The Ontario government's initiative
to control primary health costs through Family Health
Teams (FHTs) is being seriously questioned by the profession.
The teams, made up of doctors and nurses, and using
a funding mechanism based on a combination of salary
and "capitation," or patient rosters, was positioned
as a way to improve the quality of care, particularly
for chronically ill patients. Still, when pilot programs
were launched in 2001, a lot of doctors had misgivings.
An editorial in the February 2002 issue of Canadian
Family Physician, bearing the unambiguous title
"Capitation: the wrong direction for healthcare reform,"
cautioned that it was a scheme designed more to save
money than improve care and was based on US and UK models
that were, even then, in trouble. Despite misgivings
such as these, Ontario GP/FPs largely supported the
setting-up of the teams and the government hoped to
have 80% of all primary care doctors eventually enrolled.
That optimism may be misplaced.
In late October, Dr Val Rachlis,
president of the Ontario College of Family Physicians
(OCFP), sent out a letter to his members raising concerns
about the FHTs. It highlighted some major criticisms
of the teams that were published in the College's policy
paper, Family Physicians and Public Policy: The Light
at the End of the Tunnel, on October 25.
Dr Rachlis' letter raised two major
beefs. First, the FHT remuneration system, which forces
physicians who participate to move to a capitation model
funded by allotting set amounts for each rostered patient
and which effectively caps costs. His second complaint
was about the unnecessary complexity of the interdisciplinary
teams. The letter was met with lots of positive feedback
from doctors across the country. "At our annual scientific
assembly a few weeks ago people were coming up to me
to thank me for writing that letter," he says.
The Ontario government was less
amused. "The letter has made [the government] nervous,"
Dr Rachlis says. "It has them reevaluating some of the
basic principles of the FHTs."
REMUNERATION
ALIENATION
Dr Rachlis is concerned that the setup of the FHTs is
alienating a generation of FPs who were comfortable
with the way things were. "Older physicians grew up
on fee-for-service remuneration and they are very leery
of big changes," explains Dr Rachlis. "They're much
more likely to go with an incremental approach."
Dr Jim MacLean, head of Primary
Care for the ministry's Health Results Team, disagrees.
"The OMA agreement contains many enhancements for primary
care physicians, including more for senior physicians
who want to remain in fee-for-service (FFS) practice,"
he contends. He adds that there are many older physicians
who are part of FHTs and speculates that the blended
model of remuneration along with team-based care probably
benefits older doctors most because they care for a
higher percentage of elderly patients with chronic diseases.
The theory is that by spreading set costs over a patient
population made up of a range of patients from very
healthy to very sick, the greatest benefits will accrue
to those requiring the most care.
BLENDED
MODEL PREFERRED
But at the end of the day, Dr Rachlis says he knows
the capitation model is the wave of the future. "There's
a movement afoot to go in that direction," he says.
"But there was no need to hit doctors over the head
with it," he adds emphatically.
In fact, the OCFP has been promoting
the blended model for many years and it's the preferred
option for the majority of its members. Younger physicians
are more likely to go for capitation, as are women —
only 19% of younger doctors and 22% of female physicians
prefer fee-for-service. The overall percentage of docs
earning 90% of their income from FFS has dropped from
65% in 1995 to 57% in 2004. That trend is expected to
continue.
The difficulty is that these blended
models are complicated to develop and administer and
doctors have a hard time understanding them, according
to the OCFP's policy paper. Then there's the matter
of their lack of appeal to older doctors.
Dr Jim MacLean, an 'older' physician
himself, isn't so sure. "I know it's more challenging
to change as you get into the later phases of your career,
but the docs who have done it are very pleased with
the outcome," he maintains. And he puts his money where
his mouth is. "When I return to practice — and
I will — I will only practice in a team and in
a non-FFS model. I have only ever practised in FFS but
I won't go back to that model."
One of the benefits of moving to
capitation, and one that might be overlooked by some
older docs, is a welcome salary hike. Dr Rachlis has
seen his own income increase about 20% since joining
a FHT. The blended model could also mean better coverage
in the event of illness. "In the old system if you got
sick your income would drop to zero," explains Dr Rachlis.
"But in the team model you could continue to earn about
two-thirds of your income because of the stream of money
from capitation." Still, all these plusses can't make
up for the fact, insists Dr Rachlis, that older doctors
aren't given the choice.
TIED
UP IN RED TAPE
The other concern that Dr Rachlis raises has to do with
the unique setup of FHTs. "[The government] made it
really complex," he says, "Groups are trying to get
their act together but are bogged down in government
structure."
This is where Dr MacLean loses
his patience. "I've heard Dr Rachlis say a number of
times that he feels that setting up a FHT is too complicated.
Quite frankly, as a doctor, I am embarrassed at the
suggestion from a physician leader that doctors are
challenged with dealing with complexity." He says that
setting up an FHT does take effort and strong leadership,
but it's most definitely not "too complicated". He adds
that the government requires certain things to be done
to maintain accountability for the expenditure of public
funds. "As taxpayers, many physicians tell us they wouldn't
want it any other way," he says.
Sue Paul, a nurse practitioner
(NP) who used to work in a FHT, agrees with Dr MacLean.
"There is no more paperwork than in an ordinary office,"
she says. "If anything, physicians might have to keep
more detailed notes than if they were in a solo practice
because more people might have to look at them."
TEAM
TROUBLES BREWING
Speaking of NPs, another point that Dr Rachlis likes
to make is that the team dynamics aren't always healthy.
"What we see developing in FHTs is a competitive model,"
he says. "The frameworks of FHTs are causing different
practitioners to butt heads." He complains that in many
cases the problem is with NPs who will only call on
physicians when it exceeds their scope of practice.
For Dr MacLean, that notion is
far from the truth. "I feel the FFS environment promotes
competitiveness much more than good governance and accountability
frameworks," he argues.
Ms Paul has a different take. "I
think FHTs are an excellent working environment," she
says. "When you work in a multidisciplinary team you
work for the benefit of the patient. Any NP worth their
salt knows the limits of his or her abilities," Ms Paul
is quick to point out. "I don't think we are trying
to be doctors."
Dr Rachlis is still hesitant. "Some
NPs say they can do 75-80% of what a family physician
can do. I would love to see which 80% of my patients
they can help," he asks. He isn't alone in his criticism.
"NPs have been trained to be mini-docs. What we need
in primary care are super nurses," one doctor is anonymously
quoted in the OCFP's policy paper. Another said, "We
got funding for an NP. We needed help with our sickest
and most complex patients. She had been trained to look
after relatively healthy patients with a doc backing
her up. They call it collaborative practice, but it
isn't. It is doc substitution and parallel play."
Despite refinements as the system
evolves, Dr Rachlis is still concerned that FHTs won't
be sustainable. "I think we are looking at an enormous
problem. There are 1.1 million people in Ontario who
can't find an FP," he says. "I don't think NPs will
solve the problem and things will only get worse as
more and more boomers retire." He adds that the government
needs to find ways to keep the doctors they have to
fill the gap until the new crop of med students are
able to take over.
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