More doctors for the healthy and the wealthy

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Ontario's multimillion-dollar efforts to improve access to physicians have largely been successful, but there is troubling new evidence that the poorest and sickest citizens in the province have not benefited from the investments.

Reeling from ever-growing waits in emergency rooms, doctors refusing to accept new patients and the reluctance of new medical-school graduates to become family physicians, Ontario introduced two new payment methods for doctors early this decade: In 2001, it started Family Health Networks, a capitation model in which doctors are essentially paid a flat rate per patient annually; in 2003, the province followed up with Family Health Groups, an enhanced fee-for-service model, so that in addition to a set fee per medical act, doctors could collect extra payments for working nights and doing prevention work.

Largely as a result of those changes, about 500,000 more Ontarians now have a family doctor, though there are still shortages in the province. Approximately 850,000 residents are without a family doctor.

But new research, published in today's edition of the Canadian Medical Association Journal, found that the new patients are, on average, healthier and wealthier.

"When you put resources into a system and you don't regulate how they are used, those who are better-off are best able to take advantage," said Dr. Rick Glazier, a scientist at the Toronto-based Institute for Clinical Evaluative Sciences, and the lead author.

The research shows that both Family Health Networks and Family Health Groups attracted a healthier, more well-to-do clientele, though such patients were even more prominent in the capitation system.

The practices of the physicians who were paid a set fee per patient were characterized by patients with fewer chronic health conditions and who were more likely to have had a previous family doctor. Doctors also provided significantly less after-hours care and their patients were more likely to visit emergency rooms.

Dr. Glazier stressed, however, that these characteristics already seemed to be present among the physicians that enrolled in the capitation model and they simply adopted the payment model that was most advantageous to their way of doing business. In the past decade, Ontario has gone from a province where virtually all doctors were paid on a straight fee-for-service basis to one where the methods for reimbursing physicians under the Ontario Health Insurance Plan are varied and more complex.

Dr. Glazier, who is also a researcher at the Centre for Research on Inner City Health at St. Michael's Hospital in Toronto, described these changes - which are largely invisible to the public - as one of the biggest public-policy experiments in the country, if not the world.

"It's a change, an investment, that has definitely paid off," he said, but added that adjustments are required to ensure that people with chronic health conditions or those who are socially disadvantaged (both groups that tend to require more time-consuming care) are not left out in the cold.

Dr. Glazier said that in countries where capitation models are widely used, such as in Britain and the United States, doctors are paid more to care for those with chronic illnesses and the poor, and those incentives work.

Currently, there are about five million people cared for by physicians under enhanced fee-for-service models, about 2.5 million under capitation models, some 250,000 who go to community health clinics where doctors are salaried, and a small number belong to groups with alternate payment plans. The balance of residents have doctors who bill OHIP under regular fee-for-service, or they don't have a regular physician and go to walk-in clinics or emergency rooms.