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OPINION / PRIMARY CARE REFORM

Not what the doctor ordered

Family practice in this country needs first aid but family health networks aren't the best treatment

By Douglas Mark The Chinese have a wonderful saying—a curse, actually: "May you live in interesting times." For doctors practising in Canada, these past few months have been, if nothing else, very interesting.
We have seen physicians in Alberta and British Columbia go head-to-head with their respective provincial governments during fee-for-service negotiations.
Members of the Newfoundland and Labrador Medical Association have become so fed up with the conditions under which they must work that they have been left with little choice but to go on strike.
In Quebec, we have seen what happens when a government tries to repair the damage it's done to its own health-care system—in this case, through Bill 114—by trying to legislate how doctors practise medicine.
Here in Ontario, the curse for family physicians has come in the form of primary care reform.
In recent weeks, we have seen Health Minister Tony Clement and Dr. Ruth Wilson, who heads up the Ontario Family Health Network, announce that four more family health networks have been formed in Ontario, and that nearly 1,000 family physicians have contacted the network over the past few months for an analysis of their earning potential under the government's primary care reform plan.
This all sounds very encouraging. Unfortunately for Clement and Dr. Wilson, the reality is that to date less than 0.5% of family physicians who are eligible have signed up.
Of course, none of this comes as much of a surprise to us.
As the results of the Coalition of Family Physicians of Ontario's primary care reform survey made quite clear, family physicians are simply not interested in participating. A resounding 98% of the 1,350 respondents rejected the contents of the network's template agreements. A further 97% called on the Ontario Medical Association to hold a referendum on the issue.
So, what is wrong with the Ontario government's primary care reform plan?
Well, for one thing, the government is downloading all legal responsibility and insurance risk onto family physicians.
For another, both the blended base rate and reformed-fee-for-service benchmark threshold cap are dismally low when you consider family physicians will be expected to provide 24/7 care, 365 days a year.
There is also no provision for inflation or cost-of-living or practice costs increases, as well as no mechanism for future payment negotiation or dispute resolution.
Finally, and perhaps most important of all, the Ontario government has yet to produce one study which shows reforming the way primary care is delivered will improve patient care or save money.
The Coalition of Family Physicians of Ontario says primary care is not in need of major reform.
What we need instead is "family practice enhancement."
This would include:
•More doctors: If the Ontario government is serious about addressing our doctor shortage, we need to increase the number of qualified students being accepted into medical school by 200 per year.
Currently, only 28% to 29% of the crop of medical students are choosing family practice as their first choice—down from more than 50% only 10 years ago.
Sadly, money seems to be the key factor in this choice, as the net income of family physicians has fallen to just slightly more than half of that of specialists.
• Less bureaucracy and more resources: To enhance family practice, we need less government control and interference in our practices.
We also need more specialists, nurses, pharmacists, hospital beds, public health promotion and practical, affordable information technology.
The Ontario government likes to talk about how information technology is one of the great benefits of family health networks.
The reality is, however, that for the most part none of these computers—including those in the original pilot projects—are linked together.
• Adequate funding: Currently, family physicians are billing the health-care system here in Ontario about $1.7 billion a year.
Given there are roughly 11.5 million people living in Ontario, this works out to about 40 cents per day per patient—or about $148 per year—which is totally inadequate considering the huge amount of health care family physicians provide for our patients.
Even if the Ontario government were to make a modest investment and give family physicians 40% more to care for our patients, this would still only be an increase of about 15 cents per day per patient—which is small change indeed when we are talking about an overall health-care budget in excess of $20 billion per year.
In medical school, we are taught to treat the symptoms and cure disease. We are also taught a bandage is of little use when a patient is hemorrhaging.
Unfortunately, the Ontario government's primary care reform plan does little to address the real needs of our health-care system. This is why we feel it is necessary to remind the government there is no shame in admitting failure.
But to blindly charge ahead, ignoring all the evidence to the contrary and turning primary health care into a public relations exercise is not only wrong, it is downright dangerous.
—Douglas Mark is the president of the Coalition of Family Physicians of Ontario. He can be reached at dmark@cofp.com.

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