"Family Health Teams should become the norm for primary care"

The statement above appears on p.24 of the 543-page Drummond Commission report, released this afternoon. Consuming over 40% of the province’s budget, health care receives much attention in this report (pp.145-202). There are a number of recommendations that are specific to FHTs/primary care, and are pasted below. AFHTO is pleased to see some of the themes in its submission to the Drummond Commission reflected in these recommendations. For the report overall, the Globe and Mail has identified three themes that run throughout: “One is that government decisions should be “evidence-based.” Another is integration, which is to say fewer silos and more co-operation between people working toward the same goal. A third is that the public service should be more of a meritocracy, where productivity is rewarded and a lack of it is punished.” For health overall, the Commission sets a target of a 2.5 per cent annual increase in health care funding by the province, which implies that real inflation-adjusted spending per person on health care will have to FALL by 0.8 per cent per year. This requires significant reform to the system, and so the first recommendation for health calls on government to develop and publish a comprehensive plan to address health care challenges over the next 20 years. (#5.1) At the system level it also calls for integration of all health services in a region, including FHTs, FHOs, etc. under the LHINs (#5.5). It also includes public health, moving it out of the municipalities (#5.78 – 5.81), and reducing the number of organizations with which the LHINs must deal on a day-to-day basis by forming merged leadership and boards, or physically by forming merged agencies (#5.12). LHINs would be granted the authority, accountabilities and resources necessary to oversee health within the region, including allocating budgets, holding stakeholders accountable and setting incentive systems for primary care (physicians), acute care (hospitals), community care and long-term care (#5.27). Performance pay targeted to health outcomes would apply to CEOs and senior executives in all parts of the health care system and be mirrored at the physician and health care worker levels (#5.28). Where feasible, services should be shifted to lower-cost caregivers working to full scope of practice (#5.18) and all back-office functions such as information technology, human resources, finance and procurement would be centralized across the health system (#5.95). Recommendations specific to FHTs/primary care: Case Management Recommendation 5-32: Empower primary caregivers and physicians in the Family Health Teams (FHTs) or specialized clinics to play the role of “quarterback,” tracking patients as they move through the integrated health system. All FHTs should work in tandem with clerical system navigators and hospitalist63 physicians to track their patients who are in hospitals, from admission to discharge (see Recommendation 5-55 on hospitalists for more details). Recommendation 5-37: Complex care patients should be managed through interprofessional, team-based approaches to maximize co-ordination with Family Health Teams and other community care providers. Hospitals Recommendation 5-52: Create policies to move people away from inpatient acute care settings by shifting access to the health care system away from emergency rooms and towards community care (i.e., walk-in clinics and Family Health Teams), home care and, in some cases, long-term care. Recommendation 5-55: Use hospitalist physicians to co-ordinate inpatient care from admission to discharge. Hospitalists should work with Family Health Teams to better co-ordinate a patient’s moves through the health care continuum (acute care, rehabilitation, long-term care, community care and home care). Physicians Recommendation 5-56: Make primary care a focal point in a new, integrated health model. Recommendation 5-57: Regional health authorities must integrate physicians into a rostered health system and adopt the appropriate measures to address compensation issues across disciplines; that is, the proper blend of salary/capitation and fee-for-service. The primary goal for physician performance should be prevention and keeping people out of hospitals. Collective administrative support would allow physicians to concentrate on providing better care, a value proposition that should appeal to them. Recommendation 5-58: Reduce the sole proprietorship nature of the offices of many primary care physicians and encourage more interdisciplinary integration through performance incentives and accountability. Recommendation 5-59: Compensate physicians using a blended model of salary/capitation and fee-for-service; the right balance is probably in the area of 70 per cent salary/capitation and 30 per cent fee-for-service. Physicians’ compensation, and especially performance pay, should be linked to positive health outcomes that are linked to strategic targets, not to the number of interventions performed. Recommendation 5-60: Aggressively negotiate with the Ontario Medical Association for the next agreement. The government must be very strategic in its objectives to ensure the promotion of a high quality care system that runs efficiently. Since Ontario’s doctors are now the best paid in the country, it is reasonable to set a goal of allowing no increase in total compensation. However, the negotiations must go well beyond compensation. They must also address the integration of physicians into the rest of the health care system and the objective of working towards the best possible health quality regime. Recommendation 5-61: Adjust fee schedules in a timely manner to reflect technological improvements, with the savings going to the bottom line of less expenditure on health care. Technological improvements often reduce the time required for procedures. Will Falk has recently pointed to the example of radiology, where government investments, including those made through the Canada Health Infoway program, have resulted in vast productivity improvements. Despite the fact that these improvements have drastically reduced the time it takes to diagnose (and hence greatly increased the volumes of diagnoses that can be made in any given day), the fee schedule has not been adjusted to reflect these effects.64 Recommendation 5-62: Make Family Health Teams (FHTs) the norm for primary care and design the incentive structure of physicians’ compensation to encourage this development. Among the key characteristics of FHTs are the following:

• The regional health authority should play a key role in determining their relationship with the rest of the health care system and setting ground rules for their operation;

• Make outcomes the focus of FHTs, not health interventions. Their operation should be tightened through objectives, accountability and a data collection system;

• Conduct research to determine the optimal size of FHTs, taking into account factors such as geography and patient demography. Balancing economies of scale while maintaining personal connections between health care providers and patients is crucial: FHTs need the scale to support a wide range of care providers and be able to support the administration necessary, including the responsibility of tracking people through the system. It has been suggested to the Commission that the optimal size, for larger communities, may be in the range of 8 to 15 physicians, and include practitioners with a wider range of specialties than is now the case. They now typically have only three to eight physicians; and To provide a range of services at a lower cost, include other health professionals in the FHTs (nurse practitioners, registered nurses, dietitians and midwives, for example). Unlisted practitioners such as physiotherapists and massage therapists would also be part of FHTs; however, their services would be provided on a cost-recovery basis.

Recommendation 5-63: Require Family Health Teams (FHTs) to accept patients who choose them, and the FHTs should work with each patient to connect them with the most appropriate constellation of care providers. Recommendation 5-64: The regional health authority should establish incentives to discourage Family Health Teams from referring patients to acute care. Recommendation 5-65: Regional authorities should also be responsible for assigning heavy users of the health care system to the appropriate Family Health Team (FHT). If, for example, there are 300 heavy users within a region and three FHTs, the regional health authority would try to steer 100 to each, so that no FHT is overburdened. Recommendation 5-66: Because Family Health Teams (FHTs) will be responsible for patient tracking, they will need to build a critical mass of an administrative arm to carry out this task. This administrative arm should be shared among a number of FHTs. Recommendation 5-67: Better after-hours care must be offered and telephone/Internet services should direct patients to the most appropriate and convenient care provider. Recommendation 5-68: All Family Health Teams must be encouraged to add more specialists to their teams, which will reduce referrals and ease some of the complexities of patient tracking. Recommendation 5-69: The Ministry of Health and Long-Term Care should allow the flexibility necessary for Family Health Teams to share specialists by permitting part-time contracts. Recommendation 5-70: All Family Health Team physicians must begin engaging in discussions with their middle-aged patients about end-of-life health care. Recommendation 5-71: Improve access to care (e.g., in remote communities) and productivity for specialists by triaging appropriate patients for telemedicine services (e.g., teledermatology, teleophthalmology). Recommendation 5-72: Remove perverse incentives that undermine the quality and efficiency of care. For example, physicians are penalized when one of their patients goes to another walk-in clinic, but not when the patient goes to the emergency department of a hospital. More generally, the fee-for-service compensation model gives an incentive for medical interventions without due consideration to quality and efficiency of care. Such incentive issues must be addressed by focusing the Ontario Medical Association’s negotiations more on quality of care and amending payment systems for physicians and throughout the health care system. Recommendation 5-73: The model described in the above recommendations must be supported by a robust data collection and sharing system that allows the creation of the necessary records. For example, the model works only if we know how many patients are not visiting emergency departments or how many diabetes patients are not experiencing complications (see Recommendations 5-17 and 5-50 on Health-Based Allocation Model data for more details).