Ontario Ministry of Health and Long-Term Care

Evaluation of Primary Care Reform Pilots in Ontario

Phase I - Final Report

March 31, 2001
 
 

EXECUTIVE SUMMARY  (Click here for Detailed Document)

Numerous jurisdictions, both within Canada and internationally, have undertaken some type of reform of the delivery of primary health care services. Although there appears to be agreement over the need for reform, there are many models, existing and proposed, outlining how reform should be implemented.

The goals of primary care reform, as articulated in 1998 when the Ministry of Health and Long Term Care adopted recommendations from the Primary Care Reform Steering Committee are: improved access, improved quality and continuity of care; increased patient and provider satisfaction; and increased cost-effectiveness of health care services.

In Ontario, seven sites were initially selected to pilot a new model of primary care service delivery. The model currently being evaluated in Ontario is based on a Primary Care Network (PCN) of physicians and other health care providers, who enrol patients for the provision and co-ordination of primary care services. After hours assistance is provided through a telephone triage service. There are financial incentives for PCNs to provide preventative interventions. It is expected that information technology will be integrated into practice. Two physician remuneration mechanisms are being tested in the Ontario pilot. Most of the pilots are using a "capitation" model where physicians are funded based on the number of patients enrolled with them and not on the amount of service that they provide to each patient. At present, one of the pilots is testing a "reformed fee-for-service" model which is a modified version of the traditional physician remuneration method where physicians are paid based on the amount and type of service provided to patients.

PricewaterhouseCoopers has been commissioned by the Ministry of Health and Long-Term Care (MOHLTC) to conduct an evaluation of the primary care reform pilots in Ontario. This document is the Final Report of the first phase of a three-phased evaluation. The purpose of Phase 1 of the evaluation is to describe the experience of implementing the pilot networks. Future phases of the evaluation will assess the service delivery processes in place in the pilot networks and the outcomes achieved relative to the reform goals.

The evaluation methodology centres on the framework developed by Dr. Barbara Starfield of Johns Hopkins University. The Starfield framework assesses primary care reform on the following four indicators, which can be closely linked to the four goals set out for primary care reform in Ontario: first contact care, longitudinality (patient focussed care overtime), comprehensiveness and co-ordination. Research has shown that primary care reform models centred on these four elements produce the best health outcomes.

The evaluation project was officially launched in January 2001. Activities to date have focussed on gaining an understanding of the demographics of each site and gathering information related to the implementation of the pilot networks. We have also gathered basic statistics on the Primary Care Networks such as the number of providers involved, the number of patients enrolled and the physician to patient ratio.

Qualitative information has also been obtained through a variety of consultation strategies including: over 25 key informant interviews, a focus group with representatives from the Ministry of Health and Long Term Care, interviews with over 40 physicians and other staff in the 11 active PCNs and four patient focus groups.

Summary of Phase 1 Findings

Network Characteristics

We evaluated eleven active PCNs: the eight PCNs in Hamilton and one in each of Chatham, Paris and Kingston. Some of the networks were formed based on historical relationships among physicians. These groupings were often formed around larger groups of physicians who shared office space and/or after-hours call groups.

Critical differences between the networks identified include: the number of physicians in the group (from seven to 21), geography, the existence of multidisciplinary teams, the extent of shared identity; whether or not the offices are in a shared call group; the extent to which the participants and practices collaborate in community initiatives and outreach; the amount of sharing of common experiences and troubleshooting through meetings and telephone calls; collaboration related to IT. In all networks there appears to be greater interaction among health care providers than prior to PCR.

Physician Characteristics

Overall there were a number of similarities in the characteristics of the 145 physicians participating in PCR, as well as their reasons for participating. For some there was a desire to take part in a program that could lead to improved quality of care for their patients. For others the offer of financial support for the acquisition of new information technology systems by the MOHLTC was the key factor in participating in the pilot. However, physicians were interested in using the new IT systems to enhance patient care.

The average age of the participating physicians is approximately 48 years, and the average length of time in practice is 23 years. Approximately 40% of physicians in the pilot are female, compared to the provincial average where 32% of general practitioners are female. Thirty percent of the physicians formerly practiced in a Health Service Organization (HSO) – an alternative payment model that includes patient enrolment and capitation. This is substantially higher than the provincial average for HSO physicians of 2.2%.

The Contract Negotiation Process

Generally individuals described the contract negotiation process as long and arduous, and that it took up far more time in meetings than was anticipated. The contract negotiation process was difficult for every network, however, physicians were generally satisfied with their contract except for those under the reformed-fee-for service payment model.

The plan for the primary care pilot included seven sites: Hamilton, Kingston, Chatham, Paris, Parry Sound, Ottawa and Thunder Bay. To date four of these sites (Hamilton, Kingston, Chatham and Paris) are active and have established primary care networks. Parry Sound and Ottawa have signed their legal agreements and are in the process of setting up networks.

The Enrolment Process

Approximately 220,000 patients have been rostered. Some communities have had significant success with rostering. For example, Paris PCN is at 111% of its estimated enrolment target and five other PCNs are above 80% of their enrolment target.

Many physicians identified rostering as the biggest challenge to starting up their primary care network. There was general consensus that the enrolment process was tedious and very labour intensive. For many physician offices it required evening and weekend work and impinged on administration and patient care time. Some practices hired extra staff to assist with rostering. There were concerns expressed about the level of English required to complete the forms; the complexity of the Consent to Release Personal Health Information; and the lack of understanding on the part of the patient with regard to their responsibility as a rostered patient.

Governance Requirements and Leadership Roles

Under the terms of their PCN contract, all physicians within a network were required to have a written agreement setting out their decision-making approach and signing authority. Different approaches were taken to the development of these governance structures.

Individual offices within each PCN tend to operate as separate practices with separate assets. The only shared asset among the individual practices is a shared bank account for Ministry funding for the network. All networks have a network leader and some have an executive committee typically consisting of three or four members. In Hamilton where there are eight PCNs, there is also a site leader who plays a coordination role for all of the sites in Hamilton.

The Payment Mechanisms

All of the networks are using the capitation method of physician remuneration except Chatham which is using the reformed fee-for-service method. Some of the issues raised with respect to the capitation method include: roster limits; outside use or negation rates; inclusions and exclusions of services/procedures in the capitation rate; capitation rates for the elderly, capitation rate increases and on-call coverage. A much lower level of satisfaction was reported by physicians using the reformed fee-for-service method. Issues include a lower than expected level of income in the initial stages, difficulty accessing the benefits of the bonus codes, rostering requirements and on-call coverage.

Budget Requirements

The MOHLTC required budgets for: administration of the enrolment process; network administration; information technology; and nurse practitioners (where applicable). There were varying levels of satisfaction with the budgets and disbursements of funds across the PCNs. Many physicians found the process challenging because they had little or no prior experience with budgets and administration. Another common concern was the delay in approval of funding by the Ministry.

Nurse Practitioners in PCR

There are currently seven nurse practitioners, working in the PCNs. Many of them have at least a decade of nursing experience, and areas of specialty (i.e. wound care, obstetrics, women’s health etc). All of the nurse practitioners are female. The ratio of nurse practitioners to physicians varies across the networks from 1:2 in rural Kingston to 1:21 in one of the Hamilton PCNs. The role of nurse practitioners in PCR varies greatly, influenced mostly by the physicians with whom they practice. Their roles include well patient exams (especially well female exams on behalf of male physicians), home visits, preventative care, patient education and assisting with on-call coverage. Some of the nurse practitioners carry their own patient caseload, providing the full range of services that they are empowered to perform. Patient focus groups indicate that there is a high level of patient satisfaction with the introduction of nurse practitioners.

Providing Patients With 24-Hour Access To Care

The pilot PCNs use three strategies to ensure that rostered patients have access to care 24 hours per day, seven days per week: extended office hours; physician on-call coverage; and teletriage service.

Some physicians report that the opportunity to share on-call with a larger group has been one of the benefits of primary care reform because it reduces the burden on individual physicians and improves lifestyle. One of the concerns that have been raised about broader on-call coverage arrangements is the diversity of patient profiles found in different practices.

The most striking feature of teletriage utilization to date has been the high volume of calls. Between October and December 2000, rostered patients made a total of 4,840 calls to the teletriage line. The teletriage service provider reports that this represents 203% of calls estimated in the telephone triage contract. Of the calls where gender was identified, females made 62% of the calls and males made 38% of the calls. Data for the first three months of operation of the teletriage service suggests that the service has redirected callers to different care options than they would have otherwise sought. For example, from October to December 2000, 375 callers said they were planning to seek emergency care. Only 102 callers were actually advised by the teletriage service to seek emergency care. Physicians have mixed views on the teletriage service and have received mixed feedback from their patients. However, the high and growing number of calls to the teletriage line suggests some level of patient acceptance of the service.

Information Technology Assessment And Acquisition

The information technology (IT) component of PCR is extremely important to physicians. A cost-sharing arrangement is in place by which the Ministry pays two-thirds of the cost of new IT systems and the physician pays one-third of the cost. The Ministry has also set out minimum standards in terms of IT functionality.

Most of the physicians interviewed said that one of their main reasons for volunteering to be part of a primary care network pilot was to benefit from the opportunity to pursue new and advanced information technology. Some physicians expressed a specific desire to implement electronic medical records and move towards a paperless office. On the other hand, when physicians were asked to identify the "biggest challenge in getting your PCN up and running" the second highest response was acquisition and implementation of information technology.

Overall, physicians felt ill-prepared for the process of assessing their IT needs and selecting an IT system. Although the Ministry provided funding for PCNs to hire management consultants to help them with this process, many PCNs were not fully satisfied with the advice they received. Some PCNs are very pleased with their IT acquisitions but others have experienced a variety of implementation setbacks and ongoing technical support problems. Although the IT systems are not yet doing all of the things they were intended to do, many physicians are now using preventive reminders, clinical templates and laboratory linkages. Interestingly, it is not uncommon for physicians within the same network to have purchased different IT systems. This may have implications for future integration and connectivity.

Physician Satisfaction

Despite the many implementation challenges, at this stage in the reform, physicians in most networks report a fairly high level of satisfaction with primary care reform. Most of the physicians interviewed are more satisfied now than they were prior to primary care reform. However, it is also important to note that approximately one in five physicians are less satisfied now than they were before taking part in primary care reform. When asked to think back to the reasons why they decided to get involved with primary care reform, over 70% of the physicians interviewed said their expectations have been met. It is important to note that the results for Chatham are quite different. Physicians in this PCN report a very low level of satisfaction with primary care reform.

Seventy percent (70%) of physicians have not noticed changes in their practice patterns since joining a PCN. Similarly, 64% of physicians do not think that their patients have noticed any changes either. When changes were noted, they most often related to after hours coverage or information technology.

Patient Satisfaction

Based on patient focus groups at two of the PCN sites, there was general agreement that the quality of care received by patients was directly related to the way the individual doctor chooses to approach their profession. Former patients enrolled in an HSO noticed little change under primary care reform. Those patients not used to after-hours on-call access to their physicians noticed the most difference. There was consensus that patients, appreciated having access to a nurse practitioner. Patients felt that they had an appropriate level of access to the services they needed. In terms of overall satisfaction, all patients in the focus groups reported an overall satisfaction level of at least seven out of ten.





This report was prepared at a very early stage in the study process making it difficult to propose concrete recommendations. However, a great deal of very helpful and insightful information was obtained on the implementation of primary care networks. Since the province-wide expansion of primary care reform is scheduled to begin very shortly, it is important to capture the evaluation’s early learnings so that the Ministry can begin to address the questions posed by the pilot experiences. Some of the areas to be addressed going forward include the Ministry infrastructure, the evolving model, information technology and stakeholder relationships.

The complete report can be viewed or downloaded from here in PDF(adobe) format: