Symposium on primary care payment models
On December 10, the QMA organized a symposium on primary care payment models in Montréal, which was attended by several influential physicians from the network, as well as employees from the Ministère de la Santé et des Services sociaux.
The QMA believes it has an important role to play in terms of knowledge transfer, given its close ties to the medical associations in other Canadian provinces. As such, it invited several speakers from Ontario, New Brunswick and Alberta to present the primary care payment models that have been implemented in their provinces to improve the quality of care and access to family physicians.
Several provinces have in fact restructured their primary care systems in recent years.
A new model to reduce emergency room overcrowding
In New Brunswick, where most family physicians operate solo practices, the population is aging and relies heavily on emergency departments—too much, according to the New Brunswick Medical Society (NBMS), which decided to partner with the government in that province to set up a new structure to reduce the wait times needed to see a family doctor. The main reason patients in New Brunswick end up in the emergency department is because they have a hard time getting an appointment with their family doctor.
Thanks to government funding, the NBMS was able to create a new primary care practice model based on the use of the province’s electronic medical records system (accessible for free) and a group-based practice structure that doesn’t include walk-in appointments. The doctors sign an agreement that commits them to enrolling patients and providing a block of after-hours services. In return, they receive operational support to set up or make improvements to their clinics.
In this model, the physicians are compensated through capitation payments, with amounts allocated to each patient based on their level of vulnerability. For example, the cost of the care required by a 10-year-old boy is assessed at $39.60, compared to $321.30 for a 90-year-old woman. In addition to this base salary, physicians can bill for in-person consultations and, to a lesser extent, for phone calls and emails to their patients. They can also charge for certain services provided by nurses and bill small amounts for general costs.
“In clinics that use this model, the wait time to see a doctor went from 40 days to 2 days,” explained Anthony Knight, NBMS CEO. Young doctors were targeted because many of them say they prefer to have a steady income, work in a group practice, and have a good work-life balance. After 11 months, more than 38,000 patients had been enrolled, and the government intends to expand the program in the next budget.
A model that values family medicine
In the 1990s, Ontario faced a shortage of family physicians. Only 25% of medical students were choosing family medicine as their speciality, and the ones who were practising said they were dissatisfied with their pay and their working conditions (paper records, quantity over quality of care, barriers to interdisciplinary work, etc.).
As a solution, the provincial government and the Ontario Medical Association (OMA) came up with a new model based on patient enrolment, which is still available today to physicians who are interested. Whether under a fee-for-service or capitation model, Ontario physicians have access to “quality-enhancing measures” that can increase their salary by up to 30%.
The idea is to encourage physicians to meet the needs of the population by giving them bonuses for treating vulnerable patients, working in interdisciplinary teams to manage patients with chronic diseases, providing neonatal care, being on call for their patients, etc. And to collect these bonuses, physicians need to start by using an electronic medical record system to compile the information they require for their billing.
“In the early 2000s, the new model was adopted by the vast majority of family physicians, which led to a significant increase in the number of young people choosing this speciality,” stated Dr. Peter James Kuling, the speaker from Ontario.
Today, more than 60% of Ontario’s family physicians practice in a patient enrolment model, and most in a family medicine group (capitation model) or a health group (enhanced fee-for-service model). Among other benefits, these new models decrease the number and length of hospital stays, the total healthcare costs, and the number of inappropriate or unnecessary tests and procedures, while increasing the number of services offered, consultations given, and patients treated, compliance with diabetes guidelines, and frequency of preventive care and screening tests.
Collaborative primary care model
To overcome the inefficient use of primary care resources, the Alberta Medical Association (AMA) has implemented a collaborative primary care model in which doctors and local health authorities work together for the good of the patients. The two groups made a joint decision on how to finance the primary care networks, in the form of an amount paid per patient to create a multidisciplinary team. They also agreed on responsibilities and common objectives, and on ways to help physicians make the necessary changes.
The primary care networks are now well organized, and the AMA is looking to forge ties with a broader health ecosystem. Specialists will now need to make themselves more accessible, so that the primary care networks can more easily share patient information with them. This will require upgrades to the computer systems, as well as other changes in order to come up with the necessary financing.
“A budget has been allocated to setting up primary care networks, but we need to take the change one step further,” stated AMA president Dr. Alison Clarke, “in order to harmonize the physician payment system with the patient care model.”
Models for Québec?
The models in these three provinces were made possible by the joint efforts of physicians and the provincial governments, and they’ve led to improvements in quality of care and access to family physicians. While the payment mechanisms and the funding differed, they were associated with change in all three cases.
According to the QMA, while there’s no magic formula, there are four key steps in all these success stories:
- Change the organizational structure
- Change the compensation mechanism to correspond to the new organizational structure
- Use individual and collective budget incentives
- Implement an accountability structure
In all cases, what made the difference between success and failure was the level of support provide for the change, whether financial or by engineering consultants.
Finally, any new organizational model needs to be built, not negotiated—a task that fell to the professional counterparts of the medical associations.
In Québec, if negotiations on compensation are to continue with the medical federations, more stakeholders need to be invited to the table in order to build new models with real clinical governance in place, in collaboration with the healthcare network.