Preface

January 1998

The report, Primary Care Reform - A Strategy for Stability, was prepared as a discussion paper by the OMA Primary Care Reform Physician Advisory Group following extensive consultation and review of the literature. The report is representative of an ongoing process that has occurred in a number of different arenas in Canada and indeed in jurisdictions throughout the world. This discussion paper reflects the efforts and convictions of those involved in the deliberations and their awareness of the importance Canadians have attached to universal health care. Few need to be reminded that the practice of medicine has also become more politically important because of the increasing cost of providing health care coverage to the population: expenditures range as high as 10% of Canada's gross domestic product (GDP). In Canada, as well as in other OECD nations, the financing of medical care is primarily through public expenditure, yet relations between governments and medical associations in the recent past have at times become contentious if not bewildering.

Ontario residents are increasingly concerned about timely access to health care services, predictability of outcome and their personal ability to manage their own health care encounters. Those Ontarians who have a family physician believe they have the ability to receive health care services from a skilled diagnostician to whom they look for treatment and care when they are ill or injured. Public reliance on the expertise of the family physician and the establishment of a relationship of mutual trust and allegiance between primary care providers and their patients are important and valued assets. Indeed throughout the world, Canadian-trained family doctors are considered to be of the highest calibre, and are often referred to as the 'platinum' bench mark standard for primary care providers. American health economist Stuart Altman recognized this fact when, in a presentation to the OMA at the 1994 Adam Linton Memorial lecture, he challenged Ontario primary care physicians to stand their ground and assume their role as providers in the system.

However, in today's changing environment, no primary care physician is guaranteed a role, let alone a major role, in health care delivery. The profession faces enormous pressures from reform initiatives that threaten the very existence of the traditional role of medical practitioners. The onus will be on physicians to enhance their skills as managers and providers in the delivery of cost-effective care.

Primary Care Reform

Primary care reform is not a new initiative but rather one that has generated extensive interest throughout the world. The Ontario Medical Association has invested substantial financial and personal commitment over the past eighteen months in an effort to attain an understanding of this issue in its entirety, with the ultimate goal of achieving consensus regarding reform initiatives that will be achievable and beneficial to the profession, government, and Ontario residents.

Reform, defined as "improving faults and weaknesses, strengthening good qualities or persuading a person to change their [sic] ways for the better," is distinct from change, which is defined as "an alteration or exchange of one thing for another." Systematic change in the delivery of health care has occurred with the introduction of regional and envelope funding in provinces such as New Brunswick, Alberta and Saskatchewan, and efforts are underway in numerous jurisdictions to continue this push for change.

Reduced transfer payments to provinces as announced by the Federal government will necessitate the restructuring and reform of all social programs. Government has indicated its desire to significantly reduce the level of health-care expenditures relative to GDP. This has put additional pressures on health-care providers as each province defines the optimal model specific to its needs for the delivery of care, coupled with a funding method and mechanism that address the population's needs. To a certain extent, the current structure of physician practice models and organizations inhibits the initiation of an aggressive response to the multiple determinants of health, preventive medicine and rehabilitation, and has made it impractical to address the application of technology in a cost-effective manner.

As well, inadequate distribution of physician human resources in geographic areas of need, i.e., rural and under serviced areas, as well as service areas of need, such as HIV/AIDS, continues to be blamed solely on the mechanism of payment, such as fee-for-service (FFS), without comprehensive consideration of the entirety physician's working condition. Other aspects of care, such as coordination of home care services and wellness care, may be better served by compensation models which recognize the distinctive characteristics and needs of these practice settings.

OMA Goal:

The goal of the Ontario Medical Association's initiative in primary care reform is to maximize the value of primary health-care services in order to ensure that the public receives the most cost-effective quality care possible.

The underlying premise of the activities of the OMA Primary Care Reform Physician Advisory Group assumes that the traditional role and value of the physician are undergoing a transformation initiated by government, the profession, and the public. This report is designed to stimulate discussion on many of the diverse aspects and considerations pertaining to primary care reform.

In reviewing this report, it is important to keep in mind the following statements:

  1. the OMA believes that the right to choice by both patients and physicians is fundamental to a balanced reform process; i.e., physicians' right to choice of payment mechanisms and models, as well as patients' right to choice of primary care provider.

  2. The proposed Reformed-Fee-for-Service model represents another approach to the funding and delivery of primary care services in Ontario. It is therefore offered as an additional option to the models developed by other groups, such as the Blended Payment model proposed by the CFPC.

  3. Any reform initiative should be based on incremental or evolutionary change, not destabilizing revolutionary reform.

  4. All models of reform require pilot projects and evaluation throughout the process.

  5. The report is presented as a discussion document in draft form and is therefore subject to review and revision.

  6. Recognizing that health care reform is being examined in many jurisdictions throughout the world, the Physician Advisory Group believes that there is significant risk to the profession if we choose not to participate in a reform process.

Acknowledgements

The OMA Primary Care Reform Physician Advisory Group is comprised of the following members: Dr. Tom Dickson (a past OMA President), OMA Section on General and Family Practice representatives Drs. Brian Gamble, Kent Gerred, and John McDonald, Dr. Wayne Parsons (past representative of the OMA to the Joint Management Committee), and Dr. Jay Mercer and Ms. Lois Ross, PAIRO representatives. The Committee is grateful for the support and assistance of the members of the Coalition on Primary Care Reform, which included representatives of the Ontario College of Family Practice as well as the Chairs of Family Medicine from the five Ontario faculties of medicine, all of whom substantially contributed to the atmosphere and debate from which much of the policy direction has emerged. Other colleagues who have participated and contributed skilfully to this document include the OMA Section on General and Family Practice and its Chair, Dr. Ron Smuckler, Drs. Lisa Doupe and Lillian Cheung from the Section on Occupational Health, Dr. Pat Teale, OMA Section on Ophthalmology, and the OMA Sections on Paediatrics, Rural Practice and GP Psychotherapy.

The Canadian Medical Association has been very supportive and has helped to broaden the committee's understanding. Mr. John Feeley of the CMA Department of Economics has particularly assisted the committee with issues pertaining to payment mechanisms and funding. The Physician Advisory Group would also like to acknowledge the assistance of the Institute for Clinical Evaluative Sciences (ICES), particularly Drs. Warren McIsaac, Ed Brown, and David Naylor, who have acted in an advisory capacity and added breadth and depth to the OMA primary care reform model.

The Physician Advisory Group has met with a number of organizations for the purpose of discussion and consultation on specific aspects of the model, including: Mr. Michael Decter (former Deputy Minister of Health for Ontario) and his colleagues at APM consultants, who assisted the OMA in facilitating a workshop on primary care reform; the Canadian College of Family Physicians, who through its discussions of alternate payment models in response to the Kilshaw report and development of its "Green Paper" discussion document raised many issues of interest; Dr. Bruce Rosenberg and his associates at Healthnet who expanded the OMA's vision of informatics and the application of the electronic patient record; Mr. Al Gourley, President of HMR; representatives of Stentor, Purkinje, Clinidata, Bell Canada and the Royal Bank, who furthered the committee's understanding of information technology and its potential for use in the practice setting; and Mr. Alexander Graham for his technical expertise in computer technology.

Presentations made to the Task Force on the Funding and Delivery of Health Care in Ontario by the committee Chair helped to formulate the Advisory Group's development of the proposed Reformed Fee-for-Service model.

The Physician Advisory Group would especially like to thank Theodore Marmor, PhD, a political analyst at Yale and a strong proponent of the Canadian health care system, who has been invaluable in the provision of advice and ongoing consultation, and in sharing the benefit of his expertise as the committee developed its model and drafted the project report. The development and publication of this position paper would not have been possible without the contributing efforts of the Ontario Medical Association staff involved with this project. In particular the group would like to thank the Project Coordinator, Ms. Carolyn Kidd, whose personal sacrifice, literary skill and commitment over the following year have not gone unnoticed; Dr. Ted Boadway, Executive Director of the Department of Health Policy; Mr. Darrel Weinkauf, Executive Director of the Department of Economics and his colleagues, Mr. Jim Tsitanidis and Mr. Boris Kralj, whose consultation, written contributions and understanding of payment mechanisms have been invaluable; Mr. Tom Magyarody, Executive Director, Corporate Affairs and Administration, and Mr. Peter Berwick, Director, Practice Advisory Services, for their assistance in expanding the committee's knowledge of information technology; and Mr. David Pattenden, CEO for his vision of project coordination and assistance in this new strategic direction for the OMA.

Finally, we, the members of the Physician Advisory Group would like to thank our colleagues and local medical societies, and especially our patients, whose counsel and concerns have influenced us every day in the development of this reform initiative.

Wendy Graham, MD, CCFP, FCFP
Chair, Primary Care Reform
Member, OMA Board of Directors

Return to Primary Care Main Menu

[ Return to Home Page | Feedback | Other Health-Care Sites ]