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Urban, poor and new immigrants less likely to get high quality care

A version of this commentary appeared in the Toronto Star and the Huffington Post

Primary care is considered the front door to our health care system. Whether you’re going for a general check-up or have just been diagnosed with cancer, your family doctor makes sure you get the tests, treatment and care you need.

But not all family practices in Ontario are created equal.

Most Ontarians don’t realize it, but over the last decade and a half, there has been a transformation around how primary care is delivered. Much of the change has involved how doctors are paid and organized.

In the early 2000s, most doctors in Ontario were paid by the visit (fee-for-service) and most ran their own independent practices. The system was designed for a time when people went to the doctor because they felt sick. But people are living longer now and many have complicated diseases that last a lifetime and require nuanced management.

Canada was lagging behind other countries in access and quality of care, so the Ontario government increased spending in primary care. They gave family doctors large financial incentives to start working in groups and pool their resources to provide after-hours care.

Doctors who agreed to join a group were asked to formally take responsibility for their patients and “enrol” them into their practice. The provincial government also offered doctors bonuses if their patients didn’t see family doctors outside the group. There were also bonuses for meeting targets for cancer screening and immunizations.

Some of the doctors in the new groups are still mostly paid by the visit. But just over half of doctors in these new groups get most of their income from an annual payment for each patient (capitation). The annual payment is based on the age and sex of the patient and is the same whether they see the patient 10 times, once or not at all.

In theory, this new payment system gives physicians more flexibility to spend longer with patients if needed and to provide advice by phone or email if that is more efficient.

Some of the new groups were also allowed to apply for funding to hire other professionals — social workers, nurse practitioners, dietitians and others — to work alongside them in Family Health Teams.

Now, more than 10.5 million Ontarians have a doctor who works in one of these new groups. Quality of care has improved for them, particularly for patients who are part of a Family Health Team.  That’s good news.

But what about the 2.3 million who have been left behind from these new groups?

In a recent study published in the Annals of Family Medicine, my colleagues and I found that those left behind from new group practices receive poorer quality care. They are less likely to receive recommended screening for cervical, breast or colorectal cancer, and if they have diabetes, they are less likely to get the necessary tests.

Most troubling is that the patients left behind are more likely to be poor and new to Canada — and most live in urban areas.

Our study also found that the patients left behind were actually getting poorer quality care even before reforms were introduced. Why?

Joining new groups was voluntary for doctors. Perhaps doctors who were most open to change and were providing better quality care to begin with were more likely to sign up for the new groups.

Reforms were theoretically voluntary for patients too. But some probably didn’t have a family doctor and likely couldn’t get into one of the new group practices. Instead they got care from walk-in clinics. Others probably just stuck with the doctor they had — who worked alone and got paid by the visit.

Unfortunately, the gap in health services for those left behind has actually grown over time since the new health reforms.

The Ontario government has pledged that all Ontarians will have access to a family doctor or nurse practitioner close to home. But simply having a family doctor may not be enough.

Our study shows you get better care if you have a doctor who formally enrols patients, pools resources with colleagues to provide after-hours care and takes responsibility for preventing and managing chronic disease.

Unfortunately, the Ontario government has recently restricted entry into some of the new practice models. But, others are still available for physicians to join. We need to understand what’s keeping some doctors from joining the practice models that are available to them.

Most importantly, we need to reach out to those new to Canada and those living in poverty to ensure they are getting equitable care.

No Ontarian deserves to be left behind.


Tara Kiran is an expert advisor with EvidenceNetwork.ca, a Family Physician and Researcher in the Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto and an Adjunct Scientist at the Institute for Clinical Evaluative Sciences.

November 2016 


This work is licensed under a Creative Commons Attribution 4.0 International License.