For the purposes of this document, primary care service provision was defined in part by the primary care services provided in the OHIP Schedule of Benefits. The Physician Advisory Group in consultation with the OMA Department of Economics determined a methodology whereby all primary care services were identified and coded appropriately. These services were then assigned a relative value in order to determine total primary care expenditures and identify the pattern of services. When considering the review of the present data set there are a number of descriptive points.

1. The data collected is for the fiscal year 1993-94.

2. The primary care services extracted for the data set was determined in part by a methodology designed by the Physician Advisory Group.

3. Identification of the expenditures according to the gender and specialty of the practitioner is of limited value when making any reference regarding practitioner workloads given the differences in practice patterns for both men and women.

Total primary care expenditures:	$1,746,000,000
Primary care expenditures as a percentage of total payments in 1993/94:	44%
Primary care expenditures as a percentage of the 1993/94 globe:	45%
Total GP expenditures as a percentage of total 1993/94 payments:	41%
Total GP expenditures as a percentage of the 1993/94 payments:	42%
Percentage of payments to emergency care (based on H codes determined by the Group to be primary care):	4%
Percentage of total payments for emergency care H codes (determined to be primary care) delivered by GPs:	91%
Percentage of total primary care expenditures attributed to the top 210 billed codes by Section:

Primary care mental health expenditures as a percentage of total primary care expenditures	11%
Note: total primary care mental health expenditures = $190,600,000
Primary care mental health expenditures delivered by GPs as a percentage of total primary mental health care expenditures:	90%

Note: total primary mental health care expenditures for GPs = $172,300,000 GP mental health expenditure split: 75% male, 24.77% female.

11. Primary mental health expenditures: GP/non-GP; split by region:

Male/female split of primary mental health care services by region for GPs:

Privatization of Health Care

It is apparent that the expansion of private funding for supplementary health care coverage will become a reality, as insurance companies move to assume a greater share of the market in Canada as they branch out from their US interests. An indication of this interest was exemplified in the move by the US insurer Liberty Health to purchase Ontario Blue Cross. Liberty Health is self-described as, "... becom[ing] a leader in new public information systems to assist consumers in making informed choices; ...a partner with other health care providers in helping to foster a preventative care society in Canada," and further asserts that it "will bring supplementary health to the retail market at the street level."

Liberty Health's desire to move into private sector sponsorship was also made apparent in a presentation made by President and CEO Mr. Brian Johnston to the Conference on Public-Private Partnering in Halifax on April 27, 1995. While emphasizing the theme of public and private sector partnerships, Mr. Johnston stated he was not advocating a partitioning of Canadian heath care into a two-tier system of privatization which differentiates between the haves and have-nots, but rather acknowledging that,

"new concepts such as managed care have a place in the health care spectrum, and in fact may hold one of the keys to preventing the publicly-funded system from collapsing beneath its own weight."

Although Canada is unique in its ability to provide to the Canadian public universal coverage of core health care services, based on the definition of medical necessity, the reality is that the public system currently accounts for approximately 70% of all health care expenditures, with the remaining 30% borne by the private sector. A public-private partnership therefore already exists, with the delivery of core services provided by the public system, and supplementary services provided through private coverage. The latter includes coverage for:

1. disability insurance
2. supplementary health care insurance
3. automobile insurance
4. workers' compensation provided by employer premiums, and
5. other Employee Assistance Programs (EAPs) such as physical and rehabilitation service programs.

Managing Patient Care: Is Managed Care the Issue?

A fundamental premise of the position articulated by the Physician Advisory Group in this discussion paper is that general and family practitioners have an important role to play improving management of primary health care services. This concept is distinct from "managed care" as defined in the context of US experience where it serves as an umbrella category encompassing a diverse number of practices and claims. The marketing of this expression has generated both bewilderment and fear, especially when contrasted with the Canadian health care system. The US system of managed care is perceived as a potential threat to the underlying principles of the Canadian health care system, i.e., universality, comprehensiveness, and accessibility. Consequently, reference to this term frequently creates uncertainty in providers as well as patients.

However, it is important to consider managed care not as a system of health care delivery according to US experience, but rather in terms of its defining features, i.e., management of care. Physician management of health care is what the majority of GP/FPs already provide. It is therefore important to highlight three different areas of reform in context to this understanding of managed care.

Areas of Consideration for the Future:

The first area is the management of the costs primary care physicians fundamentally affect by the prescriptions they provide to their patients. Inappropriate, excessive and costly use of the Ontario Drug Benefit (ODB) Program is a serious policy concern in Ontario. The OMA is supportive of the development and implementation of initiatives to address this issue. The implementation of a pilot program, whereby financial incentives would be provided to family practitioners to appropriately address this cost and quality problem, exemplifies one approach that could be adopted with respect to controlling ODB expenditures. In order to implement this program, expenditures below a prescribed target could be pooled as a budget for ODB outlays. Any savings or overruns resulting from budgeted totals could be spread among the entire family practice population. Savings could be shared equally between family practitioners and government, and could be balanced by expenditures exceeding the budget. Physicians as a whole would therefore be given an interest in the actual level of outlays as well as savings. The savings or clawbacks would be distributed on a per capita basis that depended on the family practice's rostered population aged 65 and over and their covered dependents.

The pilot program described above highlights a second area of managing health care services: the question of who decides what treatment practices are defensible within budgetary limits. To implement the drug benefit reform professionally requires acceptable guidelines for pharmacotherapy. Otherwise, this financial inducement can compromise what medical professionals regard as fundamentally sound practice. This in turn requires monitoring: as with referrals, acceptable program performance requires monitoring by professional peer experts in reference to broadly accepted guidelines. This mode of managing' patterns of care is sharply different from some versions of managed care pre-and post-utilization review, where unknown practitioners from other jurisdictions use guidelines as standards', excluding payment for care that is deemed to fall outside' the rule book. It is to avoid this form of intrusive and morale-depleting management that the Physician Advisory Group is suggesting more professionally-acceptable forms of review. The invocation of management' does not constitute an argument; rather, it is a slogan that needs to be put aside when conquering particular means of improving the cost-effectiveness, continuity and quality of the services family practitioners provide or prescribe.

Finally, there is the management of choices available to both family practitioners and their patients. No health care system can give practitioners and patients everything they might wish exactly when they desire service. Micro-allocation - deciding who gets what at what time in what place in the queue - is an essential component of the physician's role. It is of course shared with other parties and constrained by available resources (capital and labour) as well as by law. But the capacity to choose with whom to roster, what referrals to suggest, and the timing of treatment, within broader constraints, is of importance to physicians and patients alike. The Physician Advisory Group emphasizes that it is patient and professional choices that is central to balanced reform.

Ethical Issues in Managing Care - Professionalism

As health care costs have increased and demands have been made for more cost-conscious health care, a movement toward adopting some of the principles of certain forms of managed care has occurred. Although not unique to this concept, managed care has at least two conflicting loyalties:

1. physicians are expected to balance the interest and trust of their patients with the needs of other patients in terms of prioritizing consumption of health care resources;

2. the financial interests of physicians can conflict with patient needs.

Financial incentives which limit patient care are problematic for the following reasons:

1. they exploit the financial interest of the physician;

2. unlike FFS, they are likely to result in the under servicing of patients' interests and desires, which creates conflicts since patients generally prefer the risk of too much care as opposed to the risk of too little care;

3. patients may be unaware they did not receive the maximum care available;

4. the greater the financial incentive to minimize cost the more likely it is that physicians could provide inappropriate care.

Balancing Professionalism

Judgements about the quality of physician practice should reflect several measures.

1. Consideration must be given to outcomes data, such as mortality and morbidity rates.

2. Recognizing that outcomes data are frequently beyond physician control, it is important to consider the degree to which physicians adhere to practice guidelines or community standards.

3. Patient satisfaction is considered to reflect whether the physician has addressed the goals of the patient and their right to exercise self-determination.

4. Peer review is essential to provide important assessment of quality in areas that are difficult to assess reliably.

Improving Preventive Health Care and the Realities of Clinical Practice

Government has long planned for placing a high priority on prevention and health promotion while reforming the health care system. As outlined for government in the Community Health Framework Project in 1995, preventive care has been defined as "an intervention undertaken by a person believing themselves to be healthy for the purpose of preventing disease." Clinical prevention in its broader sense is defined as a provider-patient exchange that promotes health aimed at preventing illness or injury. In the current fee-for-service model, a variety of services have been used to address preventive issues. These services include counselling, screening , (e.g. PAP tests and mammography), immunization, to chemoprophylaxis in asymptomatic individuals (e.g. tamoxifen for breast cancer).

Health promotion has not been the exclusive domain of the physician, as many allied health care providers have assisted in enabling individuals and communities to access control over their own health and improve their outcomes. However, contrary to current discussions which frequently assume that physicians have not provided care in the wellness area, but rather have only focused on illness, physicians in solo practice as well as HSOs have always been active in health promotion.

A recent US study completed at the Harvard School of Public Health Centre, Risk Analysis by Drs. Teng and Graham suggests that "medical care is far more cost-effective than environmental or safety measures when it comes to cheating a grim reaper." Astonishingly, average costs of a year of life saved for childhood immunizations and appropriate prenatal care was less than zero. Flu shots cost on average $600 per year, in sharp contrast to breast cancer screening, which is estimated to be $17,000 per year of life saved.

In summary, the findings suggested that:

1. medical care generally saves lives at a cost less than the workplace safety or environmental measures;

2. exorbitant amounts of money are spent to alleviate minor cancer risks;

3. organized medical models emphasizing prevention can fall short of maximizing cost-effectiveness;

4. cost-effective spending could cut significant expenditures in the health care budget without increasing the mortality rate.

1. identify major preventable causes of morbidity and mortality affecting Canadians,
2. evaluate the effectiveness of possible preventive manoeuvres applied to healthy individuals, and
3. to recommend age-related packages' of preventive services that could be included in the periodic health examination.

The challenge remains that even as new health-related technologies and preventions are identified, the problem facing their implementation in individual practice remains, that is,

"How does one get a group of physicians or providers to provide the desired preventive service to a target population so that the majority of the population most likely to benefit from the services actually receive it at appropriate intervals?"

1. Information is not enough. As new technologies on drugs are produced, efficacious treatments diffuse quite slowly through communities, through the social and professional interactions of physicians in their local meeting places. Consequently, considerable effort must be made to target local physician leaders with the introduction of such topics in order to generate enthusiastic support within the local physician community for such treatments.

2. Physician remuneration. Remuneration affects the organization and delivery of preventive health care.

In an ideal setting, the recognition of the practice of health promotion, preventive counselling and related activities would modify reimbursement mechanisms to encourage the practice of such services by physicians. Proponents of capitation argue that incentives are inherent in this method of remuneration: payments are defined to a population and therefore capitation should encourage targeted interventions by shifting the provider focus to wellness' versus sickness' care. However, there is no compelling evidence from the Canadian experience to support such a view.

As well, a randomized prospective study conducted by Hickson, Altemer and Perrin in 1987 examined the exact effect that the method of reimbursement has had on physician behaviour, and found that: (a) fee-for-service had the advantage of promoting well-child care, and (b) fee-for-service physicians provided superior continuity of care."

The Physician Economic Incentive

Further studies published to date, such as those by McIsaac and Frank, indicate physicians must want to change, if change is to happen. In order to increase the use of appropriate preventive screening, practice efficiency must be increased without increasing physician workload or decrease practice earnings. Information systems that save physicians time and aggravation by quickly summarizing the preventive indicated care for a given patient as part of a progress note or warning, would be an appropriate intervention. The cost incurred to the provider of course is the front-end data entry that must be done to automate existing patient records. It is the opinion of the Physician Advisory Group that rather than substituting additional economic incentives for preventive screening, investment in technology, such as appropriate software programs with rostered patient populations, is more appropriate.

Tools for Preventive Care - Limited Application for Cost-Effectiveness in Prevention

1. Recommended Core Health Maintenance Manoeuvres

Table 1
Prenatal/perinatal Manoeuvres	Childhood HMMs & Immunizations	Pap Smears and STD Screening	Elderly HMMs
Serologic testing for syphilis. Newborn 1% silver nitrate/.5% erythromycin. Urethral, cervical smears and cultures for gonorrhoea in pregnant women. Blood group and antibody tests. Hepatitis B determination. Counselling in support of breast feeding.	DPTP, MMR, Hib. Serial measures of growth, and repeated assessments of hips, eyes and hearing in first year of life. Referrals for home visits in high risk for child abuse.	Pap smear as per National Workshop Report of 1991(38). Serologic test for syphilis in high risk. Urethral, cervical smears and cultures for gonorrhoea in high risk. Post-abortion contraceptive counselling.	Invitation for fall "meds review" with concurrent administration of influenza vaccine.

2. Development and Implementation of Information Technology

Summary

In summary, many preventive interventions have the potential to improve the health of a population, but for the purposes of this discussion, they are confined to specific medical service intervention initiatives.

Preventive health interventions must be seen in the broader context of public health: health policy aimed at the prevention of:

1. poverty
2. social and domestic violence
3. degradation of the environment by pollution, and finally
4. life-style choices, such as substance abuse.

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Referrals

(According to ...)Health Care: a Public and Private Issue, Liberty Health, speech originally presented to the Conference on Public-Private Partnering, Halifax, Nova Scotia, April 27, 1995, sponsored by the Atlantic Provinces Chamber of Commerce.
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(the financial..) AMA Council on Ethical and Judicial Affairs, Ethical interests in managed care, JAMA, January 25, 1995.
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(incentive for income) AMA, Ethics of managed care, JAMA, Jan. 25, 1995, vol. 273.
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(an intervention...) Kasl and Cobb 1966
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(medical care...)The Globe and Mail, Wednesday, July 13, 1994.
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(How does...) Coleman JF, Katze, Menzel H. Medical innovation: a diffusion study, ref. 20.
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(fee-for-service...)Capitation: a wolf in sheep's clothing, BCMA, November 1995.
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(Frank) Frank J, McIsaac W, Improving preventive services in Ontario HSOs (draft), February 1994.
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(Contrary to...) Capitation: a wolf in sheep's clothing/, BCMA, November 1995.
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