My Christmas wish-list for primary care in Ontario

It’s Christmas Eve, and I only have a few hours to articulate my demands (sorry, requests) to Santa for changes I want to see to our primary care system in Ontario. I won’t be going into a ton of detail on each point, because 1) family obligations are waiting, and 2) Santa needs time to put these into action before he arrives tonight.

Off we go…

  1. Increase the fee paid for consults in specialties across the board, and decrease the fees paid for follow-up visits by specialists (with the exception of time-based services, those will remain the same). OMA Economics can do the math to ensure this remains cost neutral. This will incentivize specialists to see new patients to help family doctors, reducing wait lists, while encouraging the discharging patients who can be easily and competently taken care of by their family doctor. Require that any consult billed is preceded by a new referral by another physician. Any diagnostic test performed by a physician requires a referral from another doc for that specific test (echocardiograms, holters, etc.). Any billed visit by a specialist for consult or follow-up must produce a note to be provided to the family doctor.
  2. Any walk-in clinic visit must produce a note to be provided to the family doctor. Yes, I realize a universal EMR would solve this problem with information going in both directions, but in the meantime, we need to improve communication.
  3. I’m still waiting for this wish to come true about transparency of office hours.
  4. Make second opinions by specialists for the same issue non-insurable by OHIP, and allow specialists to bill patients privately for those consultations. The logistics of this are challenging, but we first need consensus among physicians, the public, and the government, on the general premise of the idea, before moving forward with an implementation plan that will require significant electronic infrastructure (for checking consults by other physicians, etc).
  5. Make “physicals” non-insurable by OHIP, unless done for a pre-approved indication (cancer follow-up, weight loss, lymphadenopathy, etc). If a patient still requests a physical, they can be privately billed at OMA rates. Specify what tasks are exactly encompassed within a Periodic Health Examination, based on what methods of screening there is firm evidence for.
  6. Stop the practice of primary care physicians (paediatricians or family doctors) running large ambulatory clinics manned by nurse practitioners, where the physician bills OHIP and pays the NPs a wage or salary for their services. We don’t have the money in our system to pay doctors to be middle-men. A separate OHIP Schedule of Benefits strictly for delegated acts could be a possibility in under-serviced areas where non-MDs are necessary to maintain adequate patient care.
  7. Add shadow tracking codes for family physicians in FHOs or FHGs who correspond with patients via email or telephone (or any non-in-person visit). If they’re dealing with issues outside of a traditional visit, let’s give them credit for it.
  8. Fix the FHO out-of-basket service codes that are not a reflection of adequate access to primary care. An ER physician appropriately suturing a laceration for a patient who felt it was an emergency should not penalize their family physician.
  9. House calls performed by physicians outside of the group to whom the patient is rostered, should NOT be insurable through OHIP (exceptions being those with certification in palliative care). We should not be funding convenience visits for patients who saw an advertisement for “doctors who will come to your house!”

Alright Santa, there’s the list. Make it happen.

1 thought on “My Christmas wish-list for primary care in Ontario

  1. Sarah Newbery

    Hey Mario, thank so much for articulating these ideas! I think that these are the kinds of things that we should be creating a forum to discuss, to think through unintended consequences, and to think through how we ensure accountability to our patients, to our profession and to a sustainable system. My wish is that we can create that forum to tackle these and the ideas of other great docs who are thinking a lot about how to make the system better.

    Thanks again!



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