One in six On­ta­rians left behind in health-ca­re re­forms

Ur­ban poor and new im­mi­grants are less li­kely to be part of a fa­mily health group - and less li­kely to get high-qua­lity ca­re

La Jornada (Canada) - - ENGLISH SECTION -

Pri­mary ca­re is the front door to our health sys­tem. Whet­her you’re going for a chec­kup or ha­ve just been diag­no­sed with can­cer, your fa­mily doc­tor ma­kes su­re you get the tests, treat­ment and ca­re you need.

But not all fa­mily prac­ti­ces in On­ta­rio are crea­ted equal.

Over the last de­ca­de and a half in On­ta­rio, the­re has been a trans­for­ma­tion around how pri­mary ca­re is de­li­ve­red. Much of the chan­ge has in­vol­ved how doc­tors are paid and or­ga­ni­zed.

In the early 2000s, most t On­ta­rioO ta o doc­to doc­torss we­ree e pa paidd by t the e vi­sits t ( (feeee for-ser­vi­ce) and ran in­de­pen­dent ndent prac­ti­ces. The sys­tem was de­sig­ned for when peo­ple went to the doc­tor oc­tor be­cau­se they felt sick. But peo­ple are li­ving lon­ger and many ha­ve com­pli­ca­ted di­sea­ses that last a li­fe­ti­me and re­qui­re nuan­ced ma­na­ge­ment.

Ca­na­da was lag­ging behind in ac­cess and qua­lity of ca­re, are, so the On­ta­rio go­vern­mentnt in­crea­sed spen­din­gon pri- mary ca­re. They ga­ve fa­mily doc­tors lar­ge fi­nan­cial in­cen­ti­ves to start wor­king in groups and pool their re­sour­ces to pro­vi­de af­ter-hours ca­re.

Doc­tors who agreed to o join a group we­re as­ked to fo­ror­mally ta­ke res­pon­si­bi­lity for pa­tients. The pro­vin­cial go­vern­mentn­ment al­so of­fe­red doc­tors bo­nu­ses if thei­rir pa­tients didn’t see fa­mily doc­tors out­si­de the group. The­re we­re al­so bo­nu­ses for mee­ting tar­gets for can­cer scree­ning and im­mu­ni­za­tions.

So­me of the doc­tors in the new groups are still mostly paid by the vi­sit. But just over half in the­se new groups get most of their in­co­me from an an­nual pay­ment for each pa­tient, ba­sed on the age and sex of the pa­tient. It’s the sa­me whet­her they see the pa­tient 10 ti­mes, on­ce or not at all.

In theory, this new pay­ment sys­tem gi­ves phy­si­cians mo­re fle­xi­bi­lity to spend mo­re ti­me with pa­tients if nee­ded and to pro­vi­de advice by pho­ne or email if that’s mo­re ef­fi­cient.

So­me of the new groups we­re al­so allo­wed to apply for fun­ding to hi­re other pro­fes­sio­nals - so­cial wor­kers, nur­se prac­ti­tio­ners, die­ti­tians and others - to work with them in Fa­mily Health Teams.

Now, mo­re than 10.5 mi­llion On­ta­rians ha­ve a doc­tor who works in one of the­se groups. Qua­lity of ca­re has im­pro­ved, par­ti­cu­larly for pa­tients who are part of a Fa­mily Health Team. That’s good news.

But what about the 2.3 mi­llion who ha­ve been left behind?

In a re­cent study­pu­blis­hed in the An­nals of Fa­mily Me­di­ci­ne, my co­llea­gues and I found that tho­se left behind from group prac­ti­ces re­cei­ve poo­rer qua­lity ca­re. They’re less li­kely to re­cei­ve re­com­men­ded scree­ning for cer­vi­cal, breast or co­lo­rec­tal can­cer, and if they ha­ve dia­be­tes, they’re less li­kely to get the ne­ces­sary tests.

Most trou­bling is that the pa­tients left behind are mo­re li­kely to be poor and new to Ca­na­da - and most li­ve in ur­ban areas.

Our study al­so found that the­se pa­tients we­re get­ting poo­rer ca­re even be­fo­re re­forms we­re in­tro­du­ced. Why?

Joi­ning new groups was vo­lun­tary for doc­tors. Per­haps doc­tors who we­re most open to chan­ge and we­re pro­vi­ding bet­ter qua­lity ca­re to be­gin with we­re mo­re li­kely to sign up for the new groups.

Re­forms we­re theo­re­ti­cally vo­lun­tary for pa­tients, too. But so­me pro­bably didn’t ha­ve a fa­mily doc­tor and li­kely couldn’t get in­to one of the new group prac- ti­ces. Ins­tead, they got ca­re from walk-in clin clinics. Others pro­bably just st stuck with the doc­tor they had - who wor­ked alo­ne and got paid by the vi­sit. Un­for­tu­na­tely, the gap in health ser­vi­ces for tho­se left behind has grown sin­ce the health re­forms.

The go­vern­ment has pledged that all On­ta­rians will ha­ve ac­cess to a fa­mily do doc­tor or nur­se prac­ti­tio­ner clo­se t to ho­me. But simply ha­ving a fa­mily doc­tor may not be enough.

Our study shows yo you get bet­ter ca­re if you ha­ve a doc­tor who for­mally en­rols pa pa­tients, pools re­sour­ces with co­llea­gues to pro­vi­de af­ter-hours ca­re, and ta­kes res­pon­si­bi­lity for pre­ven­ting and ma­na­ging chro­nic di­sea­se.

Un­for­tu­na­tely, the On­ta­rio go­vern­ment has re­cently res­tric­ted entry in­to so­me of the new prac­ti­ce mo­dels. But others are still avai­la­ble for phy­si­cians to join. We need to un­ders­tand what’s kee­ping so­me doc­tors from joi­ning the avai­la­ble prac­ti­ce mo­dels.

Most im­por­tantly, we need to reach out to tho­se new to Ca­na­da and tho­se li­ving in po­verty to en­su­re they get equi­ta­ble ca­re.

No On­ta­rian deser­ves to be left behind. -TROYMEDIA

Ta­ra Ki­ran is an ex­pert ad­vi­ser with Evi­den­ceNet­work.ca, a fa­mily phy­si­cian and re­sear­cher in the Department of Fa­mily and Com­mu­nity Me­di­ci­ne, St. Mi­chael’s Hos­pi­tal, Uni­ver­sity of To­ron­to and an ad­junct scien­tist at the Ins­ti­tu­te for Cli­ni­cal Eva­lua­ti­ve Scien­ces.

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