Primary Health Care Rounds December 14 2015 Tara Kiran 12 Alex Kopp 2 Rick Glazier 12 1 Department of Family and Community Medicine St Michaels Hospital University of Toronto ID: 1044361
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1. Those left behind from Ontario’s primary care reformsPrimary Health Care Rounds December 14, 2015Tara Kiran1,2, Alex Kopp2, Rick Glazier1,21Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto 2Institute for Clinical and Evaluative Sciences
2. 2
3. Primary Care Reform in OntarioPatient Enrolment Models:Formal patient enrolmentPhysicians in groupsChanges in physician paymentCapitationPay for performanceTeam-based careVoluntary for both physicians and patients
4. Primary Care Reform in OntarioPatient Enrolment Models:Formal patient enrolmentPhysicians in groupsChanges in physician paymentCapitationPay for performanceTeam-based careVoluntary for both physicians and patients
5. 5Glazier et al. Comparison of Primary Care Models in Ontario, 2012.
6. 6Glazier et al. Comparison of Primary Care Models in Ontario, 2012. Those left behind
7. Understand characteristics of patients and physicians left behind from reformsAssess quality of care for patients left behindOur Objectives
8. Linked, administrative data All Ontarians*; all primary care physiciansPatients matched to physicians using enrolment tables and virtual rostering** as of March 31, 2011*Exclusions: patients attending CHCs **Assignment based on max value of 18 common primary care fee codesMethods
9. Those left behind“Comprehensive” FFSWorked at least 50 days per yearServices billed reflected core primary careDid not have a “focused practice” designation (e.g. hospitalist, psychotherapy)Non-comprehensive FFSNo primary care visit in last 2 years
10. Diabetes Care Recommended Testing Age 40+, 1 eye exam, 1 cholesterol test, and 4 HbA1C tests in 24 months prior to Mar 31Cancer screeningCervical Age 35-69, pap smear in 30 months prior to Mar 31Breast Age 50-69, mammogram in 30 months prior to Mar 31Colorectal Age 50-74, FOBT in 24 months or colonoscopy in 10 years prior to Mar 31Data Sources: OHIP claims (physician, laboratory, OBSP, OCR)Outcomes
11. 11 Those Left Behind Chronic Disease Prevention& Management Study DesignDiabetes careCancer screeningFFS ComprehensiveFFS Non-ComprehensivePatient enrolment model
12. 12 Cross-sectional 2011Adjustment for patient factors Chronic Disease Prevention& Management Study DesignDiabetes careCancer screeningFFS ComprehensiveFFS Non-ComprehensivePatient enrolment modelThose Left Behind
13. 13 Cross-sectional 2011Adjustment for patient factors 2. “Look-back” Stratified by attachment in 2011Followed back until 2001Eligibility and outcomes assessed each yearChronic Disease Prevention& Management Study DesignDiabetes careCancer screeningFFS ComprehensiveFFS Non-ComprehensivePatient enrolment modelThose Left Behind
14. Results
15. 18% left behind82% patient enrolment modelThose left behind
16. Those left behind8% no primary care visit6% FFS comprehensive4% FFS non-comprehensive82% patient enrolment model13,161,935 Ontarians
17. Those left behind: Patient CharacteristicsNo primary care visit:low income, immigrant, healthyFFS comprehensive:low income, urban, immigrantFFS non-comprehensive:urban, <19yoPatient enrolment model
18. Those left behind: Physician CharacteristicsNo physicianFFS non-comprehensiveIMG, <40 or 65+, small panelsFFS comprehensive:IMG, <40 or 65+, small panels
19. Those with no primary care visit in 2 yearsDiabetes testing: 7%Cervical screening: 8%Breast screening: 11%Colorectal screening: 12%
20. Those left behind: Percentage receiving recommended testing for diabetesPatient enrolment modelFFS ComprehensiveRR 0.74 (0.73 to 0.75)FFS Non-ComprehensiveRR 0.68 (0.67 to 0.70) 34%25%23%
21. Those left behind: Percentage receiving cervical cancer screeningPatient enrolment modelFFS ComprehensiveRR 0.79 (0.79 to 0.79)FFS Non-ComprehensiveRR 0.76 (0.75 to 0.76) 66%52%50%
22. Those left behind: Percentage receiving breast cancer screeningPatient enrolment modelFFS ComprehensiveRR 0.80 (0.80 to 0.81)FFS Non-ComprehensiveRR 0.81 (0.81 to 0.82) 73%60%58%
23. Those left behind: Percentage receiving colorectal cancer screeningPatient enrolment modelFFS ComprehensiveRR 0.72 (0.71 to 0.72)FFS Non-ComprehensiveRR 0.73 (0.72 to 0.74) 62%45%44%
24. 2.4 million patients left behindThose left behind less likely to receive recommended testing for diabetes and cancer screeningDifferences in quality of care preceded introduction to medical homesPatients seeing “comprehensive” FFS MDs were more likely to be urban, low income, new immigrantsSummary
25. 25Limits of administrative data:No data on patient experience or timely accessNo laboratory values or blood pressure levelsCannot distinguish walk-in clinics or measure true attachmentLimitations
26. Voluntary reforms risk leaving the vulnerable behindMany of those left behind likely have no regular family doctorWalk-in clinics: more prominent in urban areasOntario’s capitation payments did not adjust for co-morbidity or SESCharacteristics of MDs who stayed FFSDiscussion
27. We need policy solutions to improve care for those left behindImproved attachmentImproved services with existing physicianDiscussion
28. Those left behindQuestions?