"This could fix the current problems with primary care," declares Dr Raymond Rupert, referring to the Doctors Care Cooperative (DCC), started by himself and other family physicians in April 2004. The solutions presented by this Toronto doctor don't involve massive cash injections from the feds, large-scale physician recruitment or any other items on the usual doctor wish list. Dr Rupert is talking about something more self-directed — people in small communities across Canada banding together in health cooperatives to purchase the type of support they need for their family practitioners. This type of grassroots, self-help movement is what he hopes will evolve from the Doctors Care Cooperative.

Membership in the co-op is open to all physicians licensed to practice in Canada. Shares cost $1,000 apiece and afford members access to centralized online services that should resolve many administrative problems, the right to vote on future directions of the co-op and a cut of any dividends issued on share capital — although, in a spirit of a co-op, most of the profits will be used to improve its services. A centralized billing system is already in place, and there are plans to make patient charts available online in the near future. Doctors who choose not to invest as members can also benefit from these services for a nominal fee.

SIGNING UP
Here's how it works: doctors sign an agreement with any of their patients who are willing to participate. For a small monthly fee, members can offer a bundle of uninsured services, which may include phone consults, online access for patients to their own records, email advice and the list goes on. Patients who participate can pay with preauthorized monthly installments taken directly from their bank accounts or credit cards. Those who don't choose the monthly package can pre-authorize payment on a per use basis. The DCC then handles all the administrative details. Training of members and their staff is also provided by the co-op, and takes just over an hour.

Dr Rupert argues that because the current medicare system only pays doctors for face-to-face consults, it's very difficult for physicians to function effectively. Around 70% of the work performed by support staff and 40% of doctor's services are uninsured — and thus unpaid. Introducing an Uninsured Medical Services Plan in practices would solve that problem, and provide a pool of funds to upgrade services, claims Dr Rupert.

PATIENTS PITCH IN
Physicians can ensure that they're providing services that best meet their patients' needs by setting up a patient advisory board (as Dr Rupert has done) or facilitating the formation of a patient cooperative, as was recently done by Dr Cathy Felderhof in New Glasgow, NS. In the latter case, the patients themselves elect a board of directors, which then contracts the doctor for the services members require. Any profits from member fees can be used to buy new equipment, hire extra staff or even fund community infrastructure projects such as housing for seniors. The DCC pledges to support such initiatives by providing both administrative services and expert advice.

Dr Rupert believes that co-ops will be especially valuable to family practitioners in rural areas, where, he says, "Primary care is broken. Rural doctors don't have the support they have in cities, fee structures haven't kept up with expenses, and the doctors burn out."

"We don't need more primary care doctors", says Dr Rupert. "We just need them to be more productive." He believes that patient co-ops in rural practices could solve this problem, since the funds raised by collecting member fees would be enough to hire a nurse to take some of the burden off the doctor.

Healthcare co-ops aren't a new idea. Dozens involving paramedics, home care providers and other healthcare workers already flourish in Canada. The DCC and its offspring of patient cooperatives, therefore, renew an old and proven concept with modern communications and technology. If successful, these co-ops will dramatically and permanently change healthcare delivery in Canada.

For more information, log on to www.doctorscarecooperative.ca