The Decibel - An experiment in Ontario to improve access to family doctors

Episode Date: November 22, 2024

There’s an experiment underway in Kingston, Ont. The regional health care team is starting to assign people without a doctor to nearby clinics based on their postal code. And one of those clinics has adopted a different way to serve patients and doctors. It’s called a health home.But is this a feasible solution for an overstressed health care system? Kelly Grant, national health reporter for The Globe and Mail, reports on this new model, how it’s working in Kingston and what it could mean for the rest of Canada.Questions? Comments? Ideas? Email us at [e-mail]

Hello? Hi, is this Dorothy-Ann? Dorothy-Ann Brown is a 65-year-old patient in Kingston, Ontario. Kelly Grant is a national health reporter with The Globe. She'd been living in Halifax for a while and moved home to Kingston during the pandemic and found that she couldn't get a doctor. For her, that was particularly difficult because she's got multiple sclerosis, diabetes, and osteoarthritis. Those are all chronic conditions where it's really helpful

to have a single primary care provider to help you out. And when I came back, I knew there was a doctor shortage, and it was pretty grim at that time. And so I knew I'd have to wait for physician care, but I didn't realize I'd have to wait for four and a half years. In Ontario, 2.5 million people don't have a family doctor. That's according to the Ontario College of Family Physicians. And StatsCan reports that 17% of people across Canada aren't attached to a doctor. Ontario actually has the highest attachment rate in the country.

Not having a doctor means instead getting care in walk-in clinics or hospital emergency departments. It puts people's health at risk and can cost the system more in the long run. So there's an experiment happening in Ontario to see if there's a better way to deliver primary care. It's being championed by former federal health minister Dr. Jane Philpott. Today, Kelly Grant is here to talk about this new model, how it's working in Kingston, and what it could mean for the rest of Canada. I'm Mainika Raman-Wilms, and this is The Decibel from The Globe and Mail. Kelly, thanks for being back on the podcast.

Thanks for having me. Kelly, let's start by looking at how primary care in Ontario works right now. So we're talking about family doctors, right? How are patients in Ontario finding their family doctor? Well, it's a bit of a hunger games, especially right now, because there are so many people who can't find a regular family doctor or nurse practitioner. So the way it works now is there is a central waiting list called Healthcare Connect that people who don't have a doctor can sign up for,

but it has long been considered kind of a purgatory where you go and sit for ages and find you don't get a call to say, hey, we've got a doctor for you. Instead, people work their connections, right? They call every single clinic within a reasonable drive of their house. They ask friends and family. They ask anybody they know who works in health care to see if they can kind of muscle their way onto a roster at a family doctor's office. Okay, so that's on the patient side, which sounds like it can be pretty difficult for a lot of people to find care. Let's actually look now at how this system is working for doctors. So how are primary care doctors set up, I guess, in Ontario? your family physicians are small business people. Those businesses work in different ways, but functionally, they run practices and they build the public insurance plans in their various provinces. And within that, there are many different models of how payment works. I won't force all of our listeners to go deep into the weeds on this, but suffice it to say you have a range of payment models that go from something that's called fee-for-service, which is

where a doctor charges the public insurance plan for every discrete episode of care they deliver, to what are known as capitation models, where you sign up patients on your roster and you're paid a set fee annually, no matter how often you see that patient. That is supposed to encourage more sort of holistic care for patients and to give doctors time rather than feeling like they're on this like fee-for-service conveyor belt. And then there are some models across the country in which doctors are salaried, but those are less common as a general rule than these what I would think of as small business models. Okay. Okay. So let's focus on this small business model then for a minute here, because that sounds very different than, I mean, if you're having to run a small business, that's kind of different work than performing the job as a doctor, right? So I guess what kind of burdens are being placed on doctors who have to essentially run a small business at the same time? So I think one of the most interesting things about this is that decades ago, doctors really

fought for continued independence. And they wanted, as a general rule, to be these small business owners. They wanted control over how they cared for their patients, when they worked, how they worked. They wanted to maintain that independence from the government. The newer generation of doctors, from everybody I speak with, seems less interested in running a family practice that is like a business and more interested in being able to just come in, provide patient care as best they can, and then go home. So when we think about some of the burdens here, we're talking about either buying or leasing a building. We are talking about hiring, firing staff, getting equipment, thinking about all

the billing side of things. And then also, even if they didn't own their own businesses, there's a really heavy administrative burden associated with the way family practice is delivered today. It has a lot to do with filling out a ton of forms for things like insurance and disability tax credits, the demand for how detailed charting has to be, checking lab results after hours and returning patient calls and emails after hours. It's one thing that I hear over and over from both groups representing physicians and physicians themselves is that the crushing administrative and business operation burden of being a family doctor is turning people off of family practice. Okay, so this is actually having the effect then of people not wanting to go into family medicine then because you're saying kind of the current crop of doctors, current generation doesn't really want to operate in that way. I mean, there are other elements of this too.

Money, right? Specialty practice does tend to pay a lot better than family practice. If you are somebody who's hundreds of thousands of dollars in debt, having gone to medical school, it can be enticing to say, let's pick a specialty where I'm going to make a whole lot more money. But the headaches of running a small business, there are serious disincentive among many young doctors, not everybody, but a lot. Yeah. Okay. So the way that our system works currently, I mean, it sounds like it's not really ideal for patients or necessarily for doctors. If we look at it at the system level, then, Kelly, I guess, what kind of pressure does the way that this is set up put on other parts of the health care system because things that should be handled upstream by a family doctor aren't being handled in that way. And patients get sicker and wind up having to turn to emergency rooms and hospitals for care. Yeah. If you're not catching an issue kind of

early with your family doctor, eventually that issue is going to get bigger and you go to emergency then essentially. Yeah. I mean, an example I can think of is there was a paper in CMAJ recently talking about the number of people who are being diagnosed with cancer in the emergency room. And, you know, that's really not the way a cancer should be found or that news should be delivered. Those people should be getting care further upstream. So you said CMAJ, which is a medical journal. It's the Canadian Medical Association Journal. Yes. Okay. So that's how things generally work in Ontario. But Kelly, I know that you recently visited Kingston, which is a city about two hours east of Toronto. And this region seems to be doing things a little bit differently. Tell me about that.

So they're trying a really interesting experiment in Kingston and the surrounding area. And what they're doing there is the Ontario health team for the region, which is sort of a coordinating body for the area, is trying to attach people to primary care offices based on where they live. So they've managed to attract a whole bunch of new doctors in the last couple of years. And we can talk about how they've managed to do that afterwards. But now that they have some more capacity, they have looked around and said, rather than making this a Hunger Games-style fight for primary care, why don't we divide the area geographically?

And then we assign patients who don't have a family doctor and need one based on their postal code, kind of like the way we assign people to public schools when they move into a new neighborhood. So one of the clinics that is at the center of this is a place they're calling the Midtown Kingston Health Home. And that is a clinic that did get some special extra funding from the provincial government. And what sets this clinic apart is it's interdisciplinary. So they've got different types of health care providers working together. Now, there are other examples of interdisciplinary team-based care within the Canadian health care system. But this is one of those clinics that has that model.

And at its center, it is offering salaried jobs similar to the salaries that are provided to doctors at something called community health centers. very helpful in terms of attracting new doctors who don't want to work in the old model, who want to work in team-based care, and who would rather work for a salary rather than work in any of these either fee-for-service or capitation models, which also comes with benefits and pension and sick time and vacation and some other benefits that maybe are not necessarily as easily available to people working in the older models. Yeah, okay. So let's talk about this idea, I guess, more broadly here, Kelly. Where does this idea come from of these health homes? So it's actually been kicking around for a little while, the idea of doing what's called geographic attachment, this sort of school zone model that we're talking about. I mean,

even in Ontario, there was an expert report in 2015, the Baker Price report, it was called, that recommended doctors practice in groups and that people be assigned to these group practices based on where they lived. Again, like this idea of school zones. But in the last couple of years, it's really come to prominence because Jane Philpott, who is a widely respected former federal health minister and until until recently, the dean of the School of Health Sciences at Queens University, which is in Kingston. Dr. Phil Pott has begun championing this idea again. She recently wrote a book, a bestseller that championed this idea. And now she has a new job that means she might actually have the power to put this in place. Starting December 1st, she's going to become the head of a primary care action committee in Ontario. So she's now essentially Premier Doug Ford's primary care czar.

Yeah, it's really interesting to see that. We actually had her on the show to talk about this model in the spring. And yeah, she's definitely a proponent of it. I wonder, does this model exist elsewhere, Kelly? Is this kind of a novel idea or has this been done before? So there are countries in Europe that do something like this. I think the key thing is that some of those European systems are designed so that everyone gets a primary care provider. Different European countries do this in different ways. Finland,

for example, all residents are automatically registered with a health center that is closest to where they live. So it sounds similar to what we're looking at here for Canada and Ontario, if Dr. Philpott has her way. In Norway, everyone is assigned automatically to a regular primary care provider. And there's an opportunity, I think, twice a year if you don't like your GP to look around and see if there's somebody nearby who has space on their roster. The UK, everyone's encouraged to register with a near automatic way, get access to this front door to the health care system. We'll be back after this message. The goal of this model then would be so that everyone has a health home that they're attached to, right? So that would be their first stop for primary care.

Presumably, Kelly, this would mean hiring more doctors and nurses and health practitioners in Ontario then, right? I guess I just wonder about money here. How much would this all cost? Dr. Philpott is pretty straightforward about the fact that up front, this will cost more money. I mean, it obviously costs less money to leave 20% of the population without any access to primary care. But you may wind up paying down the road. And that's Dr. Philpott's argument is that in the long run, there is a chance that this could save money by keeping people more healthy and keeping them out of hospital. She estimates that it would cost something in the neighborhood of one to two billion extra a year to assign every Ontarian health home. That's versus what we're spending now. And for context, the overall health budget for Ontario currently

is about $85 billion. And the best performing healthcare systems in the world do make that extra investment in primary care upfront with an eye towards keeping people healthy and keeping them out of hospital. And so when we talk about this clinic in Kingston, this kind of the model health home here, how much funding did it get to operate here? It received $4.1 million in funding earlier this year from the Ontario government. It was part of a push by the provincial government to fund some new and expanded team-based models of primary care. This is one-time funding, but the group behind this is assuming they're going forward in good faith that the funding will continue to be renewed. And considering how much attention the Ontario government is trying to give to fixing the primary care crisis, I would think

that they're probably not wrong to assume that. Okay. And when we talk about the team at this clinic, who are we talking about? Doctors, nurses, other health care professionals as well? The provincial government, in giving the funding to this clinic, earmarked the money for five doctors, three NPs, nurse practitioners, two social workers, a diabetes educator, a practical assistance worker, which is somebody who helps with things like transportation to the clinic for patients who might struggle with that, and a health educator for families with complex needs. Another interesting point about the way this clinic is set up is that the doctors and the NPs work in what they call dyads. So patients are actually assigned to a doctor and an NP as a team, and sometimes they might see the doctor, sometimes they might see the NP. It's the idea that not every health need a person has necessarily needs to be met by a medical doctor, that there are other healthcare professionals who are sometimes better suited to getting patients what they need. It also, I think, reflects the fact that we do not have enough family doctors and will not have

enough family doctors in the foreseeable future to meet the health care needs of a population that is growing and getting older. Let's talk about the patient experience here, because we haven't touched on this yet, Kelly. Have you talked to anyone who was, I guess, was in those postal codes that were invited to join this clinic? One of the patients I spoke with was Dorothy Ann Brown, who I mentioned a little bit at the top of the show. And her experience was that she had been sitting patiently waiting on Healthcare Connect, sort of cobbling together care with walk-in clinics and a virtual nursing service, but really finding that it was more and more difficult to manage her complex health needs.

Because as I mentioned earlier, she's got MS, she's got diabetes, she's got osteoarthritis, things that require a lot of care. And she actually was trained as a nurse. And so she had some medical knowledge. And even she found it really hard to manage her care. So one day, she got a call from Healthcare Connect confirming her address. Then she got a call from the folks at the Midtown Kingston Health Home. And within, I think it was about a week felt like she got excellent care. Tests caught up on. She had what she thought was a sprained foot in the NP center for an x-ray.

It turned out her foot was broken. And she was able to bypass going to the ER. She just finally had somebody looking at the big picture of her health and felt like she was in really good hands. So but I really like the pair, the idea of the two of them working together, because I know it's hard to get into doctors and things. And often a lot of the care can be managed by a nurse practitioner. And having that dyad, I think works really well. I've had that care before when I lived in Ottawa years ago. And it was great. I felt like I was completely seen. And so that's one woman's story. How many people have actually joined the clinic so far? The Midtown Kingston Health Home has rostered, this is as of November 8th, 949 patients. And

they really only started inviting patients to be rostered in the middle of September as they build up their roster. They're also acting as a booked walk-in clinic so that they can help other patients who don't currently have a family doctor. Now, their goal is to eventually roster as many as 8,000 people. But the reason they're not doing that all automatically is because they don't want to call 8,000 people and say, hey, you have a new family doctor. And the first time we can see you is eight months from now. They also want to get a sense of how complex the patients who have been without a family doctor for years actually are and how much time and how many initial appointments they're going to need. So they're sort of doing this in a stepwise fashion,

but their goal is to get up to 8,000 patients. And we talked in general terms about why doctors might want to work at this clinic, but I think you actually did talk to some doctors who were there. So what did they tell you about why they chose to work there? So I'd say it was a combination of things. The team-based care model was really attractive, as was the salaried model. So the doctors I spoke with really liked the idea of being at a place where they felt like they could provide good care, including good care for patients who may be struggling in different ways,

while at the same time having predictable hours and vacation time and sick days and a pension. One of the doctors I spoke with who's new to Midtown and new to Kingston was Eileen Nicole. And she talked to me about how attractive it was for her to be able to work at a place where she felt like she could provide this really comprehensive wraparound care to patients, including patients with pretty high medical needs, while at the same time, you know, having some work-life balance. To be honest, like I think after working in all the different models, I was really looking for something different. Like I wanted something that would provide like high quality comprehensive care, but also where, you know, if you needed to take a vacation, if you need to be homesick with your kids, if you at some point, everything didn't rest with the family physician,

that everyone's kind of working to their full scope to achieve good health care for the patient. So it sounds like there's some big benefits to the model for patients and for doctors. I'm wondering about any drawbacks that you've come across, though, Kelly. Are there challenges, I guess, that are currently associated with this pilot clinic? Right now, the biggest problem in Kingston and the surrounding area is that even though they have attracted a fair number of new doctors in the last couple of years, they still do not have enough to fully meet the needs of everybody who lives in the area. So there are postal codes and people who are excluded from this right now. And I think very understandably, that feels incredibly unfair to some patients. One of the patients I spoke with who was in that difficult boat was Karen

Cowton. And for her, I think it especially stings. It's not just that she's continuing to wait in a postal code that isn't covered by this plan. It's that she actually had a family doctor and her family doctor's clinic has agreed to be part of this larger effort to geographically assign people doctors. However, in her case, her own doctor is leaving in January. So she got this note saying you're sort of going to be out of luck. And at the same time, her clinic, which is called Greenwood Medical and has agreed to roster patients on the east side of Kingston, was able to add a thousand new patients and sort of trumpeted that as part of this like larger geographic vision, they were going to be taking new patients. But they were only taking patients from certain postal codes near the clinic.

And Karen and her family live actually just on the outskirts of Kingston, just north of the 401. And so they were excluded. It's disappointing. I mean, we pay for all these services. We all have OHIP, yet we're not entitled to have a family doctor. And we sit on Healthcare Connect for months, years. And it's so disappointing when you do what you're supposed to do, and then you can't get a doctor. And then we finally get a doctor, and now we're being told, you have to go back and go back on Healthcare Connect again. I did my time on Healthcare Connect. I did that. It didn't get me anywhere. That's the frustrating part. So at a time when her doctor's leaving, her doctor's clinic has room for new patients, she can't get in because of her postal code.

Now, in an ideal world, the way this system would work is that there would be space in a clinic even closer to where she actually lives and would be taking people from her post-cold. And that's the ultimate goal, but they are not there yet. And for patients who are left out of this first wave, that's very tough. Yeah. So what's next for this pilot program, Kelly? Will there be more health homes in Ontario? What might we see? I think it depends on how much support Dr. Philpott gets for her vision. And when I spoke to her about this, I asked, you know, how much support do you feel like you have from the provincial government, provincial officials?

And she said they seem to be taking this very seriously and that they've given her a pretty big vote of confidence for what she and her team can do. So we'll have to see how that goes. Yeah. And I imagine other provinces must be watching this carefully too, right? And maybe thinking of trying this model if it seems to be working? I think so. Everybody across Canada who's in a healthcare policy making role is looking for a way to solve this because they recognize that for patients, it's very upsetting to not have access to a family doctor or nurse practitioner if you want one. And it just has bad downstream effects for other parts of the system.

Kelly, thank you so much for being here. Thanks again. That's it for today. I'm Mainika Raman-Wellms. Our producers are Madeline White, Michal Stein, and Allie Graham. David Crosby edits the show. Adrian Chung is our senior producer. And Matt Frainer is our managing editor.

Thanks so much for listening, and I'll talk to you soon.