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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 didn’t come close• In early 2005, accounted for >1800 family

physicians, caring for >2.5 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