team of people that are trying to help you,” Dr. Arbess says, soothing his patient’s nerves, “and I know how much you’ve gotten out of it. But I know some days it’s difficult for you to get to these appointments. I get it. I hear you.”
For Canadians without a family doctor, the thought of having a physician guide – a “captain of my ship,” as Mr. Carpenter calls Dr. Arbess – is appealing in itself. But Mr. Carpenter is fortunate to have more than a captain. He has a whole crew.
His clinic east of downtown Toronto is part of the St. Michael’s Hospital Academic Family Health Team, a five-site organization with more than 200 staff, including nurses, dietitians, pharmacists and social workers, as well as clerical staff to support about 80 doctors and 36 medical residents.
This model, which Ontario calls the Family Health Team, is widely considered by health-system experts to be the best way to deliver primary care, especially for patients like Mr. Carpenter with multiple complex medical conditions. Family doctors also favour the team approach because it helps them stave off burnout by sharing the workload. The Canadian Medical Association has named “expanding team-based care” as one of its top recommendations for solving the country’s health care crisis.
Despite that, Ontario hasn’t opened a new Family Health Team in a decade, in part because of the cost.
And from 2015 until last spring, the provincial government blocked doctors from joining the most popular physician payment model that undergirded Family Health Teams unless they were replacing a departing doctor or willing to hang out a shingle in a high-needs area.
The former Ontario Liberal government’s decision to pump the brakes on its signature primary-care reforms offers lessons for other provinces departing from the old paradigm of lone doctors working fee-for-service in offices they own or rent themselves. British Columbia just announced a new approach to paying family doctors, and Alberta expects a new agreement reached with doctors in September will lead to more family physicians joining a model that includes paying physicians in team-based clinics to enroll patients for more continuity of care.
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The most important lesson of Ontario’s primary-care reforms, according to the province’s former deputy minister of health, is this: If a government is going to change the way it pays family doctors, and pay them more in the process, it needs to put clear and enforceable rules in its physician services agreement.
“There was a big mistake made in 2008,” Robert Bell said, “and the mistake was that we didn’t put in place accountability.”
Ontario began overhauling its primary-care system in the early 2000s. The new models paid family doctors working in groups mostly for the number of patients they enrolled in their practice, a departure from the traditional fee-for-service approach where doctors are paid for every discrete episode of care they deliver.
The alternative models blended capitation payments – which are annual payments to doctors for every patient on their roster – and fee-for-service to different degrees. The approach was supposed to encourage long-term relationships with patients and give physicians time to deliver comprehensive care to older, sicker patients who might have four or five health concerns to discuss at 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 a part of a Family Health Team, or FHT. What set the FHTs apart was that the provincial government paid the salaries of the dietitians, pharmacists, social workers and other health professionals who rounded out the team.
There are currently 181 Family Health Teams in Ontario, the last of which opened in 2012.
In many ways, the reforms succeeded. Doctors flocked to the new patient enrolment models, leading to a 43-per-cent increase between 2006-07 and 2015-16 in the number of Ontarians who said they had a family doctor.
Patient care improved, too, said Tara Kiran, a University of Toronto primary-care researcher and physician at the Family Health Team where Allan Carpenter is a patient. She and her research colleagues found that FHT patients received better diabetes monitoring and visited the emergency department less often than patients at non-team practices, although emergency-department use increased for both groups over time.
For these Canadians without family doctors, long waits for lower-quality care are a test of patience
So why the pause? In reports published in 2011 and 2016, Ontario’s auditor-general suggested the Ministry of Health wasn’t getting value for the money it was pouring into the new payment models.
FHO doctors earned an average of $420,600 in gross revenue in 2014-15, significantly more than the $237,100 physicians would have earned, on average, under the traditional fee-for-service model, according to the auditor-general.
The auditor-general found that in 2014-15, each physician in an FHO worked an average of 3.4 days a week and 60 per cent of Family Health Organizations were not keeping the number of night or weekend hours required by the ministry.
Dr. Bell, a former president of Toronto’s University Health Network who served as deputy minister from 2014 to 2018, said that although he believes the model is best for patients, the Liberal government he worked for decided to restrict entry into the FHO structure because it couldn’t get the Ontario Medical Association to agree at the bargaining table to 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 leave people going to emergency departments because they can’t see you. That was the real reason that enrolment in the FHO model was cut off.”
The Ontario Medical Association (OMA), which represents the province’s doctors, has long disputed the auditor-general’s conclusions, saying they didn’t capture the breadth of work family doctors do. The reports, “missed the mark,” said Rose Zacharias, president of the OMA. And as far as accountability goes, she added, “that’s baked into and built into how we operate as professionals.”
Either way, Ontario’s decision in 2015 to restrict entry into the more lucrative capitated payment models had immediate consequences, said Imaan Bayoumi, a family doctor and director of the Centre for Studies in Primary Care at Queen’s University.
She and her colleagues analyzed Ontario Health Insurance Plan (OHIP) billing data over a 10-year period to determine the share of Ontario patients “attached” to a regular primary care provider, a more reliable method than patient surveys. “At a high level, what we saw was that there was a rapid increase in the proportion of patients who were attached between 2008 and 2014,” she said. “But importantly, after the province restricted entry to new models of care, there were no further gains in attachment.”
Dr. Kiran said the restriction was “terrible” news for Ontario family medicine residents, the vast majority of whom trained in Family Health Teams and then found limited opportunities to practise in an interprofessional setting after getting their licences. The share of Ontario graduates who named family medicine as their first choice of residency dropped from a high of 37.1 per cent in 2015 to around 30 per cent in each of the past four years, according to the national service that matches medical graduates with training programs.
This spring, the OMA and the Progressive Conservative government of Premier Doug Ford reached a new agreement that reopens the FHO model so that 720 new physicians can enter it each year, up from as few as 122 in the fiscal year 2015-16, when entry was restricted to areas in high need of physicians.
The two sides agreed to insert language in the deal that says FHOs will ensure patients with time-sensitive conditions are seen on the same day or next day. They also agreed to set up a working group that will determine how to adjust the capitation models so physicians are paid more for enrolling complex patients; right now, capitation rates are tied to a patient’s age and gender.
Mr. Carpenter hopes more patients will be able to join him in benefiting from team-based care. He said he knows where he would be without Dr. Arbess and his health care crew: “In a quiet yard, under some grass.”
