PRIMARY CARE IN THE HEALTH CARE SYSTEM

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PRIMARY CARE IN THE HEALTH CARE SYSTEM

• R.A. Spasoff, MD, Epidemiology Community
  Medicine
• L. Muldoon, MD, Somerset West Community Health
  Centre
• 2006 February 27

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PBL Ms Sharon Smith

• A thirty-five year old woman has a febrile
  illness with cough, malaise and pain in the chest
  that is aggravated with each breath. She has
  been drinking more heavily since her boyfriend
  was killed in a drug dispute. She visits an
  emergency department, having previously visited a
  walk-in clinic.

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IMPORTANCE OFPRIMARY CARE

• Strong primary care is the basis for a strong
  health care system
• The best systems are the ones with strong primary
  care, e.g., UK, Netherlands
• Romanow report devoted a whole chapter to primary
  care saw it as the basis of a transformed system

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HEALTH FOR ALL 2000(WHO, 1981)

• The main social target of governments and of WHO
  should be the attainment by all the people of the
  world by the year 2000 of a level of health which
  would permit them to lead a socially and
  economically productive life.
• WHO determined that HFA2000 could best be
  achieved through primary health care

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PRIMARY HEALTH CARE(WHO)

• essential health care based on practical,
  scientifically sound and socially acceptable
  methods and technology made universally
  accessible to individuals and families in the
  community through their full participation and at
  a cost that the community and country can afford
  to maintain at each stage of their development,
  in the spirit of self-reliance and
  self-determination

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Characteristics of General Practice/Family
Medicine (Draft Charter of GP/FM, WHO-EURO, 1998)

• General (unselected health problems)
• Continuous
• Comprehensive
• Coordinated
• Collaborative
• Family-oriented
• Community-oriented

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PRINCIPLES OF PRIMARY CARE (CFPC)

• The doctor-patient relationship is central to
  what we do as family physicians
• The practice of family medicine is
  community-based
• The family physician is a resource to a defined
  population
• The family physician must be a skilled, effective
  clinician

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Other important attributes of primary care

• First contact
• Accessibility
• Continuity
• Case-management (responsibility for coordinating
  all the care that a person needs)

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METHODS OF PAYING PHYSICIANS

• Fee-for service
• Capitation
• Salary/sessional
• Combinations (blended funding)

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Fee-for-service

• Unit of remuneration is the service
• Rewards hard work, good patient relations,
  accessibility
• Encourages high-volume practice, especially when
  fees are inadequate
• Rewards talking services less well than doing
  services discourages prevention and a global
  approach to patients problems

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Capitation

• Unit of remuneration is the patient, not the
  number of services provided. Fixed payment per
  patient per month.
• Implies a list or roster of patients, which may
  strengthen accountability
• Encourages continuity of care
• Provides incentive to keep patient healthy,
  therefore should encourage prevention
• May encourage doctors to be unavailable

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Salary/Session

• Unit of remuneration is time (per hour, per
  month), not number of patients or services
• Allows efficient use of time
• May encourage low-volume practice, slacking off
• Normally associated with practice in some sort of
  institutional setting, which provides
  accountability

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SETTINGS FOR PRIMARY CARE IN CANADA

• Private solo practice
• Private group practice
• FHN (HSO)
• CHC / CLSC
• Also (and not recommended)
• Emergency department
• Walk-in clinic
• Specialist practice

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Walk-in Clinics

• Convenient for patients, flexible for physicians
• Little continuity of care
• Fee-for-service payment encourages high volume
  practice
• Skim off the easy (remunerative) patients,
  leaving older and multi-problem patients to
  family physicians and thereby making family
  practice less financially viable

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Emergency Departments

• Accessible (with long waits) 24 hours/day
• Ready access to technology
• Staff not appropriately trained for primary care
  (emphasis on episodic care)
• Very limited social support services
• Poor continuity of care
• Expensive (or are they?)

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Specialists(paediatrics, gynaecology, etc)

• Some specialists provide a certain amount of
  primary care
• They tend to work in solo practice or
  partnerships, without a broad range of support
  services
• Their training is not appropriate for primary
  care (expertise in depth rather than breadth, no
  emphasis on family or continuity)

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Solo Practice/Partnerships

• Historically the most common pattern
• For doctors maximum professional autonomy and
  individual responsibility, but minimum
  professional support
• For patients doctor-patient relationship,
  continuity (in office hours), limited services
• Fee-for-service payment encourages high volume
  practice, discourages prevention

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Group Practice

• For doctors colleague support, sharing of
  expenses and call duty, reduced capital costs
• For patients one-stop provision of medical care
  (wider range of services)
• Usually fee-for-service payment
• Similar to solo practice in terms of hospital
  utilization, costs and quality of care

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Health Maintenance Organizations (HMOs)

• USA only do not exist in Canada
• Prepayment plan (equivalent of capitation)
  combined with a large group practice, sometimes
  with own hospital
• Community-sponsored ones reduced hospitalizations
  and total costs of care
• Commercial sponsorship (managed care) has given
  a good approach a bad name

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Health Services Organizations (HSOs)

• Ontario group practices funded by capitation
• Defined patient registers
• No provision for community input
• No provision for other professionals
• There were about 50 have been replaced by Family
  Health Networks (see below)

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Community Health Centres (CHCs)

• Community-sponsored clinics with boards
• About 50 in Ontario, 6 in Ottawa-Carleton
• Wide range of health and social services
• Care mainly for disadvantaged populations
• Funded by Ministry of Health via global budget,
  with salaried staff
• Funding provides flexibility, e.g., use of nurse
  practitioners

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Centres locaux de services communataires (CLSCs)

• Cover the entire province of Quebec
• Provide a range of medical, public health and
  social services (similar to the WHO concept of
  primary health care)
• Global budget with salaried staff
• Primary medical care role has not developed to
  the extent originally envisaged

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STRENGTHS OF PRIMARY CARE IN CANADA

• Well-trained family physicians, although not
  enough of them
• Family physicians can usually obtain hospital
  privileges (although they can no longer afford to
  do hospital practice)
• Few direct financial barriers to prevent patients
  from seeking care

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WEAKNESSES OF PRIMARY CARE IN CANADA

• Patients are free to shop around
• Physicians can practise where they want, rather
  than where they are needed
• Family physicians are isolated from each other,
  other health and social workers, public health
• Fee-for-service system does not permit use of
  other health workers, e.g, nurse practitioners
• Combination of inadequate fees and inadequate
  numbers leads to overwork

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PRIMARY CARE REFORM

• Need for reform widely recognized family doctors
  leaving practice, few new graduates entering
• Many proposals have been considered

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Choices for Change Restructuring Primary Health
Care in Canada

• Prepared for Canadian Health Services Research
  Foundation, 3 provinces, Health Canada. Nov 2003
• Evaluated 4 models of care on Effectiveness,
  Productivity, Accessibility/Equity, Continuity,
  Quality and Responsiveness, using evidence and
  (mostly) expert judgment

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Findings of Report

• CHC-like model best on effectiveness,
  productivity, continuity and quality, if
  integrated with rest of health care system
• HSO-like model best on accessibility,
  responsiveness

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Recommendations of Report

• CHC-like model preferred HSO-like model
  acceptable as transitional form
• Organizations to be paid by capitation, personnel
  (including MDs) to be paid by session
• Should be multidisciplinary
• Information systems crucial

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Three Newer Ontario Models

• Family Health Networks
• Family Health Groups
• Family Health Teams

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Family Health Networks(FHNs), 2001-

• Have replaced HSOs
• Networks of family doctors working from common
  or own offices (virtual clinics)
• Defined patient registers, for which doctors
  accept responsibility for 24-7 availability
• Capitation, plus incentives for prevention.
  Access bonus if patients don't go elsewhere.

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FHNs (continued)

• Very limited provision for other professionals
• Extensive use of IT
• Was supposed to cover 80 of family doctors by
  2004, but didnt come close
• In early 2005, accounted for gt1800 family
  physicians, caring for gt2.5 million Ontarians

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Family Health Groups (FHGs), 2004- (Conservatives)

• Introduced when FHNs slow to develop
• As for FHNs, patients have to enrol, and group is
  on-call 24/7
• Payment is not by capitation. Some enhanced FFS
  billing, a few premiums andbonuses
• Attractive to many FFS doctors, partly due to
  increased income

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Family Health Teams (FHTs), 2004- (Liberals)

• Much more multidisciplinary than FHNs
• Two models
• Professional e.g., Family Medicine Centre
• Community similar to CHCs
• Payment blended capitation with bonuses,
  premiums and ability to bill up to 40,000 per
  year for non-enrolled patients.

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Summing Up

• New models should encourage continuity,
  multidisciplinarity, and prevention should
  discourage duplicated services
• Will they attract more graduates into family
  practice?
• See http//www.health.gov.on.ca for a very
  little more info