The evolution of integrated care in the Canadian provinces is as variable as the languages spoken across this great country. Each provincial area has the power to determine its own healthcare priorities. These are largely reflective of the income base of the respective jurisdiction and the presence or absence of some of the larger and more innovative healthcare providers. For example, in some provinces cancer drugs are funded and publicly funded fertility treatment is available. In other provinces, these and other components of the modern care continuum are absent.
For healthcare consumers, who I imagine are as likely to be mobile as other Westerners, this must present challenges when they move region or province. Healthcare workers are also affected by this provincial tapestry; jurisdictions have variable registration requirements for clinicians. The funding arrangements for primary care are no less confusing and heterogeneous.
Ontario appears to have one of the more mature and ambitious models of integrated care. Through a series of evolutions since 2005, primary care in Ontario has become increasingly aligned with the modern vision of a patient centred medical home. However, alignment of funding has not amounted to wholesale access. The numbers of primary care groups and doctors that can access capitation and incentive funding has been frozen. This is on top of a freeze in payment increases, effective since 2010. The consequence is patients struggling to enroll with medical centres which can offer the range and continuity of care they would prefer. Many are stranded in “walk-in” clinics which are convenient but lack the range of allied health, nursing and chronic disease supports common in the most advanced tier of service providers. Uncertainty about the renewal of contracts, imposition of not for profit structures within business groups receiving team based funding and dispersal of funding on a line item by line item basis have restricted the evolution of models of care. There seems to be less emphasis on probing which clinicians should be doing which work to drive better patient outcomes than simple use of additional capacity and reporting data to make moderate improvements in indicators. Lack of enforcement of key obligations, like provision of after hours care, may be indicative of deeper system issues which are soft in supporting ongoing innovation.
The key lesson from the Ontario is experience is that systems which evolve incrementally create legacy providers whose points of difference are not understood by the public they serve. Whilst they make it easier for the change ready to get moving, they fail to ensure that the laggards catch up. They also generate a health landscape which is not easy to manage, market or partner with across a province or nation. In addition, movements to create new solutions which are then frozen create access issues for those who want to find themselves a medical home. Paradoxically, it was access issues which drove the momentum for the original change. How Canada will streamline and support growth in medical homes, so sorely required in a era of chronic disease, is uncertain whilst four tiers of primary care providers exist in the one landscape.
Tracey Johnson, General Manager, Inala Primary Care, AAPM Canada Knowledge Exchange Tour Participant