Former Health Minister Dr. Jane Philpott calls for universal pharmacare legislation during a press conference on Parliament Hill in Ottawa on Sept. 21, 2023.PATRICK DOYLE/The Canadian Press
In her book, Health for All: A Prescription for a Healthier Canada, former federal health minister Jane Philpott asked readers to imagine a utopian-sounding scenario (well, utopian for Canada; it’s already the norm in places like the Netherlands) where nearly every citizen is registered with a family health team. She sets the scene: the year is 2035, and every Canadian has a primary-care home based on their geographic location. It would be akin to how our education system works; children have guaranteed access to the public school in their neighbourhood, so the same would be true for primary health care.
Dr. Philpott goes further: these primary-care homes would be open “seven days a week, up to 12 hours a day,” she posits. “If you need to be seen on short notice, you can walk in for care.”
For the lucky Canadians who do currently have access to a family doctor, that sounds like a dream. Many family doctors are currently so overburdened that patients have to wait weeks for appointments, and their after-hours or urgent options are slim. In Ontario, if patients choose to go to an unaffiliated walk-in clinic to address a pressing health concern, they risk being dropped from their family doctor’s roster. That’s because their family doctor might be financially penalized when their patients seek health care elsewhere – with the notable exception of the emergency room. And so, patients have a perverse incentive to go to the hospital for relatively minor but urgent concerns in order to stay on their family doctor’s roster. That, of course, ends up costing the province a lot more than a trip to a local walk-in clinic.
Dr. Philpott, who was just appointed by Ontario Premier Doug Ford to lead a new primary-care action team, has a reputation for action, ethics and pragmatism. As health minister for the federal Liberals, for example, she authorized the use of naloxone nasal spray to treat opioid overdoses without a prescription, which may seem obvious in hindsight but was an important change at the time. She has an enormous task ahead of her in trying to fulfill her mandate – that is, to see that every Ontarian is connected to primary care within five years – but there is a small change she could make now to improve access for those who do have a doctor, with trickle-down effects for others: stop penalizing family doctors when their patients seek urgent care elsewhere.
The reason why family physicians in Ontario are charged when their patients go to walk-in clinics comes down to how the government funds “family health organizations” (FHOs) and “family health networks” (FHNs). (These are not the same as “family health groups,” or “family health teams,” but I’ll keep it simple.) Physicians who work in FHOs or FHNs are paid for each patient on their roster, as well as bonuses based on a few other factors and some service fees. Essentially, your doctor gets paid for having you as a patient, whether or not you actually go in for a visit.
When you visit a walk-in clinic, that clinic bills the government for the service they provide. That means the government is essentially paying twice: once, to your family doctor for having you on their roster, and then again to the walk-in clinic, for administering a strep test or looking at your rash. So, the government then charges your family practice what it costs to have you seen at a walk-in, because it expects that the FHO or FHN would have provided urgent or after-hours care (even though it is not always possible to get an after-hours appointment, and sometimes urgent needs pop up when patients are out of town and can’t visit their primary care team). So doctors then threaten to “de-roster” patients who visit walk-in clinics, and those patients, in turn, go to ERs, or sit at home and suffer.
The knock-on effects are clear: more crowded ERs, worsening outcomes from untreated conditions, and/or Ontarians who suddenly find themselves without primary care after being dropped by their doctors for straying outside their home practice. It is unreasonable to expect doctors to absorb the cost, especially when we want to make family practice more enticing to medical students, not less. So the solution – the interim one, until primary care is fundamentally revamped, as it will have to be for Dr. Philpott to fulfill her mandate – is for Ontario to stop penalizing doctors when their patients visit a walk-in. It will cost Ontario more money, yes, but less than a visit to the ER, surely. And if there is extra money in the provincial budget for license-plate sticker rebates and Beer Store contract penalties, there should be cash on hand for this.