Many of us have been lamenting that the relationship between the Ontario government and Ontario physicians has deteriorated to a historic low.
It appears that we’ve gone from bad to worse.
I have learned from sources that the government has been working behind the scenes to implement the much-discussed Price Report, without any prior consultation of many key physician leaders and groups. Funding has already been secured for three pilot projects, and the province expects one third to one half of physician practices to be in Patient Care Groups (PCGs, also called Integrated Service Delivery Zones in some reports) within the next year. The Ontario Medical Association (OMA), the Section for General and Family Practice (SGFP), the Ontario College of Family Physicians (OCFP), and other physician groups have been intentionally kept completely in dark by the government until a leak emerged this past week.
What is the Price Report? What are Patient Care Groups?
In late 2013, the Ministry of Health and Long-Term Care (MOH) convened the Expert Advisory Committee on Strengthening Primary Health Care in Ontario to address current challenges in Ontario’s primary care system. The MOH identified four policy questions of particular interest: attaching all Ontarians to a primary care provider, ensuring all Ontarians can obtain services from an inter-professional care team, improving integration of care among providers, and ensuring access after business hours and on weekends.
This committee was chaired by Dr. David Price, Provincial Primary Care Lead and Chair of the Department of Family Medicine at McMaster University, and Elizabeth Baker, Provincial Nursing Lead. The final report from that committee was completed on November 13, 2014. It has still not been officially released to the public, ten months later.
The report recommended a complete redesign of Ontario’s primary care sector. The redesign would be a population-based model of primary care delivery, designed around Patient Care Groups (PCGs). PCGs are fund-holding organizations that are accountable to the MOH through the Local Health Integration Networks (LHINs). Citizens are assigned to a PCG based on geography, “akin to the assignment of public school students to the local school in their neighbourhood”. Funding to each PCG would be on a per capita basis, “reflecting the demographics, geographic rurality of the population, socio-economic status, and projected health needs of the catchment area”. The PCG then contracts with its local primary care providers, “honouring existing relationships and agreements currently in place”, to deliver primary care services. That would include physicians, nurses, and other health care professionals. “Provider groups and individual providers, who may be subcontracted to provider groups, earn the right, based on their ability to achieve quality benchmarks and any additional criteria/metrics captured in their accountability agreement, to participate in the system. The right to deliver service is not guaranteed but is performance-based.” Essentially Family Health Teams, Family Health Organizations, Family Health Groups, fee for service physicians, Community Health Centres, Community Care Access Centres, and Nurse-Practitioner-led Clinics would all fall under the banner of the PCG. The PCG, for example, would have the ability to decide whether a particular physician could work in a specific region governed by the PCG.
Each PCG would have a community-based board of directors. Each PCG holds an accountability agreement with the LHIN, renewed annually and monitored by the PCG’s board, subject to certain metrics (percentage of patients attached, avoidable ED usage, after-hours accessibility, etc.). Each PCG board has its own Executive Director, who develops a leadership team (existing hospital committees, Health Links structures, CHC staff, FHO/FHT staff, etc).
“Physicians will be paid through the contract between the PCG and their delivery model (FHG, FHO, etc.). Similar to the process to implement Alternative Funding Agreements for hospital-based physician (eg. E.D.), funds would be transferred to the PCG by OHIP then allocated to each physician group according to the terms of the contract. These would likely follow the existing terms of the model agreement but then could evolve over time.” What this evolution would mean for future physician compensation agreements, no one seems to know.
It’s a 34-page report, so I won’t go through every point in detail, but suffice it to say, it would completely transform Ontario’s primary care system.
I obtained a copy of the report from a source back in late February 2015. Many physician leaders have read leaked copies of the report since it was completed in November, but as the months have passed, it was assumed that the silence from the MOH indicated that they were not prepared to act on it. After all, it is a radical change, and would take years of planning and consultation to implement properly.
I learned this week that not only was the government prepared to act on the report, but they had been working on implementation for months behind the scenes. The OMA and SGFP were completely in the dark. Same for the OCFP. Most highly-connected physicians I spoke to this week had no idea that the Price Report implementation was in motion.
Three PCGs have already been formed with funding arranged, for North York, Guelph, and a group led by Dr. Price. Susan Fitzpatrick, Associate Deputy Minister, has left the MOH to become LHIN CEO, and the primary care branch of the MOH has been largely dismantled. LHINs are scrambling to create PCGs, with legislation expected to be passed in January to rubber stamp this primary care system reform. Those within many LHINs admit privately that they currently lack the organizational maturity for an undertaking of this magnitude.
Many of us will be working within this new transformed primary care system for the next decades of our careers, and it is incredibly arrogant of the government to believe that they alone have the necessary ideas and beliefs to guide Ontario primary care reform. Rubber stamping of projects is not the way to lead system reform.
I have a few simple requests for the Ontario government.
First, release the Price Report to the public. Second, be completely transparent about any ongoing implementation, meeting with physician leaders and physician groups to address concerns and seek input. We can simply look to the NHS system in the UK to see how complex a centrally-planned primary care system is to manage, and to exclude physicians from the planning process is incredibly naïve and short-sighted. The NHS has experienced decades of growing pains, and continues to experience significant short-comings, and we need to learn from their mistakes in shaping our own system.
Physicians need to be looked to for input on this program, including FHT, FHO, FHG and fee-for-service physicians at the planning table. Too much is being changed too quickly, and since patient access is still the biggest hurdle for patients, primary care physicians need to be involved in any decision-making. Leaving physicians out of any system planning will end up being a complete fiasco for this government, and for future governments that are left with layers of expensive bureaucracy that cannot be undone. Implementation has to be done thoughtfully, not in a clandestine manner without physician input. Resources need to be distributed equitably, with strong, evidence-based planning.
The report itself stated the following: “It must be noted that as of the writing of this document, the deliberations had not yet moved beyond the Committee; stakeholders will be engaged when appropriate to refine the initial model described below and help set the stage for implementation”. That sounds pretty clear to me. Stakeholders need to be engaged BEFORE implementation. The report also outlined in its Vision section that “in three years, the design elements necessary for Ontario to have an effective primary care system to improve population health outcomes will be in place.” Three years. Not overnight. The report also included an entire section entitled “Issues needing further discussion and investigation”. I will not include details here, but they are major hurdles to overcome. Finally, section 5.0 of the report is entitled “Proposed Implementation”. It includes a 12-point plan for implementation, the first two of which are “Engagement and consultation with patients, providers and other stakeholders in design development” and “Articulation of clear benefits to citizens, providers and communities”. Neither of these have occurred to date. Our LHIN (the Southwest LHIN) has not been given any marching orders from the government, and at the present time lacks the infrastructure to enact what the government is proposing.
I am not advocating for years of endless debate on the merits of the proposed system. Dozens of previous primary care reports have collected dust for years, and certainly we don’t need another report to add to the pile. But there needs to be public discussion on this system before widespread implementation. I am sure the government is wary of allowing outspoken dissenting voices with ideological opposition to central planning into the debate, but no system will be embraced by everyone, there will always be dissenters, and that cannot allow implementation to be done in the shadows.
Lift the veil of secrecy on the Price Report and primary care reform, before we end up with a dysfunctional, costly system that doesn’t serve our patients.