ICES | Primary Care Models in Ontario English - page 32

Comparison of Primary Care Models in Ontario by Demographics, Case Mix and Emergency Department Use, 2008/09 to 2009/10
Discussion
23
ICES
These analyses have demonstrated distinctly
different patterns for Ontario’s various
primary care models. CHCs served high-
needs clients and had lower than expected ED
visits. FHGs and a number of ‘Other’ models
served patients that were representative of
the population and had lower than expected
ED visits. FHNs, FHOs and FHTs—Ontario’s
capitation models—served higher income
populations and had few newcomers. They
also had somewhat lower patterns of chronic
disease, morbidity and comorbidity and had
higher than expected ED visits. Many of those
not in any of the models examined appeared
to be younger, male and have fewer health
care needs.
In the past few years, major new investments
have been made in primary care models in
Ontario, especially team and capitation
models. Ontario’s Auditor General reported
that $1.6 billion was spent on non-fee-for-
service payments to family physicians in
2009/10, amounting to 43% of total payments
to family physicians.
29
The majority of these
payments would have gone to physicians in
FHNs and FHOs, including those that were in
FHTs. By 2009/10, mean government
payments per physician were higher in the
FHN and FHO models than in other models of
care.
30
Additional funding for FHTs beyond
physician payment was $244 million in
2010/11.
29
The models of care most benefiting
from these substantial investments (FHNs,
FHOs and FHTs) all appear to proportionally
serve more socially advantaged populations
and those with fewer health care needs than
other Ontario models. These findings likely
reflect pre-existing patterns among the
physicians and groups that chose to join these
models.
31
Capitation schemes in many other
jurisdictions adjust payments for patient
health care needs, socioeconomic disparities
or both. Lack of such adjustment may have
created barriers to entry for physicians with
sicker practices
24,32
and provided an incentive
for those with healthier practices to choose a
capitation payment model. As patients with
high socioeconomic status tend to be
healthier, these healthier practices would
also be expected to be wealthier. Higher than
expected ED visits in capitation practices are
also likely to have been features of these
practices before they converted from fee for
service.
31
Ontario’s capitation models have a
major disincentive for outside use of family
physicians or walk-in clinics (they can lose a
potential access bonus of up to 18.6% of
capitation payments), but there is no penalty
for ED use. Therefore, practices in
communities with few walk-in clinics, urgent
care centres or physicians outside of their
group may receive access bonus payments
even if they provide inadequate access.
Physicians in these types of communities may
have been attracted to a larger income boost
from switching to capitation. Until recently,
physicians were able to make decisions about
switching models based on Ministry-provided
income projections. The lack of adjustment
for health care needs and the structure of the
access bonus may have contributed to the
patterns found in this study. However, the
exact mechanisms remain to be elucidated
and require further study and policy analysis.
Both FHTs and CHCs are designed to meet
local community needs, but CHCs are distinct
from other models in having a broader group
of services that include health promotion and
that address social determinants of health.
They also have governance through a
community board and accountability
agreements with Local Health Integration
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