Progress of Ontario’s Family Health Team Model: A Patient-Centered Medical Home

We are very pleased with the response to our article.

Russell wonders why this occurred in Canada's largest province that may usually be slow in its uptake of new ideas, After years of discussion, there was a true sense that Family Medicine as we knew it was soon to be extinct. The Ontario College of Family Physicians in 1999 endorsed this idea with strong opposition of the Medical Association. We then produced further papers on the subject and went to meet the opposition at the provincial level. We believe that this impressed Members of Parliament who had promised that every citizen of the province would have a family doctor when they were elected in 2004. At that time 5 million people could not get a Family Doctor. This became the main force for change. The Medical Association became involved as they saw many members wanting the FHT. Other observations remain true although a great deal of innovation has occurred over the last three years.

Muldoon and Hogg have extensive experience both working in a FHT as well as evaluating FHT’s. Their observation that we do not know the right mix for a FHT is right. My own guess is that every FHT is unique and all future FHTs should remain unique serving both the community’s needs and the personalities that make up the FHT. We also continue to need different models of care depending on the region served.

Carlos Roberto Jaen provides excellent examples of how this compares with American experience. He hopes that it works economically but we do not know if this is the case. One worry is that the evaluation may be too short to see the real economic benefit. We also are worried about how the evaluation is being carried out.

Carol Herbert put a positive spin on what has been happening. Another concern at present is that only three million of 13 million are being look after in this model. If the majority prevails then this could go either way in the future. We do need more FHTs.

Anton Kuzel talks about evaluation which should be very rigorous. We do lack confidence in the organization providing the evaluation.

Paul Grundy provides several examples of methods of developing a Patient Centered Medical Home. He has obviously thought of the model in the American context and provides optimism for the future.

We hope that bringing this forward before full evaluation will provide inspiration for the future.

Competing interests:   None declared

Rosser et al[1] paint an optimistic picture of one form of primary care delivery in Ontario, Canada, namely the Family Health Team (FHT). Their optimism is based on the claim that this approach holds many attractive features, such as increases in patient and physician satisfaction, and improved coordination and integration of health care services. But is this optimism truly justified?

It is not very surprising that FHT physicians appear to be more gratified relative to their FFS counterparts given the substantial increase in their incomes over the past five years.[1] One might fruitfully ask whether the satisfaction of physicians working in other primary-care models would have also arisen in the face of such an increase. However, disentangling the positive effects associated with putting more money in the physicians’ pockets with those arising from a better functioning approach to delivering primary care, constitutes a formidable challenge. But it is one of many challenges that would have to be met in order to demonstrate how the FHT model compares to other ways of providing primary care.

Another important issue that needs to be taken into account in any assessment of primary-care delivery models concerns the idea that physicians who would chose to switch from a retrospective payment system, like fee-for-service, to a predominantly prospective one, like FHTs, may well differ systematically from those who would not. In other words, there is a self-selection bias in the types of physicians operating in different primary care delivery models. Indeed, previous Canadian research does suggest that a selection bias is associated with non-fee-for service models.[2-4] Although not explicitly determined for the case of FHT physicians, economic theory as well as empirical evidence tells us that "less productive" and "risk averse" physicians generally transit to prospective schemes.[5-7] The resulting selection bias could potentially hamper the effectiveness of FHTs on a dollar-for-dollar basis compared to other primary care models. Any discussion of the effectiveness of the FHT approach for primary care delivery must address this issue in order to separate out the effectiveness of the approach from the effectiveness of the physicians operating in this model.

Before suggesting that that FHT approach is a successful one, it will be essential to demonstrate that it is better than other approaches at delivering appropriate primary health care services in the most cost- effective manner. Thus far, there is absolutely no evidence to suggest that the FHT meets this requirement. Happily, as mentioned by Rosser, et al,[1] the Ontario Ministry of Health and Long Term Care seeks such an determination and has thus awarded a contract to conduct an evaluation of FHTs to the Conference Board of Canada. As policymakers, clinicians and researchers keenly await the economic evaluation of the FHT model, it is important to keep in mind the methodological challenges that bedevil such an endeavour – such as those just described.

While we applaud the Ministry of Health’s initiative, we caution that the inherent challenges associated with performing careful economic evaluations coupled with the fact that health care is such a politically charged subject, may influence the messages arising from this type of contract research. We thus end with a plea: that the Ontario Ministry of Health and Long Term Care allow academic researchers appropriate access to the data and information necessary to undertake independent economic evaluations of the existing primary care models in order to further our understanding of their relative strengths and weaknesses of these approaches, as well as to validate the findings of the contract research undertaken by the Conference Board of Canada.

References

1. Rosser WW, Kasperski J, Wilson L. Progress of Ontario’s family health team model: a patient-centered medical home. Ann Fam Med. 2011; 9(2):165- 171.
2. Devlin RA, Sarma S. Do Physician remuneration schemes matter? The case of Canadian family physicians. Journal of Health Econ. 2008; 25(7): 1168-1181.
3. Sarma S, Devlin RA, Hogg W. Physician’s production of primary care in Ontario, Canada. Health Econ. 2010; 19(1):14-30.
4. Sarma S, Devlin RA, Belhadji B, Thind A. Does the way physicians are paid influence the way they practice? The case of Canadian family physicians’ work activity. Health Policy. 2010; 98(2-3):203-217.
5. Gaynor M, Pauly MV. Compensation and productive efficiency in partnerships: Evidence from medical group practice. Journal of Political Econ. 1990; 98(3): 544-573.
6. Gaynor M, Gertler P. Moral hazard and risk spreading in partnerships. Rand Journal of Econ. 26(4): 591-613.
7. Encinosa III WE, Gaynor M, Rebitzer JB. The sociology of groups and the economics of incentives: Theory and evidence on compensation systems. Journal of Econ Behvior & Org. 2007; 62(2): 187-214.

Competing interests:   All authors contributed equally and agreed to the final version. The views expressed in this commentary are those of the authors and do not necessarily reflect the views of any affiliated organization. Sisira Sarma acknowledges a Ministry of Health and Long-term Care Career Scientist Award and Amardeep Thind acknowledges a Canada Research Chair in Health Services Research. The authors have no conflicts of interest to declare.

Rosser et al. cite our 2009 paper(1) on the financial impacts on early adopters of primary care reform in Ontario, which demonstrated significant (in the range of 30%) increases in income for participating physicians. As they note, further changes implemented since then have further increased incomes for primary care physicians. There were at least 2 main objectives of attaching this degree of incentive to adoption of change that should be kept in mind as the concept of the medical home evolves and is implimented in the United States. First, it was one way to direct increased funding to primary care physicians, something that has always been a challenge in the context of fee negotiations between provincial medical associations, which are often dominated by specialists, and provincial governments in Canada. This was a key step in reversing the downward trend in the incomes of family physicians relative to specialists that was seen as one of the reasons for the declining interest in family medicine as a career choice(2) and essential for the success of future reforms as shortages of family physicians could hamper the successful implementation of reforms. Secondly, it was important to demonstrate to physicians, who had been very suspicious of any movement away from fee for service payment models, that such a move could be not just acceptable, but beneficial. The increased level of comfort of Ontario physicians with non-fee for service models of payment took years to acheive, but has now resulted in the conversion of a large proportion of physicians to such models in a relative short time period(3). This was accepted by the profession in large part by the voluntary nature of the reforms (physicians did not have to move away from FFS) and the retention of a variety of payment models within the publicly funded health care system. While a change in payment model alone is unlikely to impact patient care in a significant way, reliance on FFS payment likely does inhibit the adoption of other key elements of primary care reform(4). The full impact of FHTs on the health care of Ontarians will be unclear for many years. Future research evaluating this impact may help other jursidications understand both the benefits and pitfalls of this particular model of primary care delivery.

1. Green ME, Hogg W, Gray D. et al. Financial and Work Satisfaction: Impacts of participation in prmiary care reform on physicians in Ontario. Healthcare Policy. 2009; 5(2):e161-e176.
2. Shortt SED, Green ME and Kereztes C. Family Physicians for Ontario: An approach to production and retention policy. Canadian Public Policy, 2005; 31(2): 207-221.
3. Glazier R. Improving primary care with better data and information. ICES Health Care 2011 Conference Presentation. Accessed on March 29, 2011 at http://www.ices.on.ca/file/Glazier_presentation.pdf
4. Shortt SED. Primary Care Reform: Is There a Clinical Rationale? in Implementing Primary Care Reform: Barriers and Facilitators. Wilson R, Shortt SED, and Dorland J. Eds, Kingston, McGill-Queen’s University Press, 2004, p 11-24.

Competing interests:   None declared

I would like to commend Dr. Rosser and colleagues for a thorough and detailed description of Ontario’s Family Health Teams (FHTs).[1] This model of care, which largely frees physicians from fee-for-service reimbursement and establishes team-based care, holds the promise of enhanced access and coomprehensiveness and improved quality of care.

The Special Report, however, glosses over important challenges in the development of the model that have limited its impact.[2] For example, most American audiences would be surprised to find a capitation system without case mix adjustment and would be concerned that such a system would provide incentives for attracting healthy practices and cherry picking healthy patients. Those audiences would be further surprised to find an absence of carve-outs for mental health, addictions or HIV/AIDS and would wonder how those patients would be served in an age-sex only capitation system. The ‘access bonus’ described in the report penalizes physicians when their patients seek primary care outside of their group but not when they visit the emergency room (ER). ER overcrowding and wait times are among Ontario’s most intractable health care problems, yet the FHT payment incentive preferentially directs patients away from urgent care and walk- in clinics to the ER. Penalties also apply for visits to focused practice primary care physicians (such as sports medicine and addiction physicians) who are over-represented in large urban centres, thus creating an urban payment disadvantage. There are currently no provisions for the evaluation described in the report to be made available to the public or even to the very groups it is evaluating.

The authors of the report describe the FHT model in glowing idealized terms and hope that research will show that it enhances patient access to higher quality, more comprehensive and cost-effective care. In contrast to the wishful thinking of the report, the limited evidence that now exists is far from encouraging. There is evidence that the funding model attracts healthy non-urban practices with higher than average ER use,[3] a result that could be readily anticipated given the model’s incentives. After six years of progressive investment in FHTs, more than 730,000 Ontarians lack a family doctor and half of those with family doctors cannot see them the same day or next day when sick.[4] These access problems have changed little in recent years. In terms of quality, there have been no substantial changes in the rate of flu shots for seniors, Pap smears, mammograms, diabetes eye exams and foot checks, or hospital readmissions for most chronic conditions.[4] All of these measures fall well below relevant international best practices.

The challenges inherent in paying physicians, aligning incentives, and building teams to support enhanced access and quality in primary care are formidable. The Special Report does a disservice when it depicts these problems as solved by the FHT model. It would have better served an international audience by describing Ontario’s FHTs as a large-scale but imperfect work in progress that is struggling to achieve its goals and that lacks appropriate evaluative activities. The authors’ commitment to the model is evident. They and others have important work to do before the Ontario FHT model realizes it potential and can be seen as an example for others to follow.

References

1. Rosser WW, Colwill JM, Kasperski J, Wilson L. Progress of Ontario's Family Health Team model: A patient-centered medical home. Ann Fam Med. 2011;9(2):165-71.
2. Glazier RH, Redelmeier DA. Building the patient-centered medical home in Ontario. JAMA. 2010;303(21):2186-7.
3. Glazier RH, Klein-Geltink J, Kopp A, Sibley LM. Capitation and enhanced fee-for-service models for primary care reform: a population- based evaluation. CMAJ. 2009;180(11):E72-81.
4. Quality Monitor. 2010 Report on Ontario’s Health System. Ontario Health Quality Council, 2010. http://www.ohqc.ca/pdfs/2010_report_-_english.pdf, accessed March 18, 2011.

Competing interests:   None declared

Ontario has made striking changes to the organization and delivery of primary care. For those south of the border and beyond, it is tempting to ask: How Canada’s largest province managed to move being part of the “land of the perpetual pilot project”(1) to be on the verge of embedding substantial change in the delivery of primary care?

As Rosser and Kasperski suggest(2), important professional leadership came from the College of Family Physicians and the chairs of the five departments of family medicine in Ontario. This in itself was not unusual. Both groups represented the academic rather than the industrial aspect of primary medical care. However, the groundswell of enthusiasm generated about new models of care placed the lead professional organization, the Ontario Medical Association (OMA), in a position where they needed to make a decision.

Berwick has written of the dilemma of professional associations in the context of health care reform: “… medical associations have a choice: to become citizens in system improvement or to play the role of victim.” (3) The yet to be written history of Family Health Teams should have a chapter on how the OMA, a characteristically conservative organisation came to support the reform policies. Although the ultimate agreement between the profession and the provincial government was hard driven, and the new model more physician oriented than many would have desired, the OMA’s support was the final link in the chain that allowed Family Health Teams (FHTs) to move from concept to reality.

A few years after the first FHT opened it is clear that Ontario has far to go. Our observational work found that within these generally physician centric practices, routines of clinical care remain ‘traditional’ and strongly influenced by external demands to increase patient numbers.(4) Others have identified the potential for voluntary enrolment to generate a group of haves and have nots.(5) Indeed Rosser and Kasperski’s assertion that “access has improved” may more be a hope than grounded in data, evaluation data that may itself be difficult to obtain.

Whatever the outcome, Family Health Teams are an important template for the Patient Centred Medical Home. Those seeking similar models would be wise to consider the art of the possible as it applies to medical politics. Important lessons come not only from changes within primary care practices, but come from the decisions made in the committee rooms of a host of key professional bodies.

References

1. Begin M, Eggertson L, Macdonald N. A country of perpetual pilot projects. CMAJ. 2009 Jun 9;180(12):1185, E88-9.

2. Rosser WW, Colwill JM, Kasperski J, Wilson L. Progress of Ontario's Family Health Team Model: A Patient-Centered Medical Home. Ann Fam Med. 2011 Mar-Apr;9(2):165-71.

3. Berwick DM. Medical associations: guilds or leaders? BMJ. 1997 May 31, 1997;314(7094):1564.

4. Russell G, Geneau R, Farrell B, Ward N, Evans S, Thille P. Using Ethnography to Understand Chronic Disease Management in new Primary Care Organizations. Paper presentation to 38th Annual Meeting of the North American Primary Care Research Group; 2009 Nov 15, 2009.; Montreal, Quebec.

5. Glazier RH, Redelmeier DA. Building the patient-centered medical home in Ontario. JAMA. Jun 2;303(21):2186-7.

Competing interests:   None declared

References:
(1) Muldoon L, Rowan MS, Geneau R, Hogg W, Coulson D. Models of primary care service delivery in Ontario: why such diversity? Healthc Manage Forum. 2006;19(4):18–23.
(2) Rosser WW, Colwill JM, Kasperski J, Wilson L. Progress of Ontario's Family Health Team model: a patient-centered medical home. Ann Fam Med. 2011;9:165-71.

Competing interests:   None declared

We are thankful that Rosser et al. provide us with an excellent example of how when a region has the political will to provide the necessary tools and support to family physicians, the primary care problem can be solved.

This natural experiment provides more evidence that payment reform is a sine qua non for effective primary care reform. The fact that physicians have increased their income by 40% bringing their salaries to 80% of specialists' salaries is heartening and clearly a magnet for primary care for medical students that we are lacking in the United States. The increase comes from a blend of capitation, fee-for-service, and population management incentives, in other words rewards for doing the right thing are aligned with the health of the patients that choose to participate in these Family Health Teams. This payment support was absent among the practices in the US that participated in the National Demonstration Project (NDP). 1

Another important element of a highly effective PCMH is the participation of other health professionals in the FHTs, nurse practitioners, registered nurses, pharmacists funded by the regional coordinating center (in this case the Provincial Ministry of Health). This approach solves a capital problem often encountered in primary care in the U.S. We value and recognize their potential help in population management and clinical services but are challenged by the need to capitalize their salaries up front. The fact that social workers, psychologists, health educators, occupational therapists and others are potentially also supported is important.

All primary care is local. The fact that there are boards drawn for the community and that these boards are responsible for providing oversight of patient experience monitoring, quality care and adjustments specific to the population under service provides a mechanism to incorporate the patient’s voice in a very meaningful way.

Finally, the fact that a limited number of EHRs are available and integrated highlights the importance of having these tools talking to each other and as proactive tools.

Advanced Primary Care systems (such as the PCMH and FHT) are front and center as a sure way to achieve the Triple Aim (higher quality, lower cost and better patient experience). However, we fool ourselves if we want to implement them in the absence of payment reform, without regional support for bringing more clinicians to the front lines, local control in the allocation of resources , and EHRs that work and talk to each other. The NDP practices remind us that it is possible to implement most of the elements but more support is needed. 2

We must be vigilant and not miss the opportunity to nurture and support primary care when the threats from the status quo are mounting. We must muster the political will to make the necessary possible.

1. Stewart EE, Nutting, PA, Crabtree, BF, Stange, KC, Miller, WL, Jaen CR. Implementing the Patient-Centered Medical Home: Observation and Description of the National Demonstration Project Annals of Family Medicine 2010 Jun;8(Sup 1):S21-S32.

2. Nutting, PA, Crabtree. BF, Miller, WL, Stange, KC, Stewart EE, Jaen CR. Transforming Physician Practices To Patient-Centered Medical Homes: Lessons from the National Demonstration Project Health Affairs 2011 Mar;30(3):439-445.

Competing interests:   Dr. Jaen was the Principal Investigator of the Evaluation Team for the AAFP's National Demonstration Project

The Family Health Team (FHT) is an excellent example of disruptive innovation in the complex system of health care that bears attention and replication. Our historical leaders in Family Medicine such as McWhinney, Carmichael, Stephens, Medalie, and many others bravely broke with past beliefs and practices, to establish radically new approaches to education and to care delivery that would better serve the health needs of individuals, families, and populations. It is in that tradition of leadership for patient-centred care that the Chairs of the Ontario Departments of Family Medicine in 1994 published their call for change in the reward system for family physicians and that the Ontario College of Family Physicians in 1996 proposed alternative organizational models for primary care. Not surprisingly, it required political will to transform a proposal into a series of actions that led to the successful FHT model.

Rather than continuing to report on insufficient and inefficient access to primary care and care for the chronically ill, the intrepid developers and early adopters of FHT have operationalized principles that have been endorsed by multiple organizations and reports in both the United States and Canada. We need to apply the knowledge we have gained from experiments that disrupt conventional approaches to care.

Research findings to date support the FHT as a model that provides incentives to achieving patient-centred care. It is a model that makes it possible to answer a generation of disappointed and frustrated family practice graduates who have come back to us, their teachers, to say they cannot practise the way they were taight in their residency programs - the system doesn't let them.

A recent evidence-based report from the Canadian Academy of Health Sciences (CAHS is the Canadian equivalent to the IOM) on Chronic Disease Management calls for models of care that will enable primary care providers to manage the complex web of care that is required for those with chronic illness and ofen multiple co-morbidities. The FHT model was of particular interest. The report calls for transformation - different models of care, measurement of outcomes, and a commitment to quality improvement.

Previous experiments, such as community health centres in the 1970's, were criticized because of decreased throughput. In this round of experimentation, we must determine what is the gold standard for number of patient visits just as we must monitor the reward systems to ensure that 'pay for performance' does not become a perverse incentive.

We know what to do, we just need to do it!

Competing interests:   None declared

Rosser et al have done us a service by giving more details about the ambitious implementation of FHTs in Ontario. These practices seem to have most or all of the characteristics of the idealized primary care practice envisioned in the Future of Family Medicine report, and have made a major impact on FP salaries, which can only help student recruitment. It will be crucial to get the coming results of the evaluation of this model on the key elements of quality - safety, timeliness, efficiency, effectiveness, equitable, and patient-centered. Given the runaway inflation of healthcare costs in the US, the most compelling data will be those that evaluate whether this model is at least cost neutral while enhancing other key elements of quality. Health service researchers in the US would do well to get acquainted with the plans for evaluating this enormous program. The AAFP would do well to point out the ambitious program from our neighbors to the North as they advocate for fundamental change in the US healthcare system.

Competing interests:   None declared