"We already had the idea, the concept
for Family Health Teams 20 years ago," says Dr Caroline
Brown, an FP from Bancroft, Ontario. "My husband and
I had a multi-disciplinary clinic here years ago, but
we just couldn't afford to get it off the ground ourselves."
That's why Dr Brown signed her
practice up right away when Ontario announced plans
to help finance 150 Family Health Teams (FHTs) throughout
the province in 2004. Hers became one of the first wave
of 52 practices that pioneered Ontario's new program.
In Dr Brown's FHT, and others across
the province, a few FPs are brought together under one
roof and partnered with health professionals like nurse
practitioners, dieticians, pharmacists and physiotherapists.
These NPs take on the care of less complicated patients
and aid in disease management, freeing up physicians
for more complex tasks.
Four years after adopting the FHT
model, Dr Brown says she wouldn't go back to the way
things were. "I've been really pleased with how the
Family Health Team has worked," she says. "It really
helps with continuity of care."
Experiences like Dr Brown's have
piqued the interest of other provinces in Ontario's
Family Health Teams, but not all Ontario FPs are impressed
with the new model, citing flaws in funding and care
as well as potentials for abuse of the FHT system.
First,
the good news
Dr Brown's FHT's success shows how powerful the model
can be when it's successful. One of the greatest boons
is the easier access to nurse practitioners, whose salaries
are paid by the government, says Dr Brown. "I feel like
they're our colleagues. The biggest question though
is how to amalgamate all these new people into your
clinic."
The way she has structured her
FHT allows nurses to concentrate on the patient's overall
health. "Nurses see when the patient's last Pap smear
was or help manage their diabetes. It used to be that
if a patient had high blood pressure I would track it,"
says Dr Brown. Now it's a nurse practitioner's job.
MIXED
BUSINESS
The FHT payment model allows Dr Brown to make house
calls. When she was recently asked to make a visit to
a home-bound patient who lives 40 minutes away, she
didn't think twice about how much it would cost her
before she hopped in the car. Her FHT's mixed capitation
plus fee-for-service (FFS) billing plan allows her to
visit her rostered patients and collect a fixed salary
rather than the paltry fees for house calls offered
by Ontario's public insurance plan.
Patients become rostered by signing
up with an FHT as their primary care provider, indicating
the FHT as the home base of their family physician.
For each rostered patient, Dr Brown receives an annual
fee, adjusted for age and medical conditions. The average
annual fee per patient is about $100.
The provincial government offers
a few different payment schemes for physicians in FHTs
to accommodate those working in either urban or rural
areas. Blended capitation models allow small FFS charges
when seeing a rostered patient. There's also a blended
salary model in which physicians are salaried and receive
benefits as well as FFS for some patient care. Another
variation is geared toward rural areas.
Dr Brown believes the FHT has allowed
her to deliver better care. "You feel like you're helping
patients more," she says. "I find that I get to spend
more time with each patient and that I'm making more
money."
and
the bad news
If Dr Brown's experience is largely positive, then Peterborough's
Dr Ronald Curtis sits far at the other end of the spectrum.
While he believes in the idea of working in a collaborative
practice, which he did for over 10 years, he has witnessed
too many abuses and too much government bungling of
funding schemes to have any faith in FHTs, he says.
He moved to a walk-in clinic in Toronto in 2006 because
he had such a hard time making a living in his collaborative
practice as it moved toward becoming an FHT.
Dr Curtis says capitation doesn't
work when it comes to treating patients with multiple
comorbid conditions; he calls the idea "ludicrous."
Dr Stewart Harris, a University
of Western Ontario prof who also runs his own FHT, agrees
that the current system could lead to physicians derostering
complex patients. "If these patients need to be viewed
frequently it just doesn't add up," he says.
Doctors in large group practices
like the one he was in, Dr Curtis alleges, would literally
have to roster thousands of patients to meet the costs
of their overhead and staff, let alone fees to the CMA
and provincial college. The province, however, has offered
to cover part of the costs of FHTs' overhead.
Some physicians are trying to game
the FHT system by only taking on young and healthy people,
says Dr Curtis. "The problem is that any older patient
or complex patient gets discriminated against. If you
think this doesn't happen you need to wake up."
HERE
TO STAY
Like it or not, it looks like FHTs in Ontario are here
to stay. One in five family physicians in Ontario are
now working in one. "In principle I think it's a good
step forward," says Dr Harris, "but it's a matter of
getting the right people hired. You've got to ensure
there's continued quality of care." Some FHTs have struggled
with high physician turnover and integrating new staffers.
But Dr Harris is enthusiastic overall.
"Just by getting their patients rostered many physicians
are making 10% to 20% more, and there's the potential
that they won't be working as hard," he says. "More
and more physicians are becoming chronic disease managers
and the fee-for-service model is not an ideal system
to tackle that."
MULTIDISCIPLINARY
MODEL?
The Ontario Ministry of Health and Long-Term Care recently
put out a call for FHT evaluation proposals, which will
get underway this year.
"The game plan is that over the
next three years Ontario will run a formalized evaluation.
Then we'll see if chronic care in FHTs is achieving
recommended benchmarks and whether more patients are
actually being seen," says Dr Harris.
Despite the mixed reactions to
Ontario's FHTs and the absence of any analysis, other
provinces are looking on expectantly. Dr Ken Buchholz,
an advisor to Nova Scotia's Department of Health, says
Ontario will "pave the way for multidisciplinary teams."
A recent report on Nova Scotia's healthcare system recommended
the province forge ahead to create teams with payment
models similar to those of FHTs.
Dr Harris believes more provincial
governments will begin making the move to FHT models
when Ontario releases the results.
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