‘In Dialogue’ Episode 18: Primary Care Crisis: What Do We Do Now?

Introduction
CPSO presents “In Dialogue,” a podcast series where we speak to health system experts on issues related to medical regulation, the delivery of quality care, physician wellness, and initiatives to address bias and discrimination in health care.

Dr. Keith Hay (KH):
This is part two of our conversation with Dr. Tara Kiran and Dr. Kamila Premji about the future of family medicine.

What can we do to strengthen primary care and increase patient access? You’ve already touched on many of the solutions, but I’d like to amplify them a little bit more. So, I’m going to start first. While increasing physician supply is an obvious answer, if we can expand our residency positions for family physicians, that will work. It takes a few years and requires some political will to do that. CPSO has recently made changes to our registration policies, making it easier for internationally trained physicians, including family doctors, to practise in the province — and already we’re seeing increased numbers of applications. And finally, CPSO is supportive of national licensure.

So, we’ve talked already at some length about team-based care, pointing out that we had a pause once they stopped funding new family health teams. I’ve practiced under both a fee-for-service model and as part of a family health team, and I can certainly confirm that I could provide much more comprehensive care when I was a member of a health care team — and I was a happier doctor. So, Tara, explore if you will a little bit more about how team-based care can help with family physicians and, particularly, equitable access.

Dr. Tara Kiran (TK):
Yeah Keith, done right, team-based care has the potential to improve outcomes for patients, improve joy in work for clinicians, and, importantly, also increase provider-clinician capacity to actually see more patients and take care of more people. Because as you mentioned, yes, we can try and grow our family doctor workforce, we can add nurse practitioners into the mix, but even with the family doctors and nurse practitioners we have and are planning to have in the coming years, that actually won’t be enough to meet our care needs for primary care. So, we have to start to think more creatively. And I’ll be honest, I think family health teams have done a terrific job. Some of our own research has actually shown that patients who are part of teams are less likely to have increases in their emergency department use over time than people who aren’t in teams. We’ve shown that patients who are part of teams who have diabetes are more likely to get recommended testing and actually have their care improve over time relative to people who are not in teams. So, we’ve seen some real improvements in outcomes.

But our research has also shown a couple of other things. One, it’s shown that the distribution of teams in the province isn’t quite right. And so, there’s actually a tenfold variation in Ontario in terms of the amount of team-based primary care there is per capita; so, a tenfold variation in regions’ access to team-based care. And unfortunately, that variation isn’t rational. If we were going to have variation, you would think, “Okay, the areas that need it most, those are the areas where we should have more teams.” But actually, when we look at the areas that are highest need and we look at that in terms of medical complexity, but also social complexity, in fact, those are the areas that are least likely to have a team. And so, what’s been great to see is that there’s going to be some new investment in teams. It’s a modest, small investment at this time, but it’s a step in the right direction. And what we really have to make sure is that that investment goes to the patients, the communities that really need it most.

And then I’d say the other thing that we’ve got to do is reorient our teams. So, even the ones that we do have and the ones that are going to be new. I don’t know about you Keith, but even in our own team — and I have to say I love working in a team, I’m really lucky to do so — but even in our own team, often the way things are run is that the team members provide often add-on care to the physician care. So, people will see a nurse for their diabetes check, let’s say, but then still see a doctor. But I think more and more, we as physicians have to start to feel comfortable to let our other colleagues really take the lead on some types of visits. And so, we can really share the care, and try and see the things that really are within our scope that other people can’t do. We have some very special training as clinicians. So, how can we work to the top of our scope and let others work to the top of theirs, so that we can serve even more patients. And so, I think that’s the next frontier as well in team-based care.

KH: Couldn’t agree more. Kamila, you’ve touched on physician compensation already. I think it’s fair to say that fee-for-service is going the way of the dodo. Any other thoughts on how compensation models can improve patient access?

Dr. Kamila Premji (KP):
I think that it really does improve the health care providers supply to have a stable, predictable financial model of care. We saw that the introduction of capitation-based models of care in the early 2000s grew the family physician workforce. So, we know that this was attractive to family physicians and did actually grow the supply. So, while I agree with Tara that simply growing the number of family doctors and nurse practitioners is not going to be enough, it certainly will help to have a payment model that is appealing to primary care professionals, including physicians. I think that a critical enabler of access to primary care is health human resources. So, we do need to focus some of our efforts on making sure that we have that model of care readily available to those who want to go into it.

Family medicine was one of the most popular specialties to enter when I graduated medical school. I think roughly half of our class went into family medicine. And I don’t think that’s what we are seeing now. Certainly, the CaRMS [Canadian Resident Matching Service] data does not show that to be the case. It’s a declining proportion and now closer to about 30 percent who are choosing family medicine as their first choice. And I really do think that that’s in part because when you graduate from medical school, especially nowadays, where over the last few years, the median debt load for a graduating medical student was in the $80,000-100,000 range, having predictable income is a consideration. CaRMS has surveyed graduating medical students to find out what it is that they’re looking for when they’re considering their specialty choice and although it’s not the only factor, it is a factor.

KH: Yes, I can understand that.

TK: I just want to jump in there to say that I’m a big fan of alternate payments or capitation payments. [But] a couple of things we have to keep in mind as we potentially grow that type of compensation. One is that the current funding formula actually doesn’t take into account patient complexity. The capitation formula adjusts for age and sex of the patient, and that’s been a weakness that’s been pointed out actually for a decade and a half or more. Very early and after the reforms were introduced, people noted that this was a problem and that, in fact, it may be leading to inequity with more of the physicians who are going into the capitation models actually having healthier, wealthier practices. So, not that they were necessarily cream skimming themselves, but actually the ones who had healthier, wealthier practices were choosing capitation because it was most financially viable for them. So, we really need to address this capitation formula if we really want to move towards equitable primary care, and ensuring those, in fact, who are most in need have access to family doctors and teams.

And I think the second thing we need to watch out for is that part of the reason I think the Ministry of Health put a pause on the expansion of these types of payment models was that they weren’t seeing the return on investment. It was expensive for them and one of the areas which was really tricky was where these positions were going into capitation, were they actually seeing patients in a timely way. And interestingly, the capitation models in and of themselves can be structured in a way that really provides physicians with a lot of autonomy, which is obviously always nice for us as physicians, but sometimes actually needs to be balanced also with health system needs in terms of timely access. So, we as physicians might need to be open to more accountability if we want the kind of freedom and stability that capitation alternative payments allow for.

KH: That’s an excellent point.

KP: I’ll just add to this part of the discussion, the interesting model that B.C. has just unveiled, which includes compensation for administrative time, which in family medicine is a huge burden and a deterrent it seems for new graduates to enter this field and for existing family physicians to stay in family medicine or at least comprehensive family medicine. So, this model has only been implemented within the last few months. So far, anecdotally, we are hearing positive feedback from physicians practicing in that environment. How it rolls out evidence-wise in terms of outcome and retention and recruitment for the family physician workforce is yet to be seen and will need to be studied.

But it’s an interesting approach to the administrative burden in the healthcare system. And it might incentivize governments, if they are paying for that administrative time, it might incentivize governments to actually improve the system level inefficiencies that contribute to our administrative burden. Because, currently, it’s physicians who are absorbing the cost of that administrative time by not being able to take on more patients and by spending their time doing administrative work without compensation. But if they are being compensated for it, I think that that creates an impetus for governments to really meaningfully tackle the system level inefficiencies.

KH: I agree that it would be great if the government would take that on in a timely manner. Let’s just assume for a moment that might not happen as quickly as any of us would like. Have either of you any other thoughts on how we can reduce the administrative demands on physicians, freeing them, as Tara pointed out earlier, to provide time for more direct patient care?

TK: I mean, I think there are many ways in which we can do that. I think one of the most common struggles, right now, for family doctors is actually navigating specialists’ and diagnostic task referrals. The way it works right now, as you know, many of your listeners will be familiar with, is we need to find the specialist that we want to refer the patient to, make the referral and then the specialists can tell us actually, “No, this is not in my scope. My waitlist is too long, sorry, I can’t see them.” And then the referral comes back to us. And we have to start again to find another specialist who might better meet the needs of our patient, and round and round it goes, and the more and more difficult it’s become three years into the pandemic.

And so, what many of us have been calling for and many system leaders have been calling for, honestly for decades, is that we need a centralized triage and referral system for specialists and tests. Ideally, there’s one standardized kind of referral form or portal. We shouldn’t have to go on to 15 different portals, each of which require different logins and passwords, in order to make referrals. And the way a centralized referral and triage system would work is we would identify what kind of specialist our patient needs, prepare a referral letter that outlines the reasons why, we send it in and then somebody else triages and says, “How urgent is this? Where does the patient live? Who are the specialists who have that expertise that are working in that geographic area and what’s their waitlist? Who has the shortest waitlist?” None of those things are clear to us as family doctors and take an inordinate amount of time for our offices to navigate. So, implementing that kind of centralized referral and triage system would be terrific.

And just to say that, as I’ve been going across Canada, learning more about the different primary care systems in each province, this is something where we can learn from other provinces. Quebec has such a system actually, B.C. has better system than us. Now remember, I did say that the family doctor crisis was worse in those two provinces. So, it’s not like this is going to be a panacea, but we can learn from others and try and adopt what is working from them into our system.

KH: Indeed. In a recent policy paper, authors from the CD Howe Institute recommended mandatory utilization of eReferrals and eConsults. Mandatory. That was a strong comment. The electronic medical record has been touted as a way to make family doctors more efficient. Alas, that’s not been always the case. How can technology and integrated data management make a difference?

TK: Yeah, we’ve recently done some work looking at countries that actually have higher primary care attachment than we do. And we looked to identify what are some of the commonalities threading through these countries. So, these are countries, like the Netherlands, Norway, Finland, the UK. And there are many — they’ve got teams, they’ve got more alternative payment. Importantly, they spend more on primary care.

But one of the ways also is that they have smarter information systems. And by smarter information systems, this means information systems that allow communication with patients in a smarter way and allows patients more ownership of their own records. And it allows more integration of our records with other parts of the healthcare system, so that the information systems are not as siloed. So, a country like Finland, there’s one patient record, and patients and their providers can actually readily access that — the clinicians would need the permission of patients. So, there’s a lot that we can do to make our information systems smarter.

It’s crazy to me that we live in a world where we talk about AI and that our electronic medical records, honestly, are basically as advanced as word processing machines. I mean, the most advanced thing that’s come to be, I think, is that we now have spellcheck in them. But it still can’t help me to easily identify patients who are overdue for tests. I can do that, but I have to myself program a search in order to do that — it doesn’t have embedded decision support. So, if I’m seeing a complex patient with diabetes, it doesn’t tell me automatically — it doesn’t flag some of the things that I need to think about from a management perspective. So, there’s so many ways in which our electronic medical records can support us better, but then, more importantly, I think our digital infrastructure can do to advance care.

KH: Virtual care blossomed during the pandemic and most primary care physicians continue to use virtual care to advantage. Do either of you have thoughts about where virtual care fits into the future?

KP: Sure. I can start this off and I know Tara has done some research in this area as well. Virtual care is a really interesting innovation in health care, including primary care, and has the potential to enable better access to care for patients, and improve even continuity of care between patients and their family physician. But it has to, just like everything else that we’ve talked about, be done right and the current model of virtual care being embedded within a longitudinal, comprehensive family medicine setting is likely the ideal way to use virtual care, both effectively, and for the patient and for the health outcomes for that patient, and for the physician, but also most cost effectively. And we do see that virtual care, when operated on platforms that are not part of a continuous primary care setting, where there isn’t the option for an in-person assessment, for example, or there isn’t continuity of care with that provider or with a team, that actually can lead to more fragmentation of care, which we know leads — from previous decades of research — fragmented care leads to poor health outcomes and increased health system costs, but has also led to potentially higher ED use and I’ll let Tara elaborate on that because that’s within her area of work.

But we know that there are some great potential advantages to virtual care, but also some pitfalls we should avoid. In some areas like rural Ontario, for example, remote areas where they do not have very good access to primary care within their local geography, virtual care especially has potential to improve access. And there is a program out of Renfrew County called VTAC program that has done a really great job of using virtual care to improve access in otherwise lower access communities.

TK: Yeah, I’d just add there that our care findings, both the survey and our in-person dialogues, reaffirmed that really the most important modality that patients are interested in is in-person care. People want in-person care, that is what’s most important for them: they want it scheduled, they want to actually be able to have it walk-in or unscheduled as well. And people like phone calls more than they find video, email or secure messaging to be important. So, if they had to kind of pick what’s most important, phone calls would probably be their higher up.

And then the second point I’d make is that we have to really think about equity in the implementation of virtual care. So done badly, virtual care can make equity worse. It can increase gaps in care because sometimes some of our most marginalized folks may not have access to a phone. They may find it very awkward — when you don’t speak English as a first language, it’s actually a lot harder to communicate even on the phone with your health care clinician. I’ve had patients in my practice with severe mental illness who are paranoid and a virtual appointment is not something that they’re interested in. So, we have to really be careful with how we implement it. On the other hand, it can actually really improve equity and access, as Kamila mentioned, for rural, remote populations.

I think the third point I’ll make is that we have to be careful how we fund and regulate virtual care because early in the pandemic in Ontario, it was funded the very same as in-person, like the same dollar value. And you can imagine when you’re funding something in-person, that means you’re paying rent, you’re paying staff, all that sort of thing. And if you’re funding just a phone call, then very little infrastructure is needed, so the profit margins are much higher. And we’ve already seen encroachment of corporate footprint into primary care pre-pandemic and with the virtual care billing codes, that’s just grown. And there are some consequences to that that we need to be mindful of, some of which are unintended consequences. So yes, it may open up some access, but it also can lead to supply induced demand and it can take parts of our workforce away to do things that maybe are of less value. But it also — many of these are corporations are using data and have agreements that are not actually at the forefront of people’s minds who are accessing the care. So, they don’t realize that their data might be used in different ways, for example, to support marketing or pharmaceutical sales, but they sometimes are. And what we’ve learned through some of our care engagement is that people are not at all interested in that. They would rather have care that is not at risk of being influenced by corporate interests.

KH: So, there are pros and cons to virtual care. Used properly, it certainly can be valuable as Kamila pointed out, especially for remote or rural regions. Thanks to both of you for proposing your promising solutions. Kamila and Tara, are there other ways to resolve concerns about access, equity and the crisis in primary care? Your thoughts?

TK: Keith, I’d love to speak to our audience. I’d love to share some of the things we’ve been learning in our dialogue with members of the public. The Our Care initiative, seeking to engage thousands of people across Canada about the future of primary care, and my hope is through these dialogues that we actually start to think about things differently and recentre our vision about the future based on what is most important to those people using the system. And so, as part of that, we held what we call our Ontario priorities panel, where we gathered 35 randomly selected members of the public who roughly represented the demographics of Ontario.

So, we randomly selected them from a pool of 1,200 volunteers and we brought them together for 40-plus hours of learning. They heard from more than 17 different speakers across that time and really started to understand primary care. But more than that, they also had discussions and deliberations with each other. So, these were people who were strangers prior to this process, but they came together virtually and then in-person for four days where they deliberated, and really had the hard task of coming to consensus and deciding what the values were that should underlie our system, what the key issues were, and then what some of the solutions and recommendations would be. And just briefly, I was heartened to hear that one of the values they put front-and-centre was equity. They really believed strongly in that. They named a number of issues, including the ones we discussed today, but then put forth about 23 recommendations and I want to highlight just a few of them today for the listeners.

So, first is that they recognize that we need to invest more in primary care. In comparison, OACD countries, many of them spend an average of eight percent on primary care of their total health budget. We, in Canada, spend about five percent. Many countries spend far more than eight percent. So, we need to raise the proportion of the total health budget that is in primary care and they were clear about that. They also saw the importance of upstream action, and that we need to actually start to cover more things like mental health and eye care and dental care, and that we need to link primary care to social services. Importantly, they made the recommendation to legislate digital interoperability and they really strongly wanted to have access to their own personal health record. And really, they recognized the only way that would happen is if we legislated the digital interoperability.

And then they made a number of recommendations about the models of care. They recommended expanding team-based care to everyone in Ontario. Then they also went further and they talked about restructuring the way we deliver care so that it was more like the public school model, where people were automatically, for example, assigned to a team within their region. There will be some element of patient choice, so patients could actually choose a different health centre if they wanted to, but that it would make it easy for patients to be attached. And those centres would be resourced appropriately. Walk-in clinics would be amalgamated in there, so we didn’t have duplication of services or discontinuity. And some of the other pieces we talked about would be embedded, including, for example, regional afterhours care. So, I am really taken with the recommendations that they put forward and I hope that our listeners could go to ourcare.ca, because if you do and you watch the short video of them, I think you’ll be inspired by the solutions they put forward.

KH: In fact, I did read the report. It is a marvelous report and I applaud you for it. They have a lot to say and it’s all well-worth reading. And you’ve condensed it very nicely. Kamila?

KP: I’ll just add to the excellent points that Tara raised. One thing that I find really puts into very clear focus just how foundational primary care is to our system is the amount of care in any given day that takes place in primary care compared to other parts of the system. So, on any given day, within a 24-hour period, this has been shown both across Canada, but also in Ontario specifically, there are more visits to family physicians than all other specialists combined. And I think that that really helps to emphasize the need to adequately fund and support primary care. It truly is the foundation of our health care system and it rightly is so. It really is where we get the biggest bang for our health care dollars with respect to health outcomes for patients, equity and health system costs. In Ontario and across Canada, the fact that most care takes place in primary care needs to be reflected in the way that we are funding and supporting it.

KH: Well put. Foundational, indeed. Well, thank you for your practical, constructive and actionable thoughts. I’m going to wrap up by exploring how we, as primary care providers, can move forward. In a recent Canadian Family Physician opinion piece, Dr. Lawrence Loh acknowledges the disappointing number of this year’s first-round, unmatched family medicine residency positions. Looking at the flip side, Dr. Loh sees reasons for hope: 1,361 family medicine spots were filled, giving us 1,361 reasons to celebrate. And recently, the Medical Post profiled a number of these physicians — it was an inspiring read. I’d like to ask each of you how you see the future of family medicine evolving and what gives you hope?

KP: I think what gives me the most hope is the nature of the job itself is still incredibly fulfilling and rewarding. The CaRMS surveys medical students around what factors they consider when they choose a specialty. Yes, they factor in income, but they also factor in the very things that are important to me and are the reason I enjoy family medicine: it’s the relationships, the variety we see and the complexity of the medicine that we see. It’s all really interesting, challenging and personally fulfilling. And to provide that longitudinal cradle-to-grave care, where you’re taking care of multiple generations of families, there’s no real other area of medicine that is quite like that — that I can think of off the top of my head anyhow. And I think that that’s something that continues to make family medicine unique and uniquely appealing.

TK: Primary care is in crisis in Canada and part of what gives me hope, to be honest, is that people across the spectrum recognize that now and do seem committed to doing something about it. We, in primary care, have been talking about it for a while. I’ve been doing this kind of research for a decade and a half, and it got some attention, but not much. But now we have hospital CEOs writing editorials about how the single thing that needs to be improved in our healthcare system is primary care. We have senior people in government who recognize that we’re hosting these dialogues among people across the country and there’s been huge engagement, not just with the members of the public, but actually also with our primary care colleagues and senior decisionmakers. We’re collaborating, for example, with I think over 140 individuals representing more than 60 organizations, and they’re all coming together to listen to what it is that public members want to see change in the system. So, I have to hope that although things are really bad right now, I am hopeful that this is the nadir. And just like back in 2002 when I graduated, things will get better because I graduated at a time when family medicine was really unpopular. And then fast forward to the time where Kamila graduated, and actually it was a popular specialty again. And that was possible because we made some changes in the system. So, let’s make some bold moves and I do feel hopeful that we’ll improve the system as a result.

KH: Well, you’re both wonderful advocates for a primary care system that promotes affordable, accessible and, most importantly, equitable health care for all Ontarians. Thank you for sharing your research insights and hopes for the future of family medicine.

KP: Thank you very much for that.

TK: Thanks Keith.

Closing:
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