Chapter VII
Conclusions
As health care reform evolves in Canada, primary care is rising to the top of the agenda as a logical starting point, and is therefore coming under increasing scrutiny. The World Health Organization has acknowledged the superiority of Canada's primary care system by ranking it the highest in the world. Canadians also recognize the value of this system, and place strong emphasis on retaining what they perceive as their fundamental right of universal health-care coverage. Any change contemplated should be evolutionary and build on the obvious strengths of the current system. The goal of government to achieve expenditure predictability as well as increased efficiency without sacrificing quality or access cannot be attained by many of the current proposals extant in the Canadian health care debate. Physicians share the same goals with respect to quality and access, but also require in this era of restraint and fiscal uncertainty some stability and predictability in the management of their practices and their staff. The Physician Advisory Group has included proposals in this report which use the current strengths of the system as a foundation upon which to build, while endeavouring to avoid the current and potential weaknesses of other proposals. The loss of billing information and the potential for under-servicing of patients inherent in some models are of particular concern to the committee.
The two models described for primary care reform are variations of blended payment models. The Reformed Fee-for-Service model is at present the preferred model of choice as the committee believes it lends itself to easier implementation. As well, equal emphasis is placed on the role of informatics in creating a true, integrated primary health care system as the first step in refining the entire health care system.
The Reformed Fee-for-Service model is a blend of population-based funding and fee-for-service payment which maintains the predictability of capitated funding methods yet preserves essential encounter data while diminishing the potential for under-servicing inherent in fully capitated-based models. The model encourages functional grouping of physicians to facilitate responsiveness to the needs of the rostered population. For the provider, the Reformed Fee-for-Service model continues to reward the practitioner for the services provided. Rostering of the populace will be used to establish, via accepted methods of funding allocation, an individual physician threshold or Bench Mark Threshold (BMT) which will be attained through traditional fee-for-service billing. This individual threshold will be based on the roster developed by the physician or primary care agency, adjusted by various factors, and will capture the office or community-based aspect of primary care. Billings for other features of traditional practice, such as emergency services, obstetrics, anaesthesia, etc., would remain in the fee-for-service pool subject to clawback if applicable, in order to encourage the provision and maintain access to these essential services.
By establishing an individual Bench Mark Threshold target as determined by the roster size and complexity of the practice population, the Reformed Fee-for-Service model avoids basing the target on historical practice patterns which may be aberrant, while allowing funding to follow the population. It preserves flexibility for new physicians in contrast to the option of restricted billing numbers, yet retains reasonable choice for patients. Distribution of physicians will be more equitable as the rostering process motivates movement of physicians to areas of relative under-supply.
The Physician Advisory Group advocates physician choice in the method of payment for primary care services and the continuation of the fee-for-service model, but also supports the composite payment scheme for primary care as an option for GP/FPs. These recommended payment methods provide for patient choice, allow public funds to ‘follow patients,' offer incentives for task delegation, enhance health system competition, and contain the financial liability for government. Indeed, such payment models, by emphasizing patient choice and the associated physician competition for patients, motivate primary care physicians to be assertive in their role as agents for patients in the provision of quality health care services.
The payment models recommended provide physicians (as agents for patients) with opportunities to negotiate service contracts with cost-effective health providers. Such arrangements enhance health system competition and moreover yield price and outcomes signals for both performance appraisal and resource allocation. Furthermore, private funding for health care, either through direct payments or health insurance, enhances patient choice when health care services are rationed. These payment models of public/private finance provide for client choice, enhance competition between providers, and allow governments to contain their share of health expenditures.
The recommendations proposed in this report represent a comprehensive framework for primary care reform. Rather than competing with previous proposals, the Physician Advisory Group has endeavoured to build on the work of other stakeholders.
It is internationally recognized that there is a need for primary health care reform. While the proposals presented by the OMA Physician Advisory Group may not satisfy all interest groups, the committee has endeavoured to highlight the fact that primary care services are the backbone of the Canadian health care system. The committee has therefore built consensus with respect to the critical role of the primary care physician in the reform process.
Key to the review of any proposed reform is an implementation and evaluation process undertaken by means of pilot projects. Evaluation is an enormously difficult process and every attempt must be made to define the variables and criteria with which to promote explicit clinical management systems. Reform should anticipate implementation issues, mid-course corrections, and ensure input from those stakeholders directly affected.
This discussion paper exemplifies the OMA's endeavours to identify a way in which to balance the needs of fiscal restraint with a method of primary care remuneration and organization. The proposed Reformed Fee-for-Service model is a responsible effort to participate constructively in the debate on health care reform.
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