Primary Care Reform in Ontario: The Emperor Has No Clothes

Primary Care Reform in Ontario: The Emperor Has No Clothes

Published in winter issue of Hospital Quarterly (www.hospitalquarterly.com)

In the May 4, 1999 issue of the Medical Post I hypothesized that the prevailing debate around primary care reform (PCR) in Ontario raised two questions: Is PCR part of an overall strategy to "bureaucratize" medicine by the bureaucratic/pseudo-academic conspiracy that manages health? Or is PCR a Machiavellian plot by the OMA to preserve the status quo for yet another three years?

In that article, I went on to suggest that physicians are essentially civil servants with entrepreneurial privileges, and that there appears to be a battle for the minds of physicians who are challenged to submit to the civil-servant model or to subscribe to the independent solo-practice model as the only alternatives.

My reading of the articles on primary care reform by Sinclair, Bergman and Rogers in the Fall 2001 edition of Hospital Quarterly would appear to support one part of my hypothesis that PCR in Ontario is essentially an intellectual exercise. Sinclair begins by evoking the ghost of Tommy Douglas and acknowledges that after 55 years we haven't revamped the system. Douglas's 1940s vision was to provide acute care at time of need. It is unlikely that he envisioned government-sponsored home-care programs or chronic care services since in Douglas's era such support mechanisms were largely the assumed duty of the family and/or church.

The Calgary mental health program described by Bergman, as an example of where Sinclair's comments on relationship building were weak, has to be challenged. A mental health program provides a form of ongoing chronic-care service. These programs tend to adopt patients, multi-discipline teams are traditional and physician reimbursement practices tend to be more creative. Access to community-initiated, episodic acute-care services, which is the main purpose of PCR, requires a totally different paradigm of "team partnerships."

Finally, if Ontario physicians were as willing to operate within a capitation method of reimbursement as their U.K. colleagues, the Rogers article on primary care NHS style would be more relevant, however, in the context of primary care in Ontario, the article is largely academic. The lack of originality within the Hastingian1 prose, describing how the doctors, nurses and patients should perform their roles in accordance with quasi-government edicts, is a product of a decision-making system that has failed to deliver a health system that is responsive to current Canadian consumer expectations.

The three authors ignore the reality that the practice of medicine is a business enterprise. The conventional medical practice model in Canada offers a guaranteed cash flow to the practitioner, with little financial accountability- a privilege few entrepreneurs would give up. It is only through seeing comparable financial rewards, possibly with lifestyle benefits, that the majority of primary care physicians, or any clinicians, will consider changing their present practice arrangements. There is little evidence that not-for-profit, community health boards are the answer. Strategies are required that leverage targeted fee-for-service revenues with service guarantees and value-added community-based programs.

Changes in taxing arrangements in support of physicians collectively forming corporate entities of clinical expertise that contract with sections of the population may be a contributing factor in challenging the comfort level of the present regime. Under the present arrangements there is little in the way of residual value left in a medical practice following retirement or death of the practitioner. A corporate strategic perspective is required that defines both the tangible and intangible equity that a critical mass of clinical expertise could own. Part of this equity will include the ownership of the list of persons who have contracted to receive care through such an access point as well as the credentials of the physicians who own the corporation.2

A corporate model of clinical expertise would also serve to preserve knowledge gained in practice over time and, with modern IT capability, provide better management of such resources as we move further into a knowledge-based economy. These corporate group practices must be able to promote their "brand-name" quality relative to the status quo, provide a service 365 days a year, offer both private and public services, establish provincial, and national, integrated group practices and possibly offer a depth of practice that competes for available funds with hospitals. The goal would be to achieve a sustainable model that would evolve in response to tax incentives and market forces rather than by committee-generated, ministerial edicts. Through standard business practices such arrangements would be far more accountable than being managed as branch plant operations by well-meaning provincial health ministry employees.3,4

There will always be a role for academic analysis and interpretation in Canadian healthcare, particularly with respect to outcome evaluation. But, more ways must be found for giving lay business people the opportunity to engage their expertise in leveraging the cash flow arrangements supporting clinical practice. With such business opportunities, the physicians initiating such ventures, and their business investors, would likely accumulate a great deal of wealth. Arguments that such arrangements only further reward persons licensed to practice medicine are understandable but, beyond supporting one's ideological biases, are not justifiable reasons for preserving the status quo.

Tim Lynch, Health Services Reimbursement Consultant

Info-Lynk Consulting Services, www.infolynk.ca

1 Reference the original work in Canada on PCR that was done by the 1972 Community Health Centre Project Task Force chaired by Dr. John Hastings. The Task Force recommended making primary care physicians work for not-for-profit, volunteer-governed, publicly-funded, community health clinic boards.

2 "A Discussion Deck: The Bethune Clinic Inc. A Physician-owned Integrated Primary Care Service." 1998. Presented by T. Lynch, Info-Lynk Consulting Services, to Dr. Duncan Sinclair, Commissioner, Health Services Restructuring Commission. Toronto, September 14.

3 Bramham, Daphne. 2001. 'A System without Accountability: Want details of Vancouver General Hospital's Operating Budget? Don't Ask "There Isn't One." Vancouver Sun. December 14.

4 Editorial. 2001. "Restructuring Health Boards Doesn't Address Incompetence." Vancouver Sun. January 15.

Acknowledgements: The author wishes to acknowledge the critical appraisal provided by the following individuals in the preparation of this article: Dr. Robin Hutchinson, Ladysmith, B.C; David Home, Ajax-Pickering, Ontario; John Smith LL.B., Saanich, B.C.; Paul Sigurgeirson, Steveston, B.C.