Vulnerable Patients Losing Out on Voluntary Reforms

Reforms to primary care in Ontario implemented a decade and a half ago are ripe for evaluation and some of the findings show a significant gap in quality of care for vulnerable patients.

This was the outcome of a study conducted by faculty members Tara Kiran and Rick Glazier from St. Michael’s Hospital and their team at the Institute for Clinical Evaluative Sciences published in the Annals of Family Medicine late last year titled “Those Left Behind From Voluntary Medical Home Reforms in Ontario, Canada”. 

The study looked at the quality of care in Ontario provided by group-based models that formally enroll patients, provide after-hours care, and receive some annual payments for patients. Since 2001, when voluntary reforms were first implementd and family doctors were given financial incentives to start working in team-based care, more than 10.8 million Ontarians have benefited from being part of group-based models, but Kiran’s study shows that the 2.4 million Ontarians who have been left behind from these groups are receiving poorer care.

These individuals are less likely to receive recommended screening for cervical, breast or colorectal cancer, and if they have diabetes, they are less likely to get the necessary tests. Most troubling is that the patients left behind are more likely to be poor and new to Canada — and most live in urban areas. Kiran’s study also found that the patients left behind were actually getting poorer quality care even before reforms were introduced. 

“One lesson learned from studying these reforms” says Kiran, “is that we need to consider how policy changes will affect our most vulnerable patients right at the start, in the development phase. Otherwise, there is a risk of making disparities greater. If anything, the goal should be to improve care specifically for vulnerable patients.”

She further questions why newcomers are often left out of models of primary care, as her study showed. Some may not have had a family doctor and couldn’t get into a new group practice, some may go to walk-in clinics, or some may stay with their current doctor even if they haven’t switched to a group-based model. Kiran hypothesizes that many newcomers likely aren’t aware of how primary care can help them preventatively and that it’s important to see the doctor even if you’re not sick.

“I often wonder if we need to communicate better to newcomers about what primary care looks like in Canada and how to access it?” says Kiran. She estimates that many newcomers come from countries without a primary care system so the concept of achieving better health through continuity of care over their lifetime is a new possibility that they may not be familiar with.

A major challenge in answering these questions is that reforms were implemented without an evaluation plan. Data used in the research is analyzed retrospectively and collected for purposes other than research (I.e. billing) which limits the ability to measure the impact on quality of care.

Improving availability of data is one of the goals of UTOPIAN, DFCM’s practice-based research network, which is currently working to create one of the largest research networks in North America for representative data. But in the meantime, researchers must rely on the systems in place and this means working with limited data.

Next on the horizon for Dr. Kiran is a project evaluating the impact of mandating after-hours coverage in group-based models on emergency department visit rates.