Ontario's ambitious primary care reform plan slow in attracting MDs

The Ontario government hopes to have 80% of family physicians practising in new family health networks (FHNs) by 2004, but it appears unlikely that hope will turn to fact. Only a handful of the province's 6300 FPs have signed on since the $463-million program was launched in May, and even the chair of the province's Family Health Network, Dr. Ruth Wilson, agrees that 80% is “an ambitious goal.”

Physicians who join an FHN are encouraged to work in multidisciplinary teams and provide 24-hour-a-day service to rostered patients through a combination of extended evening and weekend hours, a shared on-call service and an after-hours telephone advisory service. They are also encouraged to provide a broad range of medical services, including obstetrical and palliative care.

The carrots being dangled include financial incentives to provide preventive care and funding to offset the cost of new computers. As well, FPs have a choice of payment models.

Earlier this year, the Ontario Medical Association (OMA) developed a contract setting out terms and conditions for joining an FHN. President Elliot Halparin says the OMA supports physicians' right to choose the method of practice best suited to them. And even though FHNs provide many benefits, including a potential increase in income, a more manageable work schedule and access to a heavily subsidized computer system, Halparin says they won't appeal to everyone.

Broadly speaking, FHNs are a primary care reform initiative designed to keep care affordable and increase access to doctors. However, the president of the Coalition of Family Physicians (CFP) says they doesn't address the underlying physician shortage. Dr. Douglas Mark says the CFP advocates increasing medical enrollment by about 200 places annually, recruiting expatriates and restarting the 1-year internship program in an attempt to catch up. The CFP doesn't dismiss FHNs entirely — Mark likes the focus on FPs as the primary patient contact — “but our biggest concern is the increase in control over how we practise. We want to keep our autonomy.”

Wilson remains optimistic about the eventual outcome. Since May, 48 doctors in Oakville, Guelph, Stratford, Campbellford and Mount Forest have agreed to form FHNs, and 750 more have requested revenue analyses. “My sense is that there is a momentum building,” she says.

Thirteen pilot project networks involving 170 physicians and 250 000 patients have been operating since 1998.

Doctors who join a network can choose a reformed fee-for-service model or a new blended payment model that combines capitation and fee-for-service. Under the blended system, doctors receive an annual fee for each enrolled patient, based on the patient's age and sex, regardless of the amount or type of service the patient receives. This base-rate amount is expected to comprise about 55% of a participating doctor's annual income. The rest would come from fee-for-service payments and bonuses — incentives for providing preventive care, for meeting certain service targets and for CME, among other things.

Dr. George Southey of the Dorval Medical Associates FHN in Oakville says this payment model provides a stable income that over time can be used to expand services to include nurse practitioners. “It allows us to plan for the future,” he says, and in the long run could provide an opportunity “to stretch our family practice resources over a larger population.”

Since agreeing to form an FHN in May, Southey's group has seen little change in the way it operates. It is operating on a fee-for-service basis until it has enough rostered patients to switch over to the blended-payment method, and Southey expects this to occur in several months. The only drawback so far has been the added administrative work resulting from the enrolment process. FHNs must also negotiate internal governance agreements that set out schedules for extended office hours and on-call services. — Rosanna Tamburri, Oakville, Ont.; Barbara Sibbald, CMAJ