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PRIMARY CARE

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PRIMARY CARE Powered By Docstoc
					PRIMARY CARE IN THE
HEALTH CARE SYSTEM
R.A. Spasoff, MD, Epidemiology &
      Community Medicine
 L. Muldoon, MD, Somerset West
    Community Health Centre
         2006 February 27

                                   1
       PBL: Ms Sharon Smith
• A thirty-five year old woman has a febrile
  illness with cough, malaise and pain in the
  chest that is aggravated with each breath.
  She has been drinking more heavily since
  her boyfriend was killed in a drug dispute.
  She visits an emergency department, having
  previously visited a walk-in clinic.

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         IMPORTANCE OF
          PRIMARY CARE
• Strong primary care is the basis for a strong
  health care system
• The best systems are the ones with strong
  primary care, e.g., UK, Netherlands
• Romanow report devoted a whole chapter to
  primary care; saw it as the basis of a
  transformed system

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    HEALTH FOR ALL 2000
                 (WHO, 1981)

• “The main social target of governments and
  of WHO should be the attainment by all the
  people of the world by the year 2000 of a
  level of health which would permit them to
  lead a socially and economically productive
  life.”
• WHO determined that HFA2000 could best
  be achieved through primary health care
                                                4
   PRIMARY HEALTH CARE
                    (WHO)

• “… essential health care based on practical,
  scientifically sound and socially acceptable
  methods and technology made universally
  accessible to individuals and families in the
  community through their full participation
  and at a cost that the community and
  country can afford to maintain at each stage
  of their development, in the spirit of self-
  reliance and self-determination”
                                                  5
     Characteristics of General
     Practice/Family Medicine
      (Draft Charter of GP/FM, WHO-EURO, 1998)

•   General (unselected health problems)
•   Continuous
•   Comprehensive
•   Coordinated
•   Collaborative
•   Family-oriented
•   Community-oriented                           6
  PRINCIPLES OF PRIMARY
       CARE (CFPC)
• The doctor-patient relationship is central to
  what we do as family physicians
• The practice of family medicine is
  community-based
• The family physician is a resource to a
  defined population
• The family physician must be a skilled,
  effective clinician
                                                  7
     Other important attributes of
             primary care
•   First contact
•   Accessibility
•   Continuity
•   Case-management (responsibility for
    coordinating all the care that a person
    needs)


                                              8
       METHODS OF PAYING
          PHYSICIANS
•   Fee-for service
•   Capitation
•   Salary/sessional
•   Combinations (blended funding)




                                     9
            Fee-for-service
• Unit of remuneration is the service
• Rewards hard work, good patient relations,
  accessibility
• Encourages high-volume practice,
  especially when fees are inadequate
• Rewards “talking” services less well than
  “doing” services; discourages prevention
  and a global approach to patients’ problems
                                            10
               Capitation
• Unit of remuneration is the patient, not the
  number of services provided. Fixed
  payment per patient per month.
• Implies a list or roster of patients, which
  may strengthen accountability
• Encourages continuity of care
• Provides incentive to keep patient healthy,
  therefore should encourage prevention
• May encourage doctors to be unavailable 11
             Salary/Session
• Unit of remuneration is time (per hour, per
  month), not number of patients or services
• Allows efficient use of time
• May encourage low-volume practice,
  slacking off
• Normally associated with practice in some
  sort of institutional setting, which provides
  accountability
                                                  12
    SETTINGS FOR PRIMARY
       CARE IN CANADA
•   Private solo practice
•   Private group practice
•   FHN (HSO)
•   CHC / CLSC
•   Also (and not recommended):
    – Emergency department
    – Walk-in clinic
    – Specialist practice
                                  13
             Walk-in Clinics
• Convenient for patients, flexible for physicians
• Little continuity of care
• Fee-for-service payment encourages high volume
  practice
• Skim off the “easy” (remunerative) patients,
  leaving older and multi-problem patients to family
  physicians and thereby making family practice
  less financially viable

                                                   14
     Emergency Departments
• Accessible (with long waits) 24 hours/day
• Ready access to technology
• Staff not appropriately trained for primary
  care (emphasis on episodic care)
• Very limited social support services
• Poor continuity of care
• Expensive (or are they?)
                                                15
               Specialists
     (paediatrics, gynaecology, etc)
• Some specialists provide a certain amount
  of primary care
• They tend to work in solo practice or
  partnerships, without a broad range of
  support services
• Their training is not appropriate for primary
  care (expertise in depth rather than breadth,
  no emphasis on family or continuity)

                                              16
   Solo Practice/Partnerships
• Historically the most common pattern
• For doctors: maximum professional
  autonomy and individual responsibility, but
  minimum professional support
• For patients: doctor-patient relationship,
  continuity (in office hours), limited services
• Fee-for-service payment encourages high
  volume practice, discourages prevention
                                               17
            Group Practice
• For doctors: colleague support, sharing of
  expenses and call duty, reduced capital
  costs
• For patients: one-stop provision of medical
  care (wider range of services)
• Usually fee-for-service payment
• Similar to solo practice in terms of hospital
  utilization, costs and quality of care
                                                  18
       Health Maintenance
      Organizations (HMOs)
• USA only; do not exist in Canada
• Prepayment plan (equivalent of capitation)
  combined with a large group practice,
  sometimes with own hospital
• Community-sponsored ones reduced
  hospitalizations and total costs of care
• Commercial sponsorship (“managed care”)
  has given a good approach a bad name
                                               19
 Health Services Organizations
            (HSOs)
• Ontario group practices funded by
  capitation
• Defined patient registers
• No provision for community input
• No provision for other professionals
• There were about 50; have been replaced by
  Family Health Networks (see below)
                                           20
    Community Health Centres
           (CHCs)
• Community-sponsored clinics with boards
• About 50 in Ontario, 6 in Ottawa-Carleton
• Wide range of health and social services
• Care mainly for disadvantaged populations
• Funded by Ministry of Health via global
  budget, with salaried staff
• Funding provides flexibility, e.g., use of
  nurse practitioners
                                               21
    Centres locaux de services
    communataires (CLSCs)
• Cover the entire province of Quebec
• Provide a range of medical, public health
  and social services (similar to the WHO
  concept of primary health care)
• Global budget with salaried staff
• Primary medical care role has not
  developed to the extent originally envisaged

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  STRENGTHS OF PRIMARY
     CARE IN CANADA
• Well-trained family physicians, although
  not enough of them
• Family physicians can usually obtain
  hospital privileges (although they can no
  longer afford to do hospital practice)
• Few direct financial barriers to prevent
  patients from seeking care

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   WEAKNESSES OF PRIMARY
      CARE IN CANADA
• Patients are free to “shop around”
• Physicians can practise where they want, rather
  than where they are needed
• Family physicians are isolated from each other,
  other health and social workers, public health
• Fee-for-service system does not permit use of
  other health workers, e.g, nurse practitioners
• Combination of inadequate fees and inadequate
  numbers leads to overwork

                                                    24
  PRIMARY CARE REFORM
• Need for reform widely recognized: family
  doctors leaving practice, few new graduates
  entering
• Many proposals have been considered




                                            25
      “Choices for Change:
  Restructuring Primary Health
        Care in Canada”
• Prepared for Canadian Health Services
  Research Foundation, 3 provinces, Health
  Canada. Nov 2003
• Evaluated 4 models of care on
  Effectiveness, Productivity,
  Accessibility/Equity, Continuity, Quality
  and Responsiveness, using evidence and
  (mostly) expert judgment
                                              26
         Findings of Report
• CHC-like model best on effectiveness,
  productivity, continuity and quality, if
  integrated with rest of health care system
• HSO-like model best on accessibility,
  responsiveness



                                               27
  Recommendations of Report
• CHC-like model preferred; HSO-like model
  acceptable as transitional form
• Organizations to be paid by capitation,
  personnel (including MDs) to be paid by
  session
• Should be multidisciplinary
• Information systems crucial

                                         28
 Three Newer Ontario Models

• Family Health Networks

• Family Health Groups

• Family Health Teams

                              29
     Family Health Networks
         (FHNs), 2001−
• Have replaced HSOs
• Networks of family doctors working from
  common or own offices (“virtual clinics”)
• Defined patient registers, for which doctors
  accept responsibility for 24-7 availability
• Capitation, plus incentives for prevention.
  Access bonus if patients don't go elsewhere.

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         FHNs (continued)
• Very limited provision for other
  professionals
• Extensive use of IT
• Was supposed to cover 80% of family
  doctors by 2004, but didn’t come close
• In early 2005, accounted for >1800 family
  physicians, caring for >2.5 million
  Ontarians
                                              31
  Family Health Groups (FHGs),
     2004− (Conservatives)
• Introduced when FHNs slow to develop
• As for FHNs, patients have to enrol, and
  group is on-call 24/7
• Payment is not by capitation. Some
  enhanced FFS billing, a few premiums and
  bonuses
• Attractive to many FFS doctors, partly due
  to increased income
                                               32
   Family Health Teams (FHTs),
         2004− (Liberals)
• Much more multidisciplinary than FHNs
• Two models:
  – Professional: e.g., Family Medicine Centre
  – Community: similar to CHCs
• Payment blended: capitation with bonuses,
  premiums and ability to bill up to $40,000
  per year for non-enrolled patients.

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              Summing Up
• New models should encourage continuity,
  multidisciplinarity, and prevention; should
  discourage duplicated services
• Will they attract more graduates into family
  practice?
• See http://www.health.gov.on.ca for [a very
  little] more info

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