Walter W. Rosser, M.D., Jack M. Colwill, M.D., Jan Kasperski, R.N., M.H.Sc., and Lynn Wilson, M.D.
As the United States debates health care reform, the concept of “patient-centered medical homes” is receiving increasing attention.1 Many experts believe that medical homes with multidisciplinary teams and financial incentives for providing comprehensive care will lead to improvements in health, increase efficiency, andreduce costs of care while making practice more attractive for primary care physicians. Lessons regarding the implementation of medical homes and their ability to accomplish these goals can be gleaned from Ontario’s experience with Family Health Teams (FHTs).
Back in 1969, Canada adopted a universal health insurance program. The federal government provided partial funding, and each province developed its own health care system under national guidelines. At first, the system was well funded, and most Ontarians were satisfied. Family physicians practiced solo or in small groups and were paid on a fee-for-service basis. But by the mid-1980s, family doctors struggled to keep up with practice demands. Rising costs and either static or falling incomes pressured physicians to increase the number of patient visits, which, many observers believe, negatively affected both the quality of care and physicians’ personal lives. Interest in family medicine declined, and the proportion of Ontario medical graduates entering the field fell to 24% in 1998, though the health care system was based on the expectation that 50% of physicians would be in family practice, Canada’s only primary care specialty.
In the early 1990s, the chairs of Ontario’s five university departments of family medicine became increasingly concerned that the payment system rewarded high-volume practices rather than broad, patient-centered care.2,3 In response, a government-appointed committee identified a “basket” of services that family practicesshould provide. After physicians and politicians had been persuaded of its merits, the FHT was introduced in 2004. The FHT model is designed to expand the capacity of primary care through development of interdisciplinary teams and to improve the breadth and quality of care through incentives provided by a blended payment model. Today, about 720 physicians in 150 FHTs serve more than 1 million patients.
The model is flexible, and no two FHTs are the same. A typical practice includes at least seven family physicians and a multidisciplinary team that provides a broad range of services and 7-day-a-week access to care. Physicians sign a contract with the Ministry of Health to provide the basket of services and agree to theremuneration package. Patients wishing to receive care from an FHT must register with the Ministry and select a physician at a given practice. There is no certification process for FHTs, but electronic data, such as results of screening for colon cancer, document the services and provide information for reimbursement by the Ministry.
Primary care services focus on patient advocacy and coordination of care. Specifically included are episodic and acute care; mental health care; chronic disease care; evidence-based prevention; education for self-care; care in the hospital, at home, and in the community; support for the terminally ill; and arrangements for around-the-clock response for urgent problems. In essence, the FHT serves as the focus for all patient care, providing the majority of care and coordinating that provided by specialists and by other community resources. Not every physician delivers every service, but each group must be organized to do so. The patient’s physician sees to it that appropriate services are provided.
Physicians have responsibility for a defined panel of patients and are assisted by other health professionals, such as nurses, nurse practitioners, psychologists, pharmacists, social workers, and health educators. A typical physician panel includes about 1400 patients, smaller than a typical U.S. practice. Inclusion of a nurse practitioner adds 800 patients to the expected practice size. The Ministry provides salaries for the other health professionals and funding for an electronic record system meeting Ministry requirements.
Physician payment is based on age- and sex-based capitation that is calculated from Ontario’s fee-for-service experience. Additional fees are provided for services deemed to require added emphasis — visits for infants, for instance, or patients over 75 years of age. Physicians receive fees for procedures and for visits to hospitals, homes, and nursing homes. Graded bonuses are provided for achieving prevention goals for one’spatient panel. Family doctors receive a bonus of $100 to $300 for every new patient, depending on the complexity of that patient’s needs. The physician forfeits 1 month’s capitation fee when a patient seeks care elsewhere. About 60% of physicians’ incomes come from capitation and 40% from other fees and bonuses. Each FHT has a governing board with community representatives and is responsible for ensuring that standards are met, but standards of care are established by physicians.
Primary care reform in Ontario took more than a decade from conceptualization to implementation. Although many physicians were initially skeptical about its potential for success, as-yet-unpublished studies document high levels of patient and physician satisfaction. When the Ministry recently sought to delay expansion to 200FHTs, protests by patient groups and physicians led to cancellation of the delay.
The use of interdisciplinary teams expands the range of services provided and reduces overload for individual physicians. Since income is not based primarily on physician visits, practices can explore broader roles for team members and may use telephone, e-mail, and group visits to enhance efficiency. The total number of visits per patient has not declined, but more visits appear to be occurring with team members other than the primary physician. One study has shown that control of hypertension is better among patients in FHTs than among those in fee-for-service practices.4 The use of integrative electronic record systems appears toimprove efficiency and communication, and we believe that quality incentives have made participating physicians more proactive in providing preventive services and providing care management for chronically ill patients. A full evaluation of this model’s effects on health outcomes, quality measures, and costs will be completed in 3 to 5 years. One effect that is already obvious is an increase of approximately 40% in physicians’ incomes: the average net income for a family physician has increased from $180,000 (Canadian) in 2004 to $250,000 within FHTs, but it has not risen substantially in the fee-for-service sector.
Most Ontario teaching practices are FHTs and emphasize the values of patient-centered care in both family medicine residency programs and undergraduate medical education. The percentage of Ontario medical school graduates entering family medicine has increased from 25% in 2004 to 39% in 2009 (as compared with an increase from 24% to 29% in other Canadian provinces). Anecdotal information suggests that the first choice of Ontario’s family medicine residents is now to practice in FHTs. Family physicians who were initially skeptical are now seeking to participate.
Per capita, Canada has one third fewer active physicians than the United States, 15% more primary care physicians, and half as many specialists. Consequently, the heavy responsibilities of Canadian specialists promote shared care with family physicians, and specialists rarely see patients without referral. In the United States, only 30% of visits to specialists occur through referrals,5 and patients are likely to see multiple specialists. Canada’s physician mix has helped to contain costs, but the government recognizes that it faces shortages of both primary care and specialist physicians. Its goal is for every person to have a family physician. Ontario’s large investment in FHTs signifies its commitment to enhancing the capacity and qualityof primary care.
Could medical homes be implemented in the United States? For many in primary care, Ontario’s model represents the type of practice they always hoped to have. Already, many managed care organizations and some integrated delivery systems are headed in that direction. But multiple insurers in a region, rather than a single payer, would have to invest in the medical home for it to be viable for most primary care practices.
U.S. health care reform legislation anticipates a strong foundation of primary care — but that foundation is crumbling. Having faced similar problems, Ontario continues to convert fee-for-service practices to patient-centered medical homes, so far with positive results, including more graduates entering family medicine. Its experience can provide useful lessons for the United States as it addresses its primary care crisis.
Financial and other disclosures provided by the authors are available with the full text of this article at NEJM.org.
Source Information
From the Department of Family Medicine, Queen’s University, Kingston, ON, Canada (W.W.R.); the Department of Family and Community Medicine, University of Missouri School of Medicine, Columbia (J.M.C.); the Ontario College of Family Physicians, Toronto (J.K.); and the Department of Family and Community Medicine, University of Toronto, Toronto (L.W.).
This article (10.1056/NEJMp0911519) was published on January 6, 2010, at NEJM.org.
References
- The patient centered medical home: history, seven core features, evidence and transformational change. Washington, DC: Robert Graham Center, November 2007. (Accessed January 5, 2010, at http://www.graham-center.org/online/etc/medialib/graham/documents/publications/mongraphs-books/2007/rgcmo-medical-home.Par.0001.File.tmp/rgcmo-medical-home.pdf.)
- Forster J, Rosser W, Hennen B, McAuley R, Wilson R, Grogan M. New approach to primary medical care: nine-point plan for a family practice service. Can Fam Physician 1994;40:1523-1530. [Web of Science][Medline]
- Rosser WW, Kasperski J. Organizing primary care for an integrated system. Healthc Pap 1999;1:5-21. [Medline]
- Tu K, Cauch-Dudek K, Chen Z. Comparison of primary care physician payment models in the management of hypertension. Can Fam Physician 2009;55:719-727. [Free Full Text]
- Valderas JM, Starfield B, Forrest CB, Sibbald B, Roland M. Ambulatory care provided by office-based specialists in the United States. Ann Fam Med 2009;7:104-110. [Free Full Text]
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