In the context of the Government of Ontario’s recent actions of limiting entry into capitated models of Primary Care, I wanted to examine the public health benefits of these team-based models of care. Many people are beginning to wonder if we can afford capitated models given Ontario’s current fiscal situation while others, including me, believe that the evidence supports team-based primary care.
Paying physicians by capitation means that the doctor receives an annual fee for each patient in his or her practice. One of the main criticisms levelled by many against paying physicians through a capitated model is that, since they get paid even if they don’t see patients, they do less work. This is so widely believed that many physicians discussing the current situation between the Ontario Medical Association (OMA) and the Government of Ontario actually say this to me. As an OMA Board Director, I speak with many doctors and I have not yet found the ones who are not working hard. I do believe that the team-based models of care allow doctors to conduct some medical care by phone or email, without having to see patients to generate some payment. As a patient, I see that as a positive development for everyone and not “less work”. In these capitated models, an appointment is not always needed in order to discuss test results, or next steps in routine health care. I also believe that the new models allow doctors to spend more time with patients. That time spent with patients is, in my view, one of the major public health benefits of team-based care and capitated models.
Public health measures are largely preventative and anyone with a family doctor knows that prevention and early detection of health problems are the main benefits of annual physicals (periodic health assessments). There are tremendous savings to be had for this investment, to the point where both primary and preventative care have garnered political attention in recent years when legislators are seeking to improve healthcare: http://www.nejm.org/doi/full/10.1056/NEJMp0708558 The Government of Ontario realized this when the Primary Care models were introduced in the province, but now, they are not willing to see the investment through to the point where it begins to yield savings because of a healthier population. This is very short-sighted.
Let’s consider two situations where time spent by a family physician educating and counselling a patient might prove to be a benefit. First, consider the current concern many parents have about vaccines. I spent much of the summer considering why this might be the case when the evidence supporting the use of vaccines is so overwhelming. I found this book by the journalist, Seth Mnookin, helpful in explaining the origins of parental fears about vaccination: http://drgailbeck.com/2014/08/27/balance-or-bias-my-favourite-vaccine-book/ On the weekend, this article by Tom Blackwell caught my attention: http://news.nationalpost.com/2015/02/27/vitamins-minerals-health-benefits/ In this article, Blackwell outlines that there is a lot of misinformation about the benefits of vaccines. Without good information and access to reputable studies, Canadian are consuming more vitamins than they need – possibly more than are good for them. Understanding evidence helps patients make the best health care decisions: getting your children vaccinated and taking only the vitamins you need.
These are two issues that someone could easily discuss with their family doctor if the doctor is practicing in a model that values the physician’s role in patient education. Family doctors have access to reputable studies and balanced information about both these public health issues and will gladly speak with their patients about these issues. A few years ago, when studies suggested that maybe I didn’t need ASA: 81 mg. daily as a preventative measure, I discussed the issue with my family doctor. Discussions like these take time and capitated models allow for this extra time in a way that fee-for-service models do not.
Public health or prevention is not easy to accomplish because it requires an investment years before there will be a benefit, not an easy sell when the limits of a government’s vison are at most four years. What is ironic is that the OMA warned the government of the expense of the new models and tried to help make them more efficient, but transforming Primary Care from fee-for-service to something better does not take four years. It is concerning that this work to improve Primary Care capitated models has been stopped by the Government of Ontario before it is completed and can demonstrate its value. Like any good investment, it’s never a good idea to sell for short term gains.