What the rest of the country can learn from Ontario’s family doctor payment model

From The Globe and Mail article

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.

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.

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