comparison of primary care models in ontario

Comparison of

PRIMARY CARE MODELS IN ONTARIOby Demographics, Case Mix and Emergency Department Use, 2008/09 to 2009/10

Comparison of Primary Care Models in Ontario by Demographics, Case Mix and Emergency Department Use, 2008/09 to 2009/10

ICES Investigative Report

Authors Richard H. Glazier Brandon M. Zagorski Jennifer Rayner

March 2012


PUBLICATION INFORMATION ©2012InstituteforClinicalEvaluativeSciences

Allrightsreserved.Nopartofthispublicationmaybereproduced,storedinaretrievalsystemortransmittedinanyformatorbyanymeans,electronic,mechanical,photocopying,recordingorotherwise,withouttheproperpermissionofthepublisher.

Theopinions,resultsandconclusionsincludedinthisreportarethoseoftheauthorsandareindependentfromthefundingsources.NoendorsementbytheInstituteforClinicalEvaluativeSciences(ICES),theOntarioMinistryofHealthandLong-TermCare(MOHLTC)ortheAssociationofOntarioHealthCentres(AOHC)isintendedorshouldbeinferred.TheAOHChadnoinvolvementinorcontroloverthedesignandconductofthestudy;theanalysisandinterpretationofthedata;thedecisiontopublish;orthepreparation,reviewandapprovalofthemanuscript.

Institute for Clinical Evaluative Sciences (ICES)G106,2075BayviewAvenueToronto,ONM4N3M5Telephone:416-480-4055www.ices.on.ca

Canadian Cataloguing in Publication Data ComparisonofPrimaryCareModelsinOntarioby

Demographics,CaseMixandEmergencyDepartmentUse,2008/09to2009/10.ICESInvestigativeReport.

Includesbibliographicalreferences.

ISBN978-1-926850-30-6(PDF)

How to Cite This Publication GlazierRH,ZagorskiBM,RaynerJ.Comparisonof

PrimaryCareModelsinOntariobyDemographics,CaseMixandEmergencyDepartmentUse,2008/09to2009/10.ICESInvestigativeReport.Toronto:InstituteforClinicalEvaluativeSciences;2012.

http://www.ices.on.ca


TABLE OF CONTENTS I Authors’Affiliations

I Acknowledgements

II AboutOurOrganization

III ExecutiveSummary

V ListofExhibits

1 BACKGROUND

3 OBJECTIVE

4 METHODS

4 Participants 4 DataSources 6 CaseMix 7 Analyses

8 FINDINGS

23 DISCUSSION

24 Limitations 26 PolicyImplications 27 ImplicationsforEvaluationandResearch

28 CONCLUSIONS


AUTHORS’ AFFILIATIONS Richard H. Glazier, MD, MPH, CCFP, FCFP, ABMP

SeniorScientist,InstituteforClinicalEvaluativeSciences/Scientist,CentreforResearchonInnerCityHealth,TheKeenanResearchCentreintheLiKaShingKnowledgeInstituteofSt.Michael’sHospital/Professor,DepartmentofFamilyandCommunityMedicine,UniversityofToronto/FamilyPhysician,St.Michael’sHospital

Brandon M. Zagorski, MSAnalyst,InstituteforClinicalEvaluativeSciences/AdjunctProfessor,InstituteofHealthPolicy,ManagementandEvaluation,UniversityofToronto

Jennifer Rayner, MScRegionalDecisionSupportSpecialist,LondonInterCommunityHealthCentre

ACKNOWLEDGEMENTS ThestudywassponsoredbytheAssociationof

OntarioHealthCentresandwearegratefulfortheirassistancewithcollectionofdatafromtheparticipatingCommunityHealthCentres.

WearealsogratefultoThérèseStukelandMichaelSchullfortheirinsightfulcommentsonthestudyresults,andtoBrianHutchison,MichaelRachlis,LiisaJaakkimainen,MaryFleming,LauraMuldoonandJanHuxwhoprovidedhelpfulfeedbackonearlierversionsofthisreport.

IICES


ABOUT OUR ORGANIZATION TheInstituteforClinicalEvaluativeSciences(ICES)

isanindependent,non-profitorganizationthatproducesknowledgetoenhancetheeffectivenessofhealthcareforOntarians.Internationallyrecognizedforitsinnovativeuseofpopulation-basedhealthinformation,ICESevidencesupportshealthpolicydevelopmentandguideschangestotheorganizationanddeliveryofhealthcareservices.

Keytoourworkisourabilitytolinkpopulation-basedhealthinformation,atthepatientlevel,inawaythatensurestheprivacyandconfidentialityofpersonalhealthinformation.Linkeddatabasesreflecting13millionof33millionCanadiansallowustofollowpatientpopulationsthroughdiagnosisandtreatmentandtoevaluateoutcomes.

ICESbringstogetherthebestandthebrightesttalentacrossOntario.Manyofourscientistsarenotonlyinternationallyrecognizedleadersintheirfieldsbutarealsopracticingclinicianswhounderstandthegrassrootsofhealthcaredelivery,makingtheknowledgeproducedatICESclinicallyfocusedandusefulinchangingpractice.Otherteammembershavestatisticaltraining,epidemiologicalbackgrounds,projectmanagementorcommunicationsexpertise.Thevarietyofskillsetsandeducationalbackgroundsensuresamulti-disciplinaryapproachtoissuesandcreatesareal-worldmosaicofperspectivesthatisvitaltoshapingOntario’sfuturehealthcaresystem.

ICESreceivescorefundingfromtheOntarioMinistryofHealthandLong-TermCare.Inaddition,ourfacultyandstaffcompeteforpeer-reviewedgrantsfromfederalfundingagencies,suchastheCanadianInstitutesofHealthResearch,andreceiveproject-specificfundsfromprovincialandnationalorganizations.ThesecombinedsourcesenableICEStohavealargenumberofprojectsunderway,coveringabroadrangeoftopics.Theknowledgethatarisesfromtheseeffortsisalwaysproducedindependentofourfundingbodies,whichiscriticaltooursuccessasOntario’sobjective,crediblesourceofevidenceguidinghealthcare.

“ICES brings together the best and

the brightest talent across Ontario.

Many of our scientists are not only

internationally recognized leaders

in their fields but are also practicing

clinicians who understand the

grassroots of health care delivery.”

IIICES


Executive SummaryISSUE

AretheredifferencesbetweenOntario’sprimarycaremodelsinwhotheyserveandhowoftentheirpatients/clientsgototheemergencydepartment(ED)?

STUDY

Thisstudyexaminedpatients/clientsenrolledin:CommunityHealthCentres(CHCs,asalariedmodel),FamilyHealthGroups(FHGs,ablendedfee-for-servicemodel),FamilyHealthNetworks(FHNs,ablendedcapitationmodel),FamilyHealthOrganizations(FHOs,ablendedcapitationmodel),FamilyHealthTeams(FHTs,aninterprofessionalteammodelcomposedofFHNsandFHOs),‘Other’smallermodelscombined,aswellasthosewhodidnotbelongtoamodel.Electronicrecordencounterdata(forCHCs)androutinelycollectedhealthcareadministrativedatawereusedtoexaminesociodemographiccomposition,patternsofmorbidityandcomorbidity(casemix)andEDuse.EDvisitsrateswereadjustedtoaccountfordifferencesinlocationandpatient/clientcharacteristics.

IIIICES

KEY FINDINGS

•ComparedwiththeOntariopopulation,CHCsservedpopulationsthatwerefromlowerincomeneighbourhoods,hadhigherproportionsofnewcomersandthoseonsocialassistance,hadmoreseverementalillnessandchronichealthconditions,andhadhighermorbidityandcomorbidity.Inbothurbanandruralareas,CHCshadEDvisitratesthatwereconsiderablylowerthanexpected.

•FHGsand‘Other’modelshadsociodemographicandmorbidityprofilesverysimilartothoseofOntarioasawhole,butFHGshadahigherproportionofnewcomers,likelyreflectingtheirmoreurbanlocation.BothurbanandruralFHGsand‘Other’modelshadlowerthanexpectedEDvisits.

•FHNsandFHTshadalargeruralprofile,whileFHOsweresimilartoOntariooverall.ComparedwiththeOntariopopulation,patientsinallthreemodelswerefromhigherincomeneighbourhoods,weremuchlesslikelytobenewcomers,andlesslikelytousethehealthsystemorhavehighcomorbidity.EDvisitswerehigherthanexpectedinallthreemodels.

•Thosewhodidnotbelongtooneofthemodelsofcarestudiedweremorelikelytobemale,younger,makelessuseofthehealthsystemandhavelowermorbidityandcomorbiditythanthoseenrolledinamodelofcare.TheyhadmoreEDvisitsthanexpected.


IMPLICATIONS

Differentmodelsofprimarycareservedifferentpatientpopulationsandareassociatedwithdifferentoutcomes.CHCsstoodoutintheircareofdisadvantagedandsickerpopulationsandhadsubstantiallylowerEDvisitratesthanexpected.Thereasonsforthesebetteroutcomesarenotknownandrequirefurtherinvestigation.Ontario’scapitationmodelsservedmoreadvantagedpopulationsandhadhigherthanexpectedEDrates.Thedetailsofphysicianreimbursementmechanismsincapitationareimportantforachievingdesiredresults.Therefore,thepaymentandincentivestructuresunderlyingthesemodelsrequirere-examination.OntariansnotbelongingtoamodelofcareexaminedherehadhigherthanexpectedEDuse,suggestingthattheyexperiencedbarriersinaccessingprimarycare.FurtherevaluationoftheperformanceofOntario’sprimarycaremodelsinrelationtocosts,andcomparisonswithmodelselsewhere,isneeded.

IVICES


List of Exhibits

VICES

Exhibit 1/SelectedcharacteristicsofprimarycarefundingmodelsinOntario

Exhibit 2/NumberofrosteredpatientsindifferentprimarycarepaymentmodelsinOntario(excludingCommunityHealthCentres),2004to2010

Exhibit 3/NumberandsociodemographiccharacteristicsofOntariansbyprimarycaremodel,forall,urbanandruralresidents,2008/09to2009/10

Exhibit 4/MorbidityandcomorbidityofOntariansbyprimarycaremodel,forall,urbanandruralresidents,2008/09to2009/10

Exhibit 5/StandardizedACGMorbidityIndex(SAMI)ofOntarioresidentsbyprimarycaremodel,forall,urbanandruralresidents,2008/09to2009/10

Exhibit 6/Observedandexpectedmeanemergencydepartment(ED)visitsperpersonforOntarioresidentsbyprimarycaremodel,forall,urbanandruralresidents,2008/09to2009/10

Exhibit 7/Ratioofobserved/expectedmeanemergencydepartment(ED)visitsperpersonforOntarioresidentsbyprimarycaremodel,forall,urbanandruralresidents,2008/09to2009/10


Background Thedominantmodelofprimarycareacross

Canadahastraditionallyrestedonphysicianspractisingsolooringroupsandbeingreimbursedlargelythroughfee-for-servicebillingclaimstoprovincialhealthplansforeligibleservices.Overthepastdecade,manyprovinceshavesoughttoexpandandimproveaccesstoprimarycare,whileatthesametimeenhancingthequalityofcareprovided.1Insomeprovincesthefocushasbeenonstructuralchanges(i.e.,newpaymentsystemsandinterdisciplinaryteams),whileinotherprovincesthechangeshaveleftexistingpractitionerarrangementsintactbutsoughttoenhancetheiraccessandcapacitythroughfeeenhancementsandothersupports,suchascarecoordinators.2Atthesametime,manyprovinceshavehadCommunityHealthCentres(CHCs)existingalongsidethereformstakingplaceintherestofprimarycaredelivery.CHCsareusuallycharacterizedbycommunitygovernance;afocusonparticularpopulationneedsandsocialdeterminantsofhealth;anexpandedscopeofhealthpromotion,outreachandcommunitydevelopmentservices;andsalariedinterprofessionalteams.

1ICES

CHCshaveexistedinOntarioforover40years.Atotalof73CHCsserveapproximately357,000peoplein110communitiesthrough-outOntario.3LikemanyotherCHCsinCanada,Ontario’sCHChealthprofessionalsarereimbursedthroughsalariedarrange-mentsandareconsideredemployees.In2001,theFamilyHealthNetwork(FHN)wasintroducedinOntario.Thisnewmodelofcarewasbasedoncapitationreimbursementforphysicians,blendedwithlimitedfee-for-servicepaymentsandincentives.Itrequiredformalrostering(enrolment)ofpatientswithlossofaccessbonuspaymentsifpatientsreceivedprimarycareoutsideoftherosteringgroup;eveningandweekendclinics;andaphysicianoncall‘24/7’withteletriagenursesupport.Incentiveswereprovidedforpatientsseenafterhours,forchronicdiseasemanagementandforachievingcumulativepracticethresholdsforcertainpreventivehealthcaremanoeuvres.Capitationpaymentswerebasedontheexpectedfrequencyofofficevisitsineachfive-yearage-sexgroupbutwerenotadjustedforhealthcareneedsorsocialdisparities.Anadditionalmonthlypaymentcalledthecomprehensivecarefee

waspaidperrosteredpatient,andmostofficevisitswerepaidat10%ofthefullfee-for-servicevalue.TheFHNmodelthereforerepresentedablendedreimbursementmodelwiththemajorityofpaymentsbasedoncapitation.Anothernewmodel,theFamilyHealthGroup(FHG),wasintroducedin2003.ItcontainedmostofthesameprovisionsastheFHNmodelbutretainedfullfee-for-servicepayments,aswellasthemonthlycomprehensivecarefeeperrosteredpatient.Itthereforerepresentedablendedreimbursementmodelwiththemajorityofpaymentsbasedonfeeforservice.WhereastheFHGmodelrequiredaminimumofthreephysicians,theComprehensiveCareModel(CCM)hadsimilarprovisionsastheFHGbutwasdesignedforsolophysicians.In2005,twooldercapitationmodels,theHealthServiceOrganizationandthePrimaryCareNetwork,wererolledintoanothernewprimarycaremodel,theFamilyHealthOrganization(FHO).Botholdercapitationmodelswerebasedonage-sexpaymentsandwerenotadjustedforhealthcareneedsorsocialdisparities.ShortlyafterestablishmentoftheFHOmodel,itwasopeneduptoallprimarycarephysician


groupsinOntario.TheFHOhadalargerbasketofservicesandalargercapitationpaymentthantheFHN,butotherwisethetwomodelssharedmanyofthesameprovisions.AnothersetofprimarycaremodelswasdevelopedinOntariotomeetspecificcommunityneeds.Thesetendedtoberela-tivelysmalllocalmodelsthathadalternatepaymentplans.By2010,overninemillionOntarianshadrosteredwithoneoftheprimarycaremodels—FHOandFHGwerethetwolargestmodels,eachwithapproximatelyfourmillionpeople.Ontario’sprimarycaremodelsaredescribedinmoredetailbyHealthForceOntario,4andselectedfeaturesofthemajorfundingmodelsarepresentedinExhibit 1.

In2006,FamilyHealthTeams(FHTs)wereintroduced.FHTswerenotfundingmodelsbuttheyrequiredthatphysiciansbepaidthrougheitheroneoftheblendedcapitationmodels(FHNsorFHOs)orablendedsalarymodel.Fee-for-servicephysiciansandthoseinFHGswerenoteligibletobelongtoaFHT.FHTsincludedaninterdisciplinaryteam,fundingforanexecutivedirectorandelectronicmedicalrecords.By2010,150FHTswereservingovertwomillionOntariansand50moreteamsarecurrentlybeingimplemented.5

2ICES

Therehavebeeneffortstocharacterizethedimensionsofprimarycareandhowwelleachmodelofcaredeliveryperformsacrossthem.6TherehavealsobeeneffortstocompareprimarycaremodelsinOntario.7–12Differencesinage-sexcomposition,urban-rurallocationandhealthneedsmakethesecomparisonschallenging.Forexample,patientsinaprimarycaremodelthatispredominantlyruralwouldbeexpectedtomakegreateruseofemergencydepartment(ED)servicesthanpatientsinapredominantlyurbanmodel,astherearefewalternativesforafter-hourscare(e.g.,walk-inclinicsorurgentcarecentres)inaruralsetting.Amodelthathasgenerallyolderand/orsickerpatientswouldalsobeexpectedtomakemoreuseofservices.

Thefocusofthisreportisonthefollowingdimensionsofprimarycareandhowwelleachfundingmodelperformsacrossthesedimensions:

•Sociodemographiccharacteristics

•Patternsofmorbidityandcomorbidity(casemix)

•EDuse

EDvisitsarefrequentlyusedasanindicatorofaccesstoprimarycareservicesinthecommunity.13,14Whereprimarycareisreadilyavailableonanurgentbasisandafter-hours,EDvisitsshouldbelowerthaninareaswheretheseservicesarenotasaccessible.Timelyandafter-hoursaccesstoprimarycareisamajorchallengeforCanadianjurisdictions.Onpatientsurveysconductedin11developedcountries,CanadahadthehighestEDuse,thesecondhighestinabilitytogetsame-dayornext-dayappointmentswithadoctorornurseandthethirdhighestdifficultyaccessingcareafterhours.15Thissuggeststhattimelyandafter-hoursaccesstoprimaryhealthcareoughttobeamajorpolicyfocusforOntarioand,furthermore,raisesquestionsabouthowwelldifferentmodelsofcareaddressthischallenge.Sincedataonpatient-reportedaccesstocarearenotavailablebymodel,EDvisitsareusedasaproxymeasurefortimelyandafter-hoursaccesstocareinthisreport.UseoftheEDisalsoanimportantmeasureinitsownright,givenhighratesofEDuseinCanada,frequentEDovercrowding,andthedemonstratedrisksassociatedwithEDovercrowding.16


Objective

3ICES

OurobjectivewastocharacterizeprimarycaremodelsinOntariobydemographics,practicelocationandcasemixandtoexamineEDusebypatients/clientsineachmodelbeforeandaftercontrollingfortheircharacteristics.


Methods

4ICES

PARTICIPANTS AllresidentsofOntarioeligibleforhealth

carein2008/09to2009/10,withaphysicianvisitduringthistimeperiodandaliveonMarch31,2010wereincluded.ThemodelscomparedincludedCHCs,FHNs,FHGs,FHOs,othersmallermodelsgroupedtogether,andFHTs.TheFHNsandFHOsthatwerepartofaFHTwereincludedintheFHTgroupandnotincludedintheFHNandFHOgroups.WealsoexaminedOntariansnotbelongingtoanyofthesegroups(noothergroup—NON).TheNONgroupwascomposedofthosebeingseeninstraightfee-for-serviceprimarycare,thoseseeingspecialistphysiciansbutnotprimarycarephysicians,andthosebeingseenbyphysiciansinaprimarycaremodelwhowerenotformallyenrolled.

ThestudytimeperiodwasApril1,2008toMarch31,2010.CHCdatawerenotroutinelyavailableatthetimeofthestudy,andforthatreasonCHCswereapproachedtoparticipate.CHCswererequiredtohaveclientencounterdataduringthestudytimeperiodtobeeligible,andCHCclientswhohadaface-to-faceencounterwithaphysicianduringthestudytimeperiodwereincluded.PatientsrosteredtoaphysicianintheothermodelsasofMarch31,2010wereincludediftheyhadaphysicianvisitduringthestudytimeperiod.

DATA SOURCES Datawereutilizedfromavarietyofsources.

CHCdatawereextractedfromelectronicrecordsandlinkedwithdataholdingsattheInstituteforClinicalEvaluativeSciences(ICES)thatwereaccessedthroughacomprehensiveresearchagreementbetweenICESandOntario’sMinistryofHealthandLong-TermCare.Theseincluded:CHCdata,theRegisteredPersonsDatabase;physicianbillingsfromtheOntarioHealthInsurancePlan;hospitalDischargeAbstractDatabase;EDvisitsfromtheNationalAmbulatoryCareReportingSystem;theOntarioDrugBenefitProgram;ClientAgencyProgramEnrolmenttables,theRuralityIndexofOntarioforurban-ruralresidence,and2006CensusofCanadadataforsociodemographicvariables.Abriefexplanationofeachisprovidedbelow.


CHC DataTheelectronicrecordsystemsusedattheparticipatingCHCsincludedPurkinje,P&PDataSystemsandHealthScreenSolutions.Datacleaningandvalidationwasconductedbyoneoftheauthors(JR)priortosubmittingthedataforlinkagetoICES.LinkagewasperformedusingthehealthcardnumberforeachclientontheCHCfiles.Followinglinkage,onlytheuniqueICESencryptedidentifierremainedonthefilesusedforanalysis.TheCHCdataconsistedofauniquesiteID,physicianandnursepractitionerencounters(dateofencounter,issuesaddressed/reasonforvisit[usingICD-9]andprovidertype).Clientdemographicswerealsocollected(uniqueclientid,sex,age,healthcardnumberifapplicableandpostalcode).Intotal,71CHCsandtheirsatellitesparticipatedinthisstudy,comprising97.3%ofthoseeligibletoparticipate.AmongCHCclients,11.5%didnothaveahealthcardnumberandcouldnotbelinkedtoadministrativedata.

5ICES

Registered Persons Database (RPDB)TheRPDBincludestheresidentpopulationofOntarioeligibleforhealthcoveragebyage,sexandresidentialaddress.ResidentsareeligibleforhealthcoverageiftheyareCanadiancitizens,landedimmigrantsorconventionrefugees,maketheirpermanentandprincipalhomeinOntario,andarephysicallypresentinOntario153daysinany12-monthperiod.TheRPDBalsocontainsdatesofeligibilityforhealthcarecoveragewhichwereusedtoidentifythoseovertheageoftenyearswhowerefirsteligibleforOntariohealthcarecoverageduringorafter1998.ThesenewcomersareexpectedtobecomprisedlargelyofrecentimmigrantstoCanada,withtheremainderbeinginter-provincialmigrants(someofwhomwouldalsoberecentimmigrantstoCanada).InthisreportweusednewcomerstatustoserveasaproxyfornewimmigrantstoOntario.

Ontario Health Insurance Plan (OHIP)ThisdatabasecontainsclaimspaidforbytheOntarioHealthInsurancePlan.ThedatacoverallhealthcareproviderswhocanclaimunderOHIP,includingphysicians,groups,laboratoriesandout-of-provinceproviders.Out-of-provinceclaimswerenotincludedinthisstudy.

Discharge Abstract Database (DAD)HospitaldischargeabstractsfortheprovincearecompiledbytheCanadianInstituteforHealthInformation.Eachrecordinthisdatasetcorrespondstoonehospitalstay,andavailablevariablesincludepatientsex,dateofbirth,postalcode,diagnoses,procedures,attendingphysician,admissioncategoryandlengthofstay.

National Ambulatory Care Reporting System (NACRS)NACRScontainsinformationonoutpatientvisitstohospitalandcommunity-basedambulatorycare,suchasEDs,cancerclinics,renaldialysisclinicsandothers.NACRSwasusedinthisreporttoidentifyallvisitstoEDs.


Ontario Drug Benefit Program (ODB)TheODBprogramprovidesdrugbenefitsforalladultsaged65andolderandthosereceivingsocialassistanceinOntario.TheODBwasusedtodeterminetheproportionofpatientsonsocialassistance—welfare(OntarioWorks)anddisability(OntarioDisabilitySupportProgram)—whohadreceivedaprescriptionundertheplanwithinthestudyperiod.Low-incomeseniorsaged65andolderwereidentifiedintheODBusingameanstest.Theproportionoflow-incomeseniorswasidentifiedasthenumberoflow-incomeseniorswhofilledaprescriptiondividedbythetotalnumberofseniors.Peopleonsocialassistanceandlow-incomeseniorswouldbeundercountedinthesedatabasesastheyonlyincludethosewhofilledaprescription.

Client Agency Program Enrolment (CAPE) TablesThisinformationsourcewasusedtoidentifywhichpatientshadenrolledinwhichmodelwithwhichphysiciansovertime.AseparatefileprovidedbytheMinistryofHealthandLong-TermCareidentifiedthephysiciansthatwerepartofaFHT.

6ICES

Rurality Index of Ontario (RIO) Urban-ruralresidentiallocationwasassessedusingtheRIO.Thisindexiswidelyusedasanaidtodefineruralareas.Itwasrecentlyupdatedwith2006Canadiancensusinformation.TheseupdateshavealsoincludedchangestothemethodologytoincreasethestabilityoftheRIO.17ThosewithaRIOscoreof0–39wereconsideredurbanandthosewithaRIOof40andabovewereconsideredrural.Thesemeasureswereusedtostratifytheresults,asdemographics,patternsofmorbidityandEDuseareknowntovarybyurban-rurallocation.

Census of CanadaDatafromthemostrecentCensusofCanada(May2006)wereprovidedbyStatisticsCanada.ThecensustakesplaceeveryfiveyearsinCanadaandisareliablesourceofinformationforpopulationanddwellingcounts,aswellasdemographicandothersocioeconomiccharacteristics.Forthisstudy,themaindataelementusedwasincomequintile,ameasureofrelativehouseholdincomeadjustedforhouseholdsizeandcommunity.Roughly20%ofOntariansfallintoeachincomequintile,withquintile1havingthelowestincomeandquintile5thehighest.Incomequintilewasderivedbylinkingthesix-digitpostalcodeofresidencetocensusdataatthesmallestpossiblelevel(disseminationarea),usingthePostalCodeConversionFilePlus(PCCF+).18

CASE MIX BoththeJohnsHopkinsAdjustedClinical

Group(ACG)methodology,aswellasdiseasecohorts,wereusedasmeasuresofcasemix.ACGsareusedtomeasurepatientillnessburden.19Thesystemestimatestheillnessburdenofindividualpatientsand,whenaggregatedacrossindividuals,ofpopulations.TheACGmethodologyisoneofseveraldiagnosis-basedriskadjustmentsystemsdevelopedtopredictutilizationofmedicalresources,andisbasedonthefactthatpatientswhohavecertaingroupsofdiagnosestendtohavesimilarhealthcareutilizationpatterns.Patientsusingthemosthealthcareresourcesarenottypicallythosewithsinglediseasesbutratherthosewithmultipleandsometimesunrelatedconditions.Thisclusteringofmorbidityisabetterpredictorofhealthcareutilizationthanthepresenceofspecificdiseases.20IntheUnitedStates,ACGsareabletoexplainmorethan50%ofsame-yearresourceusebyindividuals.SimilarpredictiveabilityhasbeenreportedinCanada.21Incontrast,ageandsexonlyexplainapproximately10%ofthevariationinresourceuseandcost.21,22


TheACGsystemassignsallICD-9andICD-10codestooneof32diagnosisclustersknownasAdjustedDiagnosisGroups(ADGs).IndividualdiseasesorconditionsareplacedintoasingleADGclusterbasedonfiveclinicaldimensions:durationofthecondition,severityofthecondition,diagnosticcertainty,etiologyoftheconditionandspecialtycareinvolvement.InadditiontoADGs,theACGsoftwarewasusedtogenerateResourceUtilizationBands(RUBs)whichinvolveaggregationsofACGswithsimilarexpectedutilization(1=low,5=high)andtheStandardizedACGMorbidityIndex(SAMI).TheSAMIwasdevelopedattheManitobaCentreforHealthPolicy.23ThisindexisasetofillnessweightsfortheACGsusingaverageprovincialhealthcarecosts,andcanbeusedforexaminingdifferentialmorbidityatapracticelevelandexplainingvariationbetweenpractices.SAMIhasbeenadaptedbyICESforuseinOntarioandhasusedthefullvalueofin-basketFHOprimarycareservicestoweighttheACGs.24TheseweightsareameasureofexpectedworkloadinaFHOpractice.

7ICES

Allphysiciandiagnoses,includingthosemadebyprimarycarephysiciansandspecialists,andallhospitaldischargeabstractswereusedtoruntheJohnsHopkinsACGs.CHCproviderscanrecordmorethanonediagnosisateachvisit,butOHIPallowsonlyasinglediagnosispervisit.Inordertoallowfaircomparisonsacrossmodels,arandomdiagnosiswaschosenforeachCHCvisit.Inaddition,analyseswerelimitedtophysiciansbecausenursepractitionerdatawereavailableattheencounterlevelinCHCsbutnotinFHTs.

Diseasecohortswereusedasasecondarymeasureofcasemix.Inthisstudythefollowingcohortswereincluded:diabetes,asthma,chronicobstructivepulmonarydisease,andmentalillness(psychoticandnon-psychotic).25–28Mostofthesecohortsderivefromvalidateddiseasealgorithmswhichincludehospitaladmissiondata,requiremorethanonephysicianvisitandarecumulativeovertime.OurapproachtoproducingdiseasecohortsthatwerecomparableacrossmodelswastolinkCHCdatawithphysicianvisitsandhospitaladmissions.AstherewereonlytwoyearsofCHCdataavailable,weadaptedthesealgorithmstouseasinglephysicianvisitorhospitaladmissionwithadisease-specificdiagnosiswithinatwo-yearperiod.Thisapproachissimilartothevalidationusedformentalhealth29butwouldresultinslightlyhighersensitivityandlowerspecificityfortheothervalidatedalgorithms.

ANALYSES Descriptiveanalyseswereconductedto

determinethenumberandproportionofpeopleineachdemographic,urban-rurallocationandcasemixgroup.ThenumberofEDvisitsandaveragenumberofEDvisitswerecalculatedforcomparisonsacrossmodels.Poissonmultipleregressionwasconductedtoproducearisk-adjustedrateofEDutilizationperperson(i.e.,expectedEDvisits)controllingforage,sex,SAMI,incomequintileandrurality.Theobservedutilization(unadjusted)istheactualnumberofEDvisits.ThesedatawereusedtoproducetheratioofobservedtoexpectedEDvisitsand95%confidenceintervals.

ThisstudywasapprovedbySunnybrookHealthSciencesCentreResearchEthicsBoard.


Findings

8ICES

Exhibit 2 •Exhibit2illustratestheuptakeofvarious

physicianpaymentmodelsovertime.In2008,theFHGmodelhadthelargestnumberofrosteredpatients,butby2010,thenumberofpatientsrosteredintheFHOmodelexceededthatintheFHG.

Exhibit 3•AcrossOntario,11,896,508residentswere

includedinthestudy,with10,759,566(90.4%)residinginurbanareasand1,136,942(9.6%)inruralareas.CHCshadcloseto110,000clients(0.9%ofthetotal),FGHsclosetofourmillionpatients(33.3%),FHNscloseto100,000(0.8%),FHOsovertwomillion(18.9%),FHTscloseto1.9million(15.7%),‘Other’modelsabouthalfamillion(4.5%)andthosenotinagroup(NON)justoverthreemillion(25.8%).FHNsandFHOsthatwerepartofaFHTwereincludedasFHTandnotincludedintheFHNorFHOcategories.Theproportionofeachgroupthatwasruralvariedwidely,from3.4%inFHGsto36.0%inFHNs.

•ThepercentfemalewaslargerthanmaleforallmodelsexceptthosewhowerenotinaCHCandnotrostered(NON),wheretherewereslightlymoremales.

•Theproportionofchildrenaged18yearsandyoungerwaslargerinruralthanurbanareasforallmodelsandwashighestintheNONgroupinbothurbanandruralareas.TheproportionofseniorswaslowestintheNONgroupandhighestintheFHNgroupinurbanareasandin‘Other’modelsinruralareas.

•Bydefinition,thelowestincomequintilerepresentscloseto20%ofresidentsineachcommunity.Thoselivinginthelowestincomeneighbourhoodswereover-representedinCHCsinbothurbanandruralareas,reaching34.5%inurbanareas.Thoselivinginlow-incomeneighbourhoodsweremostunder-representedintheFHN,FHOandFHTmodelsinurbanareasandintheFHGandFHNmodelsinruralareas.

•Newcomers,aproxyfornewimmigrantstoOntario,werefarmoreprevalentinurbanthanruralareasandweremostover-representedinCHCsandintheNONgroup,inbothurbanandruralareas.Newcomerswereunder-representedinFHN,FHOandFHTmodelsinurbanareas,withroughlyhalforlessoftheproportionforOntario.

•Thosereceivingprescriptionsthroughwelfare(OntarioWorks)ordisability(OntarioDisabilitySupportProgram)andseniorswithlow-incomewereover-representedinCHCsinbothurbanandruralareas.


Exhibit 4•Seriousmentalillnesswasmuchmore

commoninCHCsinurbanandruralareasthaninothermodels,reaching6.0%inurbanCHCsbutlessthan2%inanyothermodel.Othermentalillnesswasslightlylowerinruralthanurbanareasandsimilaracrossmodels.

•TheproportionwithasthmawasslightlyhigherinurbanthanruralareasandhighestinurbanandruralCHCs.Diabeteswashighestin‘Other’modelsandlowestintheNONgroupinbothurbanandruralareas.Chronicobstructivepulmonarydiseasewashigherinruralthanurbanareas,whileacrossmodelsitwashighestinCHCsandlowestintheNONgroupinbothurbanandruralareas.

•Resourceutilizationbands(RUBs)representquintilesofexpectedresourceuse.ThosewithnoutilizationandthoseinthelowesttwoRUBshadthegreatestrepresentationintheNONgroupinbothurbanandruralareas.CHCshadthelargestrepresentationofthosewiththehighestexpectedresourceuse(RUB4and5)inbothurbanandruralareas.AsimilarpatternwasfoundforAdjustedDiagnosisGroups,ameasureofcomorbidity.

9ICES

Exhibit 5•TheStandardizedACGMorbidityIndex(SAMI)

representsthemeanACGweightofexpectedresourceuse.Forexample,aSAMIof1.85(e.g.,urbanCHCs)canbeinterpretedasanexpectedneedforhealthcarethatis85%higherthaninthegeneralOntariopopulation,andaSAMIof0.88(e.g.,ruralNONgroup)canbeinterpretedasa12%lowerexpectedneedforhealthcarethaninthegeneralOntariopopulation.

•TheSAMIwashighestinCHCsandlowestintheNONgroupinbothurbanandruralareas.Amongtheremaininggroups,theSAMIwashighestforFHGand‘Other’modelsforbothurbanandruralareas.

Exhibit 6•ObservedmeanEDvisitswerecomparedto

expectedEDvisits(adjustedforage,sex,SAMI,incomequintileandrurality).EDvisitsinruralareaswereconsiderablyhigherthaninurbanareasforallgroups.

•ObservedratesofEDvisitswerehighestinurbanareasforCHCs,FHNsandFHTs;andinruralareasfor‘Other’modelsandFHNs.ExpectedratesfollowedasimilarpatternexceptforruralCHCswhichhadveryhighexpectedrates.

Exhibit 7•Theratioofobserved/expectedEDvisits

variedacrosslocationandprimarycaremodel.Anobserved/expectedratioof1.19(e.g.,urbanFHNs)canbeinterpretedasEDvisitsthatare19%abovethelevelexpectedwhilearatioof0.50(e.g.,ruralCHCs)canbeinterpretedas50%lowerthanthatexpected,giventhelocationandcharacteristicsofthepopulation.

•Forurbanareas,CHCs(ratio0.88),FHGs(ratio0.87)andothermodels(ratio0.99)hadratioslessthan1.0,meaningthattheirEDvisitswerelowerthanexpected.OthermodelsandtheNONgrouphadratiosabove1.0,meaningthattheirEDvisitswerehigherthanexpected.Inruralareas,CHCshadaverylowratio(0.50)andFHG,FHOand‘Other’werebelow1.0.Theremainingmodelswereabove1.0.

•Theseresultscanbeinterpretedtomeanthatafteradjustment,CHCs,FHGsand‘Other’modelswereassociatedwithlowerEDvisits,whileFHN,FHO,FHTandNONmodelswereassociatedwithhigherEDvisitsthaninthegeneralpopulation.Giventhelargepopulationsexamined,the95%confidenceintervalsforalloftheseratioswerenarrowandnonecrossed1.0,meaningthatalloftheseresultswerestatisticallysignificantatap-valueof‹0.05.


Primary Care Model Profiles Theprimarycaremodelsinvestigatedinthis

reporthadsociodemographic,morbidityandcomorbidityandEDuseprofilesthatwerequitedifferentfromeachother.Basedonthestudyfindings,abriefprofileofeachmodelcanbesummarizedasfollows:

•Community Health Centres (CHCs)aredistinctfromotherprimarycaremodelsinOntariointheirfocusontheneedsofspecificpopulations,salariedemploymentarrangements,orientationtooutreachandhealthpromotionandgovernancebycommunityboards.AlthoughafewFHTshavecommunitygovernance,thosecommunity-governedFHTscouldnotbeincludedinthisreportandarethefocusofongoinginvestigation.CHCshadpopulationsthatwereslightlyyoungerthanothermodelsandtheyweremorelikelytoberuralthanthepopulationofOntario.TheremainderofthesociodemographicprofileofCHCswasstrikinganddistinctfromtheothermodels.CHCsservedpopulationsthatwerefromlowerincomeneighbourhoods.TheyalsohadahigherproportionofnewcomerstoOntarioandahigherproportiononsocialassistance.CHCshadthehighestproportionofpeoplewithseverementalillness,asthmaandchronicobstructivepulmonarydisease,aswellasahighlevelofmorbidityandcomorbidity.Inbothurbanandruralareas,theyhadEDvisitratesthatwereconsiderablylowerthanexpected.

10ICES

•Family Health Groups (FHGs)constitutetheonlyformalprimarycaremodelthathasthemajorityofphysicianreimbursementthroughfeeforservice.Theyincludesmallcapitationpaymentsandmanyofthesamecommit-mentsandincentivesastheotherprimarycareenrolmentmodels.FHGswerealmostall(97%)urbanandhadasociodemographicprofileverysimilartothatofOntarioasawholebutwithahigherproportionofnewcomers—likelyreflectingtheirurbanlocation.ThemorbidityandcomorbidityprofileofFHGswasalsosimilartothatofOntarioasawhole.BothurbanandruralFHGshadlowerthanexpectedEDvisits.

•Family Health Networks (FHNs)werethefirstgenerallyavailableprimarycareenrolmentmodel.Theyhaveblendedreimbursementwithalargecapitationcomponent,alongwithpartialfee-for-servicepayments(10%duringthestudytimeperiod)andavarietyofobligationsandincentivesthataresimilartootherpatientenrolmentmodels.FHNwasthesmallestmodelexaminedandhadalargeruralrepresentation(36%ofFHNpatients).FHNshadahighproportionofhighincomepatients,especiallyinruralareas,andarelativelylowproportionoflow-incomepatients.FHNslookedafterfewnewcomers.FHNshadthelowestproportionofpatientswithseriousmentalillnessandrelativelylowproportionswithchronicconditions,morbidityandcomorbidity.EDvisitsinFHNswerehigherthanexpectedinbothurbanandruralareas.

•Family Health Organizations (FHOs)wereinitiallyintroducedasawaytoharmonizethePrimaryCareNetworksandHealthServiceOrganizationswithotherpatientenrolmentmodels;andtheFHOmodelalsobecameavailabletoallprimarycarephysiciansinOntario.FHOwasverysimilartotheFHNbuthadalargerbasketofservicesandahighercapitationpaymentrate.Itrapidlygainedpopularityandby2010hadbecomethemostcommonpatientenrolmentmodel.ManyFHTsarealsoFHOsbutthosepracticesaregroupedwithFHTsinthisreport.FHOshadalowproportionofpatientsfromlow-incomeneighbourhoodsandinurbanareastheyhadthehighestproportionofanymodelofpatientsfromhighincomeneighbourhoods.Theyalsolookedafterfewnewcomers.FHOwassimilartoFHNinitschroniccondition,morbidityandcomorbidityprofileandhadhigherthanexpectedEDvisitsinurbanareasbutlowerthanexpectedinruralareas.

•Family Health Team (FHT)isaninter-professionalteammodelandnotafundingmodel.TheFHTsexaminedinthisreportwereeitherFHNsorFHOsbutwereconsideredonlyasFHTsinthisreport.Intermsofsociodemographics,FHTshadahighruralrepresentation(17%).TheywereverysimilartoFHNsandFHOsinsocio-demographiccharacteristicsandtheywerealsosimilarintheprevalenceofchronicconditionsandinmorbidityandcomorbidity.TheyhadhigherthanexpectedEDvisitsinurbanandruralareas.


•Othermodelsincludedseveralsmallermodelsthatwereresponsibleforavarietyofspecificpopulations.Thisgrouphadhighruralrepresentation(21%),morelowerincomepatientsandahighproportionofnewcomers.ItalsohadslightlyhighermorbidityandcomorbiditythanforOntarioingeneralandEDvisitsthatwereslightlylowerthanexpected.

•NONpatientsthatwerenotseenatCHCsandwerenotrosteredinapatientenrolmentmodelformedthethird-largestgroupexamined(afterFHGsandFHOs).Unliketheothergroups,ithadahigherproportionofmalesthanfemalesanditalsohadamuchlargerproportionofchildren,especiallyinruralareas.Itssociodemographicprofilewassimilartothatoftheprovinceasawholebutithadamanymorehealthcarenon-usersthananyothergroupandapatternoflowerchronicdisease,morbidityandcomorbidity.IthadslightlyhigherthanexpectedEDvisitsinurbanandruralareas.

11ICES


EXHIBIT 1 Selected characteristics of primary care funding models in Ontario

PRIMARY CARE FUNDING MODEL*

Community Health Centre (CHC)

Family Health Group (FHG)

Family Health Network (FHN)

Family Health Organization (FHO)

PHYSICIAN REIMBURSEMENT Salary Blended fee for service Blended capitation Blended capitation

GOVERNANCE Community board Physician-led Physician-led Physician-led

AFTER-HOURS REQUIREMENTS Yes Yes Yes Yes

ACCOUNTABILITY AGREEMENT WITH LOCAL HEALTH INTEGRATION NETWORK Yes No No No

FORMAL ENROLMENT No Yes Yes Yes

COMMUNITY OUTREACH AND HEALTH PROMOTION SERVICES Yes No No No

LOSS OF BONUS PAYMENT FOR OUTSIDE PRIMARY CARE USE No No Yes Yes

12ICES

*FamilyHealthTeamsareexcludedsincetheyarenotfundingmodels


EXHIBIT 2 Number of rostered patients in different primary care payment models in Ontario* (excluding Community Health Centres), 2004 to 2010

Dec

Nov

Oct

Sep

Au

gJu

lJu

nM

ayA

pr

Mar

Feb

Jan

Dec

Nov

Oct

Sep

Au

gJu

lJu

nM

ayA

pr

Mar

Feb

Jan

Dec

Nov

Oct

Sep

Au

gJu

lJu

nM

ayA

pr

Mar

Feb

Jan

Dec

Nov

Oct

Sep

Au

gJu

lJu

nM

ayA

pr

Mar

Feb

Jan

Dec

Nov

Oct

Sep

Au

gJu

lJu

nM

ayA

pr

Mar

Feb

Jan

Dec

Nov

Oct

Sep

Au

gJu

lJu

nM

ayA

pr

Mar

Feb

Jan

Dec

Nov

Oct

Sep

Au

gJu

lJu

nM

ayA

pr

Mar

Feb

Jan

NUMBER OF ROSTERED PATIENTS

FHN FHO OtherFHG

2004 2005 2006 2007 2008 2009 2010

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

10,000,000

13ICES

FHG=FamilyHealthGroup,agroupblendedfee-for-servicemodel FHN=FamilyHealthNetwork,agroupblendedcapitationmodelFHO=FamilyHealthOrganization,agroupblendedcapitationmodel Other=Othersmallalternatepaymentmodels,mostlyblendedcapitationmodels*FamilyHealthTeamsareexcludedsincetheyarenotfundingmodels


EXHIBIT 3 Number and sociodemographic characteristics of Ontarians by primary care model, for all, urban and rural residents, 2008/09 to 2009/10

ALL RESIDENTS

CHC FHG FHN FHO FHT OTHER NON ONTARIO

Number 109,689 3,967,171 97,790 2,253,234 1,871,124 531,712 3,065,788 11,896,508

FEMALE (%) 57.9 54.5 53.5 53.7 54.5 52.9 46.9 52.3

AGE IN YEARS (%)

≤18 20.2 19.8 20.6 19.9 20.5 17.9 29.8 22.4

19–44 35.8 35.3 27.5 31.9 31.2 32.0 37.4 34.4

45–64 28.4 29.9 31.5 30.7 30.3 32.3 23.0 28.4

≥65 14.0 15.0 20.4 17.5 18.0 17.8 9.9 14.8

INCOME QUINTILE (%)

1 (low) 34.5 19.1 13.6 15.2 17.1 22.1 21.8 19.0

2 19.6 19.9 17.9 17.6 19.1 22.3 19.5 19.3

3 16.9 20.6 20.7 19.4 20.0 20.1 18.7 19.7

4 14.5 20.8 20.8 22.1 21.5 17.9 18.4 20.4

5 (high) 12.5 18.6 25.6 24.5 21.0 16.5 17.9 19.8

NEWCOMER** (%) 16.4 13.6 2.6 5.9 4.7 11.6 14.6 10.9

WELFARE (ONTARIO WORKS) (%) 9.2 2.9 1.8 2.0 2.2 2.9 3.8 2.9

DISABILITY (ONTARIO DISABILITY SUPPORT PROGRAM) (%) 11.0 2.6 2.6 2.5 2.8 4.0 3.1 2.7

LOW-INCOME SENIOR (%) 3.6 3.2 2.9 2.4 2.4 3.8 2.1 2.9

14ICES

CHC=CommunityHealthCentre,anemployeesalarymodel FHG=FamilyHealthGroup,agroupblendedfee-for-servicemodelFHN=FamilyHealthNetwork,agroupblendedcapitationmodel FHO=FamilyHealthOrganization,agroupblendedcapitationmodel(notpartofaFHT)FHT=FamilyHealthTeam,aninterdisciplinaryteammodelconsistingofFHNsandFHOs Other=Othersmallalternatepaymentmodels,mostlyblendedcapitationmodels NON=NotaCHCclientandnotrosteredtoaprimarycaregroup**UsedasaproxyfornewimmigrantstoOntario continuedonnextpage…


EXHIBIT3CONTINUED…

15ICES

URBAN RESIDENTS


Number 93,695 3,830,931 62,567 2,068,252 1,558,589 422,423 2,723,109 10,759,566

FEMALE (%) 58.8 54.5 54.3 53.8 54.7 53.1 46.8 52.4

AGE IN YEARS (%)

≤18 20.1 19.2 20.2 19.1 19.8 17.5 28.5 21.6

19–44 38.0 35.8 29.3 32.6 32.5 34.1 38.5 35.3

45–64 27.7 30.0 30.4 30.8 30.3 31.7 23.2 28.5

≥65 12.8 15.0 20.2 17.4 17.4 16.8 9.9 14.6

INCOME QUINTILE (%)

1 (low) 36.1 19.2 15.1 14.9 16.5 21.4 22.3 19.0

2 19.6 20.1 18.8 17.4 18.6 22.0 20.1 19.4

3 16.2 20.7 24.0 19.7 20.0 20.3 19.4 20.0

4 14.9 21.0 20.7 22.5 22.4 19.1 19.2 20.9

5 (high) 12.9 18.9 21.2 25.5 22.3 17.0 18.8 20.5

NEWCOMER** (%) 18.4 14.0 2.9 6.2 5.2 14.0 15.7 11.6




CHC=CommunityHealthCentre,anemployeesalarymodel FHG=FamilyHealthGroup,agroupblendedfee-for-servicemodelFHN=FamilyHealthNetwork,agroupblendedcapitationmodel FHO=FamilyHealthOrganization,agroupblendedcapitationmodel(notpartofaFHT)FHT=FamilyHealthTeam,aninterdisciplinaryteammodelconsistingofFHNsandFHOs Other=Othersmallalternatepaymentmodels,mostlyblendedcapitationmodels NON=NotaCHCclientandnotrosteredtoaprimarycaregroup**UsedasaproxyfornewimmigrantstoOntario continuedonnextpage…



16ICES

RURAL RESIDENTS


Number 15,994 136,240 35,223 184,982 312,535 109,289 342,679 1,136,942

FEMALE (%) 52.2 52.5 52.2 52.6 53.1 52.0 47.7 51.2

AGE IN YEARS (%)

≤18 21.1 36.6 21.3 28.6 24.2 19.8 39.9 30.6

19–44 22.6 22.5 24.4 24.5 24.9 24.0 28.6 25.5

45–64 32.1 25.9 33.6 29.3 30.2 34.6 21.2 27.4

≥65 21.5 15.0 20.7 17.7 20.6 21.6 10.3 16.5

INCOME QUINTILE (%)

1 (low) 24.8 16.5 10.9 18.7 20.1 24.7 17.4 18.9

2 19.5 15.2 16.3 20.6 21.4 23.7 14.4 18.5

3 21.4 16.8 14.9 16.9 19.5 19.3 13.3 16.7

4 12.2 15.1 20.9 17.9 17.4 13.3 11.9 15.2

5 (high) 9.8 10.1 33.5 13.6 14.4 14.6 10.6 13.1

NEWCOMER** (%) 4.3 3.0 2.2 3.2 2.2 2.7 5.7 3.6




CHC=CommunityHealthCentre,anemployeesalarymodel FHG=FamilyHealthGroup,agroupblendedfee-for-servicemodelFHN=FamilyHealthNetwork,agroupblendedcapitationmodel FHO=FamilyHealthOrganization,agroupblendedcapitationmodel(notpartofaFHT)FHT=FamilyHealthTeam,aninterdisciplinaryteammodelconsistingofFHNsandFHOs Other=Othersmallalternatepaymentmodels,mostlyblendedcapitationmodels NON=NotaCHCclientandnotrosteredtoaprimarycaregroup**UsedasaproxyfornewimmigrantstoOntario


EXHIBIT 4 Morbidity and comorbidity of Ontarians by primary care model, for all, urban and rural residents, 2008/09 to 2009/10

ALL RESIDENTS


Number 109,689 3,967,171 97,790 2,253,234 1,871,124 531,712 3,065,788 11,896,508

MENTAL HEALTH STATUS (%)

Serious mental illness 5.6 1.6 1.4 1.6 1.7 1.6 1.4 1.5

Mental illness 22.0 25.7 19.8 22.9 19.7 24.4 18.6 22.2

No mental illness 72.0 72.3 75.7 74.5 76.5 72.3 76.8 74.6

ASTHMA (%) 8.2 7.7 5.1 6.2 5.4 6.6 6.9 6.8

DIABETES (%) 9.5 9.8 9.0 8.6 8.0 10.4 5.7 8.3

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (%) 4.3 2.3 2.9 2.6 2.7 2.9 1.7 2.3

RESOURCE UTILIZATION BANDS (RUBS) (%)

No utilization 1.7 11.2 11.6 11.3 11.7 10.2 15.9 12.4

RUB 1 (low morbidity) 7.1 4.3 5.8 5.7 6.2 4.6 8.7 6.1

RUB 2 18.6 15.1 18.3 17.9 19.2 16.0 22.4 18.3

RUB 3 49.2 50.4 46.5 47.8 45.9 49.8 40.4 46.6

RUB 4 17.3 14.6 12.7 12.9 12.5 14.3 9.5 12.6

RUB 5 (high morbidity) 6.1 4.4 5.1 4.4 4.5 5.1 3.1 4.1

ADJUSTED DIAGNOSTIC GROUPS (ADGS) (%)

No utilization 1.7 11.2 11.6 11.3 11.7 10.2 15.9 12.4

1–3 ADGs (low comorbidity) 28.8 24.0 32.7 30.5 33.9 27.8 38.5 30.8

4–7 ADGs 42.2 40.5 38.2 39.1 37.7 39.6 32.1 37.6

8–10 ADGs 17.3 16.4 12.2 13.3 11.7 15.1 9.4 13.2

11+ ADGs (high comorbidity) 6.1 7.9 5.3 5.9 5.0 7.3 4.1 6.1

CHC=CommunityHealthCentre,anemployeesalarymodel FHG=FamilyHealthGroup,agroupblendedfee-for-servicemodelFHN=FamilyHealthNetwork,agroupblendedcapitationmodel FHO=FamilyHealthOrganization,agroupblendedcapitationmodel(notpartofaFHT)FHT=FamilyHealthTeam,aninterdisciplinaryteammodelconsistingofFHNsandFHOs Other=Othersmallalternatepaymentmodels,mostlyblendedcapitationmodels NON=NotaCHCclientandnotrosteredtoaprimarycaregroup continuedonnextpage…

17ICES



URBAN RESIDENTS


Number 93,695 3,830,931 62,567 2,068,252 1,558,589 422,423 2,723,109 10,759,566



Mental illness 22.9 25.8 21.3 23.2 20.3 25.5 19.1 22.8


ASTHMA (%) 8.6 7.8 5.4 6.3 5.5 6.8 7.2 7.0

DIABETES (%) 9.3 9.9 9.1 8.7 7.9 10.2 5.8 8.4



No utilization 1.5 10.9 11.5 10.9 11.4 9.9 15.2 12.0


RUB 2 18.6 15.2 18.0 18.0 19.3 15.9 22.7 18.3

RUB 3 48.8 50.6 46.6 48.0 46.1 50.3 40.7 46.9

RUB 4 17.8 14.6 13.0 13.0 12.5 14.4 9.5 12.7



No utilization 1.5 10.9 11.5 10.9 11.4 9.9 15.2 12.0


4–7 ADGs 42.4 40.6 38.4 39.3 38.0 40.2 32.6 37.9

8–10 ADGs 17.8 16.5 12.5 13.5 11.8 15.6 9.7 13.5


18ICES

CHC=CommunityHealthCentre,anemployeesalarymodel FHG=FamilyHealthGroup,agroupblendedfee-for-servicemodelFHN=FamilyHealthNetwork,agroupblendedcapitationmodel FHO=FamilyHealthOrganization,agroupblendedcapitationmodel(notpartofaFHT)FHT=FamilyHealthTeam,aninterdisciplinaryteammodelconsistingofFHNsandFHOs Other=Othersmallalternatepaymentmodels,mostlyblendedcapitationmodels NON=NotaCHCclientandnotrosteredtoaprimarycaregroup continuedonnextpage…



RURAL RESIDENTS


Number 15,994 136,240 35,223 184,982 312,535 109,289 342,679 1,136,942



Mental illness 16.7 20.3 17.3 19.2 17.0 20.2 13.8 17.1


ASTHMA (%) 5.5 6.2 4.7 5.3 4.8 6.1 4.9 5.2

DIABETES (%) 10.8 7.5 9.0 8.3 8.3 11.2 5.0 7.6



No utilization 2.8 19.3 11.9 15.5 13.3 11.1 20.8 16.2


RUB 2 18.5 13.4 18.8 17.2 18.7 16.6 20.1 18.0

RUB 3 51.5 46.2 46.5 45.5 44.9 48.1 38.5 43.7

RUB 4 14.5 12.3 12.1 11.9 12.0 13.7 9.3 11.4



No utilization 2.8 19.3 11.9 15.5 13.3 11.1 20.8 16.2


4–7 ADGs 41.3 36.5 37.9 36.0 36.2 37.2 28.4 34.1

8–10 ADGs 14.8 12.2 11.8 11.1 10.9 13.0 7.2 10.2


19ICES

CHC=CommunityHealthCentre,anemployeesalarymodel FHG=FamilyHealthGroup,agroupblendedfee-for-servicemodelFHN=FamilyHealthNetwork,agroupblendedcapitationmodel FHO=FamilyHealthOrganization,agroupblendedcapitationmodel(notpartofaFHT)FHT=FamilyHealthTeam,aninterdisciplinaryteammodelconsistingofFHNsandFHOs Other=Othersmallalternatepaymentmodels,mostlyblendedcapitationmodels NON=NotaCHCclientandnotrosteredtoaprimarycaregroup


EXHIBIT 5 Standardized ACG Morbidity Index (SAMI) of Ontario residents by primary care model, for all, urban and rural residents, 2008/09 to 2009/10

1.84

1.26

1.071.11

1.04

1.22

0.95

1.85

1.26

1.08 1.111.05

1.23

0.96

1.77

1.20

1.04 1.071.03

1.15

0.88

PRIMARY CARE MODELS

AVERAGE SAMI

CHC FHG FHN FHO FHT Other NON CHC FHG FHN FHO FHT Other NON CHC FHG FHN FHO FHT Other NON

All Urban Rural

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

ACG=JohnsHopkinsAdjustedClinicalGroups(ACG)Case-MixSystem SAMI=StandardizedACGMorbidityIndex,withACGweightsstandardizedtotheOntariopopulation(1.0=averageOntarioresident) CHC=CommunityHealthCentre,anemployeesalarymodel FHG=FamilyHealthGroup,agroupblendedfee-for-servicemodel FHN=FamilyHealthNetwork,agroupblendedcapitationmodel FHO=FamilyHealthOrganization,agroupblendedcapitationmodel(notpartofaFHT) FHT=FamilyHealthTeam,aninterdisciplinaryteammodelconsistingofFHNsandFHOs Other=othersmallalternatepaymentmodels,mostlyblendedcapitationmodels NON=notaCHCclientandnotrosteredtoaprimarycaregroup

20ICES


EXHIBIT 6 Observed and expected mean emergency department (ED) visits per person for Ontario residents by primary care model, for all, urban and rural residents, 2008/09 to 2009/10

PRIMARY CARE MODELS

ED VISITS PER PERSON


All Urban Rural

ExpectedObserved

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

21ICES

Expected=afteradjustmentforage,sex,rurality(forallandurban)andJohnsHopkinsAdjustedClinicalGroups(ACGs) CHC=CommunityHealthCentre,anemployeesalarymodel FHG=FamilyHealthGroup,agroupblendedfee-for-servicemodel FHN=FamilyHealthNetwork,agroupblendedcapitationmodel FHO=FamilyHealthOrganization,agroupblendedcapitationmodel(notpartofaFHT) FHT=FamilyHealthTeam,aninterdisciplinaryteammodelconsistingofFHNsandFHOs Other=othersmallalternatepaymentmodels,mostlyblendedcapitationmodels NON=notaCHCclientandnotrosteredtoaprimarycaregroup


EXHIBIT 7 Ratio of observed/expected mean emergency department (ED) visits per person for Ontario residents by primary care model, for all, urban and rural residents, 2008/09 to 2009/10

0.790.86

1.25

1.061.12

0.94

1.07

0.88 0.87

1.19

1.05

1.14

0.99

1.08

0.50

0.90

1.15

0.91

1.010.96

1.14

PRIMARY CARE MODELS

OBSERVED/EXPECTED ED VISITS PER PERSON


All Urban Rural

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

22ICES

Expected=afteradjustmentforage,sex,rurality(forallandurban)andJohnsHopkinsAdjustedClinicalGroups(ACGs) CHC=CommunityHealthCentre,anemployeesalarymodel FHG=FamilyHealthGroup,agroupblendedfee-for-servicemodel FHN=FamilyHealthNetwork,agroupblendedcapitationmodel FHO=FamilyHealthOrganization,agroupblendedcapitationmodel(notpartofaFHT) FHT=FamilyHealthTeam,aninterdisciplinaryteammodelconsistingofFHNsandFHOs Other=othersmallalternatepaymentmodels,mostlyblendedcapitationmodels NON=notaCHCclientandnotrosteredtoaprimarycaregroup


Discussion

23ICES

TheseanalyseshavedemonstrateddistinctlydifferentpatternsforOntario’svariousprimarycaremodels.CHCsservedhigh-needsclientsandhadlowerthanexpectedEDvisits.FHGsandanumberof‘Other’modelsservedpatientsthatwererepresentativeofthepopulationandhadlowerthanexpectedEDvisits.FHNs,FHOsandFHTs—Ontario’scapitationmodels—servedhigherincomepopulationsandhadfewnewcomers.Theyalsohadsomewhatlowerpatternsofchronicdisease,morbidityandcomorbidityandhadhigherthanexpectedEDvisits.Manyofthosenotinanyofthemodelsexaminedappearedtobeyounger,maleandhavefewerhealthcareneeds.

Inthepastfewyears,majornewinvestmentshavebeenmadeinprimarycaremodelsinOntario,especiallyteamandcapitationmodels.Ontario’sAuditorGeneralreportedthat$1.6billionwasspentonnon-fee-for-servicepaymentstofamilyphysiciansin2009/10,amountingto43%oftotalpaymentstofamilyphysicians.29ThemajorityofthesepaymentswouldhavegonetophysiciansinFHNsandFHOs,includingthosethatwereinFHTs.By2009/10,meangovernment

paymentsperphysicianwerehigherintheFHNandFHOmodelsthaninothermodelsofcare.30AdditionalfundingforFHTsbeyondphysicianpaymentwas$244millionin2010/11.29Themodelsofcaremostbenefitingfromthesesubstantialinvestments(FHNs,FHOsandFHTs)allappeartoproportionallyservemoresociallyadvantagedpopulationsandthosewithfewerhealthcareneedsthanotherOntariomodels.Thesefindingslikelyreflectpre-existingpatternsamongthephysiciansandgroupsthatchosetojointhesemodels.31Capitationschemesinmanyotherjurisdictionsadjustpaymentsforpatienthealthcareneeds,socioeconomicdisparitiesorboth.Lackofsuchadjustmentmayhavecreatedbarrierstoentryforphysicianswithsickerpractices24,32andprovidedanincentiveforthosewithhealthierpracticestochooseacapitationpaymentmodel.Aspatientswithhighsocioeconomicstatustendtobehealthier,thesehealthierpracticeswouldalsobeexpectedtobewealthier.HigherthanexpectedEDvisitsincapitationpracticesarealsolikelytohavebeenfeaturesofthesepracticesbeforetheyconvertedfromfeeforservice.31Ontario’scapitationmodelshaveamajordisincentiveforoutsideuseoffamily

physiciansorwalk-inclinics(theycanloseapotentialaccessbonusofupto18.6%ofcapitationpayments),butthereisnopenaltyforEDuse.Therefore,practicesincommunitieswithfewwalk-inclinics,urgentcarecentresorphysiciansoutsideoftheirgroupmayreceiveaccessbonuspaymentseveniftheyprovideinadequateaccess.Physiciansinthesetypesofcommunitiesmayhavebeenattractedtoalargerincomeboostfromswitchingtocapitation.Untilrecently,physicianswereabletomakedecisionsaboutswitchingmodelsbasedonMinistry-providedincomeprojections.Thelackofadjustmentforhealthcareneedsandthestructureoftheaccessbonusmayhavecontributedtothepatternsfoundinthisstudy.However,theexactmechanismsremaintobeelucidatedandrequirefurtherstudyandpolicyanalysis.

BothFHTsandCHCsaredesignedtomeetlocalcommunityneeds,butCHCsaredistinctfromothermodelsinhavingabroadergroupofservicesthatincludehealthpromotionandthataddresssocialdeterminantsofhealth.TheyalsohavegovernancethroughacommunityboardandaccountabilityagreementswithLocalHealthIntegration


Networks.CHCsservedisadvantagedpopulationsasaconsequenceoftheircommunitymandate,butthereasonswhytheyareassociatedwithlowerthanexpectedEDvisitsisnotknown.Possiblefactorsincludehealthpromotingservices,communityengagement,longerappointmentduration,thepresenceoflong-establishedinterdisciplinaryteams,extendedhours,clientpreferences,providerpracticestyles,practicelocationinrelationtoexistingservicesandthenatureofappointmentscheduling.ThemechanismsresponsibleforlowerthanexpectedEDvisitsareimportantforhealthpolicydecisionsandrequirefurtherinvestigation,asdoestheefficiencyofCHCsinrelationtooutcomes.12

24ICES

LIMITATIONS Thisreporthasanumberoflimitationsthat

shouldbeconsideredwheninterpretingitsfindings.

•AmongCHCclients,11.5%didnothaveahealthcardnumberandcouldnotbelinkedtoOntariodatabases.TheCHCprofileisthereforenotrepresentativeofallCHCclients,butitdoesincludecloseto90%ofclientsseenintheprevioustwoyears.ThecharacteristicsandpatternsofEDuseofthoselackinghealthcoveragerequiresfurtherinvestigation.

•Nursepractitionersoftenseepatientswhodonotseephysicians.NursepractitionerencounterdatawereavailableforCHCsbutnotFHTsandforthatreason,nursepractitionerencounters(representing22%ofclientsinCHCs)wereexcluded.InclusionofnursepractitionerdatamayhaveresultedinlowerlevelsofmorbidityandcomorbidityforCHCsandFHTsifnursepractitionershadpracticesthatwerelesscomplexthanthoseofphysicians.Inkeepingwiththatassumption,inclusionofnursepractitionerdataforCHCsresultedinaSAMIvalueof1.67,lowerthanthatforphysicianvisitsonly(1.84)butstillconsiderablyhigherthanthatinothermodels(datanotshown).

•PatientsandclientswhodiedbeforeApril1,2010wereexcludedfromtheanalysis.Thismayhaveunderestimatedthecomplexitywithinallofthemodelsbecausethosewhodiedmayhavehadcomplexproblemsandhighresourceutilizationneedsduringtheperiodpriortodeath.

• Incomequintilesrepresentarea-levelincomeandmaynotaccuratelyreflectincomelevelsofindividuals.Theyareverycommonlyusedinhealthservicesresearch,however,anddocorrelatewithindividual-levelincome.

•ThecompletenessofdatamayhavebeenanissueatCHCs,especiallythosethatmorerecentlybegantouseelectronicrecords,anditmayalsohavebeenanissueincapitationmodels(FHN,FHO,FHT)thatshadowbill,asthecompletenessofshadowbillingisnotknown.

•Theseanalysesarecross-sectionalanddonothelptodistinguishwhetherphysiciansalteredtheirpracticesormixofpatientsasaresultofjoiningamodelofcareorwhetherthepatternsseenherewerepre-existing.AnearliercomparisonofEDvisitsinFHNsandFHGsfoundthathigherratesofEDvisitswerepre-existinginFHNs31andwerenotlikelytheresultofchangingpractice.


•Therearesomesubtledifferencesbetweenmodelsthatcouldhaveaffectedresults.Visitfrequencyincapitation-basedpaymentpracticesmaybelowerthaninfee-for-service,33resultinginfewerdiagnosesandthereforelowerlevelsofmorbidityandcomorbidityonthemeasuresusedinthisstudy.VisitfrequencyinCHCscouldalsohaveaffectedthesemeasures,butthedirectionoftheeffectisnotknown,noristheeffectofusingasinglerandomdiagnosisforCHCvisits.BothCHCsandFHTshaveinterdisciplinaryteamsbutthoseteamsandtheirroleswereataformativestageinFHTsandwell-establishedinCHCsduringthetimeframeofthisstudy.

•EncounterdataforCHCswerederivedfromlocalelectronicrecordswhileforothergroupsphysicianbillingclaimswereused.Thesedifferencesindatasourcesmayhaveintroduceddifferencesinmeasuredpatternsofmorbidityandcomorbiditybutthenatureanddirectionofsucheffectsarenotknown.ItwaspossibleforanindividualtoappearinbothCHCdataandamongpatientsrosteredinaprimarycaremodel,althoughthathappenedrarely.Inthosecases,theindividualwasassignedtotheCHC.

25ICES

•ThelinkbetweenEDvisitsandaccesstoprimarycareismediatedbyanumberoffactorsthatwewereunabletomeasure.Theseincludetheavailabilityandappropriatenessoflocalresources,suchaswalk-inclinicsandurgentcarecentres,patientpreferencesforplaceofcare,physicianpracticestyles,distancestofacilities,availabilityofparkingorpublictransitandhoursofoperation.ItislikelythattheseunmeasuredfactorswereresponsibleforsomeofthevariationinEDvisitswefoundacrossgroups.

•Finally,manyEDvisitsarenotavoidable,evenwiththebestprimarycare.TheexistingconsensusonavoidableEDvisitshasidentifiedaverysmallproportion,34consistingofminoracuteinfections,buttheactualproportionthatisavoidableisnotknown.TriagelevelhasbeenusedasaproxyforavoidableEDvisits.31Itwasnotusedinthisreportbecausecodingwassubstantiallyrevisedduringthestudyperiod,35,36andhowcodingchangedacrossurbanandruralareasisnotknown.Nonetheless,asubstantialproportionofEDvisitsappeartobelinkedtolackofaccesstotimelyprimarycare.37,38

Thisworkalsohelpedtoidentifyseveralprovincialdatalimitations.

•ForemostamongtheseistheabsenceofCHCencounterdatainOntario’shealthdatabases.ThismadeitchallengingtocomparemodelsasCHCdatahadtobecollectedmanuallyfromelectronicrecords,whilerecordsforencountersinothermodelsarecollectedroutinelyaspartofphysicianbillingclaims.

•Asecondmajorissuewasthelackofencounterdatafornursepractitionersandothernon-physicianprovidersinallmodels.Itwillbeverydifficulttodeterminethecontributionoftheseproviders,especiallynursepractitioners,withoutsystematicallycollectingdataabouttheiractivitiesatthelevelofpatientsandclients.

•Althoughcapitationmodelsshadowbill,thecompletenessofshadowbillingisunknownandrequiresstudyandvalidation.Finally,manyhealthnumbersintheRPDBhaveoutdatedaddresses,makinggeographicinferences(suchasurban-ruralorincomequintiles)subjecttomisclassification.


POLICY IMPLICATIONS Thesefindingsprovideseveralimplications

forpolicy.

1 / CHC Model:TheCHCmodelappearstoplayanespeciallyimportantroleinOntariofordisadvantagedpopulations.AcontinuinginfluxofimmigrantstoOntarioandgrowingincomeinequalitiessuggestanincreasinglyimportantneedforcareinthesepopulations.OtherresearchhasfoundthathealthcareatCHCsisassociatedwithbetterchronicdiseasemanagementandgeriatriccare,morecomprehensivecareandgreatercommunityorientation.7–11ThecurrentanalysesfindthatCHCcareisalsoassociatedwithlowerthanexpectedEDvisits.

2 / Capitation Rates:FHGsand‘Other’modelscareforaprofileofaverageOntariansandalsohavelowerthanexpectedEDvisits.Thecapitationmodels(FHN,FHO,FHT)servemoreadvantagedOntarianswithalowerillnessprofileandhavehigherthanexpectedEDuse.Adjustingcapitationratestoaccountforhealthcareneedscouldhelptobringmorehighneedspatientsandmorehighneedspracticesintothesemodels.Currently,FHGsthatswitchtocapitationcanexpecttoloseincome32inlargepartduetohavingsickerthanaveragepractices.ThisbarriertojoiningcapitationmodelsisalsoabarriertojoiningFHTsbecauseonlycapitationmodelsareallowed.Thissituationwouldlikelychangewithappropriatecapitationadjustment.

26ICES

3 / Payment Incentives:ThecurrentaccessbonuspaymentforavoidingoutsideprimarycareuseappearstobethewrongincentivetoremedyOntario’sveryhighuseofhospitalEDs16asitdoesnothingtodiscourageEDuse.Aswell,manypracticesreceivelittleornoaccessbonusandthisoftenoccursinsettingswithmanyalternatesourcesofcare,suchasmajorurbancentres.Practicesinthosesettingsthatprovideexcellentaccessreceivethesametreatment(nobonus)asthosethatfailtoprovideaccess.Theaccessbonusmayalsoactasadeterrentforprovidersindifferentgroupsandmodelstoworktogethertoprovidetimelyandafter-hoursaccesstomembersoftheircommunity.Anotherreasontore-examinetheaccessbonusisthataccesstotimelycareandafter-hourscarehasnotimprovedinrecentyearsdespiteanincreasingnumberofOntarianshavingafamilydoctor.39Ifpaymentincentivesforaccessremainedadesirablefeatureofprimarycaremodels,thecurrentaccessbonuscouldberedesignedtoincorporateEDvisits,toreflectobservedversusexpectedoutsideuse,ortobebasedontheavailabilityofsame-dayandafter-hoursappointments.Amoreperson-centredapproachwouldbetobaseincentivesorotherformsofexpectationsoraccountabilitiesonpatient-reportedaccesstocare.Forexample,accessquestionsontheEnglishGeneralPracticeSurveyareusedforpractice-basedpay-for-performance,withadjustmentforpatientcharacteristics.40Inthatsetting,practicesarerewardedfor

offeringbothtimelyappointmentsandforofferingtheabilitytobookaheadoftime.Surveyresultsarepubliclyavailableatthepracticeandregionallevel.40

4 / ED Use: Ontario’shighrateofEDuseisalsoanimportantpolicytarget.Enforcementofexistingafter-hourscommitmentshasbeenproblematicbutisnowreceivinggreaterMinistryattention.29Furtherexpansionofhours,poolingofresourcesacrossgroupsandmodelsofcaretomeetcommunityneeds,41incentivizingofhomevisits,andofficeredesigntoensuretimelyaccesstoappointments42,43couldallplayimportantrolesinreducingEDuse.


IMPLICATIONS FOR EVALUATION AND RESEARCH

Thesefindingsalsoprovideimplicationsforevaluationandresearch.TheDecember2011reportfromtheOntarioAuditorGeneralnotedthattheMinistryofHealthandLong-TermCare“…hadnotyetconductedanyformalanalysisofwhethertheexpectedbenefitsofthesemorecostlyalternativefundingarrangementshavematerialized.”29Inthesamereport,thechallengesofdoingthattypeofanalysis,aswellasthecomplexityofprimarycaremodelsandpaymentsinOntario,wereacknowledged.Therearenotrueexperimentsandfewlongitudinalanalysesavailabletounderstandtheimpactofnewprimarycaremodels33andthesearemuchneededtohelpseparatecausesfromeffects.Investmentsmayhavepositiveeffectsthatarenoteasilydiscernedinprovince-widetrends,suchasthereversaloftheshrinkingprimarycarephysicianworkforceafter2000/01,withoutwhichaccesstocaremayhaveworsenedratherthanremainedthesame.30ComparisonswithotherCanadianjurisdictionswouldbevaluable,aswouldcomparisonswithprimarycarereformsinotherdevelopedcountries.Strongprimarycareisthefoundationofhigh-performinghealthsystems44–46buthowbesttoorganizeprimarycareisnotaswellunderstood.Eachmodelofprimarycareappearstohaveboth

strengthsandweaknesses.6Thedetailsofcapitationpaymentschemesmaybeespeciallyimportantforensuringtimelyaccesstocareandtheinclusionofdisadvantagedandsickerpopulations.Itisextremelychallengingtounderstandwhatmixofmodelsisbestinordertomeetpopulationandhealthsystemneeds.VerylittleworkhasbeendonetounderstandvalueformoneyinOntario’sprimarycaremodels12,33,47,48andsuchstudiesarelongoverdue.

“Very little work has been done to

understand value for money in

Ontario’s primary care models and

such studies are long overdue.”

27ICES


Conclusions

28ICES

Ontario’sprimarycaremodelsservedifferentpopulationsandareassociatedwithdifferentoutcomes.Amoveawayfromfee-for-servicereimbursementmaybedesirableforahighfunctioninghealthcaresystem,buthowalternatepaymentmechanismsarestructuredappearstomatteragreatdeal.Thelargestcurrentmodelsofcarehavebeencostlybuthavehadlimitedimpactonpopulationaccesstocare,whichwasakeyaim.ThecapitationandteammodelsthathavereceivedthemostnewresourcesarelookingafterrelativelyadvantagedgroupsandareassociatedwithhigherthanexpectedEDvisits.Thepaymentandincentivestructuresunderlyingthesemodelsthereforerequirere-examination.TheCHCmodeloffersanattractivealternativeinmanyrespects,butCHCsserveadifferentrolethantheotherprimarycaremodelsandareresourcedandgovernedquitedifferently.WheretheyfitwithinprimarycareinOntarioshouldalsobethesubjectoffurtherpolicyconsideration.

Sofar,littleworkhasbeendonetounderstandvalueformoneyinOntario’sprimarycaremodelsandsuchanalysesarelongoverdue.Ontario’sdiversityofprimarycaremodels,ifproperlyevaluated,canprovideawealthofinformationforpolicymakers.Decision-makersinOntarioandotherprovincesandcountriesaregrapplingwithhowtomakehealthsystemsmoreeffectiveandefficient.Ontariohasauniqueopportunitytoredesignprimarycarebyunderstandingandapplyingevidenceaboutitsmanymodelsofcare.ItishopedthatthisreportmayhelppolicymakerstounderstandhowOntario’sprimarycaremodelsrelatetothetypesofpatientsservedandtheoutcomeofEDvisits,withaviewtowardsre-orientingexistingresourcesandfutureinvestments.


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Institute for Clinical Evaluative Sciences (ICES)

G1 06, 2075 Bayview Avenue Toronto, Ontario M4N 3M5

Email: [email protected] 416.480.4055

www.ices.on.ca

mailto:info%40ices.on.ca?subject=

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