Ontarians without a family doctor may soon encounter new barriers to finding care in a variety of specialty areas. A little-noticed change to the Physician Services Agreement between the provincial government and medical practitioners places a cap on the annual billings of family doctors in areas such as addictions medicine, psychotherapy, obstetrics and urgent care.
The most vulnerable patients are also those most at risk, says Kyle Lee, financial lead of a large family medicine practice associated with the University of Toronto. For example, the effects likely will be “more pronounced in rural settings that have lower access to specialty care.” What’s more, adds Lee, the new regime may create a bigger chasm between patients with a family doctor and those without.
Though the billing caps are due to take effect by April 1, the full suite of changes in the agreement are supposedly designed to improve access to health services in the face of COVID-related stresses on the system, delayed care and new waves of viral variants and the flu season.
Most of the alterations to the agreement are to encourage in-person care by family physicians and foster relationships between care providers and patients. Fees for virtual visits have been slashed as of this month, encouraging physicians to schedule more in-person time, including after hours. The number of new practitioners allowed to join current group family-health practices, known as Family Health Organizations (FHOs), also will rise.
However, physicians and clinic administrators are concerned that the changes will have the unintended effect of limiting the care that family doctors provide, especially urgent care and specialty services. Particularly concerning, they say, are the hard caps on the number of patients with no regular family doctor that a clinic can see. The changes mean that many people without a regular clinician who need specialty or urgent care services may be turned away from practices where they currently access such care, forcing them to seek treatment at over-stretched hospital emergency departments that are already struggling with unprecedented staff shortages and record wait times.
Michael Howlett, head of the Canadian Association of Emergency Physicians, says he is “extremely concerned about any changes that would cause patients to go to the emergency department to receive care they should be able to access in the community.”
The Ministry of Health did not respond to repeated requests for comment. Although the press release announcing the new physician services agreement last April pledged that the government would provide updates on possible exemptions, those have yet to be announced. Previous ministry guidelines have laid out exceptions for geographical areas of high need and low resources.
The changes will force doctors to ‘choose a lane’ by limiting the number of procedures and visits they provide in some areas.
Stephen Gray, chief executive of a group of family doctors in Port Perry, Ont., is concerned that an influx of underserved patients turned away from other local clinics would be a significant burden on his rural practice. While he has no intention of restricting services, he notes that many of the doctors working with him do multiple jobs, such as delivering babies, providing palliative care and even providing anesthesia at the local hospital. Only a few practice urgent care and they will now be discouraged from expanding this work. The Port Perry clinic does not have the resources to dramatically increase the number of unattached patients to whom it offers family medicine services. Indeed, Gray is worried that he may not be able to recruit family doctors to replace those who are retiring.
In Ontario, twice as many family physicians stepped back from their practices during the pandemic compared to more normal times. More than half said they were likely to reduce or modify their clinical hours. As a further red flag, a 2021 study by researchers at the University of Toronto concluded that almost one in five Toronto family physicians were considering closing their practices in the next five years.
According to the Ontario College of Family Physicians, nearly 1.8 million Ontarians were without a regular family doctor in March 2020. Another 1.7 million people have a family doctor who is over 65 and probably set to retire. This means that even more Ontarians may not have access to a family doctor by 2023, when the funding changes take full effect.
Jeff Warford, CEO of the Oshawa Clinic Group, a large clinic in Durham region with more than 50 doctors, says his doctors will have to restrict services within the next few months as they hit their funding cap for the specialized services outlined in the agreement. According to Warford, the changes will force doctors to “choose a lane” by limiting the number of procedures and visits they provide in areas like addictions medicine or mental health counseling as well as after-hours urgent care.
“We want to provide care, but we cannot do it for free,” says Warford. Noting that the changes have not been widely publicized, he adds that “patients are unaware that this is coming.”
In contrast, British Columbia is taking a radically different approach. Faced with a similar crisis in primary care, the B.C. government announced in October that it plans to launch a new payment model in early 2023, with hundreds of millions in extra funding. The goal, it says, is to recruit and retain more family doctors in the province.
Yet, the new arrangements in Ontario mean that physicians in Canada’s most populous province will now rank among the lowest paid in the country despite higher living and overhead costs than most other provinces.
Lee says he is concerned about “keeping comprehensive family medicine afloat as the complexity of patients and systemic demands are preventing many newer practices from rostering more patients.”
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