Family physician views about primary care reform in Ontario: a postal questionnaire
- Duncan JW Hunter†1, 2, 3Email author,
- Samuel ED Shortt†1, 2, 3, 4,
- Peter M Walker†5 and
- Marshall Godwin†2, 3, 4
© Hunter et al; licensee BioMed Central Ltd. 2004
Received: 12 September 2003
Accepted: 01 March 2004
Published: 01 March 2004
Primary care reform initiatives in Ontario are proceeding with little information about the views of practicing family physicians.
A postal questionnaire was sent to 1200 randomly selected family physicians in Ontario five months after the initial invitation to join the Ontario Family Health Network. It sought information about their practice characteristics, their intention to participate in the Network and their views about the organization and financing of primary care.
The response rate was 50.3%. While many family physicians recognize the need for change in the delivery of primary care, the majority (72%) did not expect to join the Ontario Family Health Network by 2004, or by some later date (60%). Nor did they favour capitation or rostering, 2 key elements of the proposed reforms. Physicians who favour capitation were 5.5 times more likely to report that they expected to join the Network by 2004, although these practices comprise 5% of the sample.
The results of this survey, conducted five months after the initial offering of primary care reform agreements to all Ontario physicians, suggest that an 80% enrollment target is unrealistic.
Since the inception of Canadian medicare in the late 1960s there have been recurrent cycles, albeit largely fruitless, of demands for innovation to primary care delivery models . Increasingly, however, the need to review and revise the delivery of primary care has assumed new urgency and is currently seen as a core health policy issue in the developed world and beyond . Primary care reform has been advocated by provincial and national commissions in Canada as fundamental to health system restructuring [3–6]. In Ontario, two main models of reformed primary care (reformed fee-for-service and global capitation) have been initiated as pilot projects and evaluated. In 2001 the Ontario government launched the Ontario Family Health Care Network, intended to enlist 80% of practitioners by the year 2004 into a redesigned model of delivering primary care. The key elements in this model include: patient rostering, capitation payment with added incentives for prevention and other targeted services, provision of out-of-hours service and tele-triage, and extensive use of electronic medical records and linkages.
The move towards changes in the delivery of primary care appears to be a top-down process driven by provincial Ministries of Health. What do 'grass-roots' practitioners feel about change? A study in 2001 found that only five percent of Ontario family physicians, in practice eight to ten years, believed primary care reform would have a favourable effect on their practices. A subsequent study of physicians who were eligible for, but did not participate in, a primary care reform pilot project identified many concerns about the impact of a new system on: practice routines, working conditions, financial arrangements and loss of autonomy.
Currently in Ontario the long-standing Community Health Centre and Health Services Organization programs, and recent primary reform sites, account for only about five percent of family physician practices. This small number, along with evidence that practitioners are sceptical about current reforms, suggests that the recruitment target may be unrealistic. The aims of this study are: 1) to determine whether family physicians intended to participate in the Ontario Family Health Care Network; and 2) to identify factors that may influence their decision.
Statements used to elicit family physician views about primary care reform in Ontario.
I understand the Ontario Family Health Network well enough to make informed decisions about my involvement
I expect to be part of the Ontario Family Health Network by 2004
I expect to be part of the Ontario Family Health Network at some time after 2004
The current system for the organization of primary care delivery in Ontario needs to be changed
The current system for the financing of primary care delivery in Ontario needs to be changed
A capitation based formula for funding physician services would improve primary care in Ontario
A roster that links a patient to a single care provider would improve primary care in Ontario
Appropriate financial incentives would enhance preventive interventions in primary care
Patients should always have access to extended weeknight and weekend office hours
A telephone health line staffed by a qualified nurse is a good resource to direct patients to appropriate care
I would like to see computer systems replace most of the paper systems in my practice
Data analysis consisted of frequency distributions and the calculation of odds ratios. The variables were re-coded as follows: age-group [less than 44 vs. 45+ years], years in practice [less than 9 years vs. 10 years or greater], type of practice [solo vs. group, community health centre, health services organization, other], remuneration [fee-for-service vs. capitation, salary, other], size of practice [less than 1500 vs. 1500 or more patients], percent time in clinical practice and [less than 75% vs. greater than 75%]. Level of agreement was re-coded as either agreement [strongly agree, agree, slightly agree] or disagreement [slightly disagree, disagree, strongly disagree].
All analyses were conducted using procedures written in SAS. Ethics approval was received from the Queen's University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board.
Characteristics of respondents and their practices, family physicians in Ontario, 2002.
Age group (missing = 66)
Years in practice (missing = 90)
Practice tyype (missing = 4)
Community Health Centre
Health Services Organization
Primary Clinical Income (missing = 4)
Fee for service
Size of practice (missing = 25)
Percent time in clinical practice (missing = 2)
Use computer (missing = 12)
Billing, scheduling & registration
Full electronic record
Out of hours service*
Use on-call physician
Sign-out to emergency
Sign-out to walk-in clinic
Week-day evening hours
Week-end evening hours
Comparison of responders characteristics with the Ontario component of the National Family Physician Workforce Survey, 2001.
Years in practice
The frequency distribution of practice characteristics is presented in Table 2. The majority of family physicians (56%) worked in group practices, while the remainder worked in solo practices (30%), 'other' practices (7%), community health centres (5%), or health services organizations (3%). A substantial majority (81%) reported that they were remunerated on a fee-for-service basis – of the remainder, 10% were salaried, 5% were paid on a capitation basis and 4% were 'other'. Practice sizes were: less than 500 patients (4%); 500–1000 patients (11%), 1001–1500 patients (21%), 1501–2000 patients (26%), 2001–2500 patients (16%) and greater than 2500 patients (22%). The majority of family physicians (75%) spent between 76–100% of their time in clinical practice. All family physicians reported using a computer in their practice; 60% for billing, scheduling and registration; 30% for billing and only 10% reported that they kept full electronic records.
Percent level of agreement with statements about primary care reform.
I understand the Ontario Family Health Network well enough to make informed decisions about my involvement (n = 574)
I expect to be part of the Ontario Family Health Network by 2004 (n = 562)
I expect to be part of the Ontario Family Health Network at some time after 2004 (n = 549)
The current system for the organization of primary care delivery in Ontario needs to be changed (n = 568)
The current system for the financing of primary care delivery in Ontario needs to be changed (n = 567)
A capitation based formula for funding physician services would improve primary care in Ontario (n = 556)
A roster that links a patient to a single care provider would improve primary care in Ontario (n = 564)
Appropriate financial incentives would enhance preventive interventions in primary care (n = 567)
Patients should always have access to extended weeknight and weekend office hours (n = 568)
A telephone health line staffed by a qualified nurse is a good resource to direct patients to appropriate care (n = 569)
I would like to see computer systems replace most of the paper systems in my practice (n = 563)
Statistically significant relationship between characteristic of family physicians and their level of agreement with statements about primary care reform, odds ratios with their 95% confidence intervals.
Years in practice
Size of practice
Primary clinical Incomee
Percenttime in clinical practice
< 44 vs. 45+ years
0–9 vs. 10+ years
Solo vs. all others *
<1500 vs. 1500+ patients
Fee-for-service vs. all others**
<75% vs. 75%+
Understand the network enough to make informed decision about involvment
Expect to be part of network by 2004
Expect to be part of network afer 2004
Oorganization of primary care needs changing
Financing primary care needs changing
Capitation would improve primary care
Rostering would improve primary care
Financial incentives would preventive care
Patients should have weeknight and weekend access
Telephone health line is a good resource
Favours computer systems to replace paper
Three possible explanations for a physicians intention to join the Network were assessed. Neither a lack of understanding of the reform initiative (OR = 1.5, 95% C.I.s 0.96–2.3), nor the possibility that physicians were already practising in a manner similar to that proposed by the Network, were statistically significant explanations for the stated intention to join the Network (OR = 1.3, 95% C.I.s 0.6–2.9). The main factor associated with a physicians intent to join by 2004 was related to method of payment – physicians who favour capitation were 5.5 times more likely to report that they expected to join the Network by 2004 (O.R. = 5.5, 95% C.I.s 3.5–8.7).
This study has described the views of physicians about primary care reform in Ontario. While many physicians recognize the need for change in both the organization and financing of primary care, the majority of physicians do not expect to join the Network, and half of them do not understand the Network enough to make an informed decision about participating. Physicians are divided on issues such as patient rostering and extended hours, although many support the idea of financial incentives for preventive interventions or a telephone health line. Whether or not a physician was remunerated on a fee-for-service basis strongly influenced their views on reform. Physicians on fee-for-service were less likely to: report that they would join the Network; believe that the organization of primary care required changing; support rostering or capitation; favour financial incentives for prevention; or support extended access for patients. Physicians who spent less than 75% of their work in clinical practice were more likely to agree that the financing of primary care required changing, and to favour both capitation, rostering and extended access for patients. Physicians who favour capitation were 5.5 times more likely to report that they intended to join the Network by 2004. Although many responders did not understand the Network, the only statistically significant explanation was that physicians did not support capitation.
The limitations of this study ought to be considered before any conclusions be drawn. These results may be limited by the representativeness of the sample and by the reliability and validity of the questions used to determine views about reform. The representativeness of this sample is influenced by sampling bias and response bias. Our survey was based on a 20% random sample of the Ontario College of Family Physicians, that represents 65% of practicing family physicians in Ontario. This sampling frame excluded general practitioners who are not certified in Family Medicine, but who are eligible to participate in the reforms. These physicians are likely to be older than certified family physicians and may hold different views from those sampled in this study. The extent that this exclusion may bias these results is unknown, although that it may be minimal is suggested by the finding that non-certified general practitioners were equally likely to join a pilot primary care reform site as those who were members of the Ontario College of Family Physicians . Responders in our survey were more likely to be younger, to be women and to have practised for less time, than physicians who responded (53%) to the Ontario portion of the National Family Physician Workforce Survey. While, we acknowledge the possibility of sampling bias, we feel that the views of younger physicians may be more relevant because they are more likely to be the ones who are targets of the reform initiative. The low response rate (50%) was expected as it is well known that busy clinicians frequently do not complete questionnaires. Nevertheless, our response rate is comparable to that of the National Family Physician Workforce survey (53%) and a recently published survey of Ontario family physicians (47%) [11, 13].
Second, the way that the questions were phrased could bias the results. The questions used to determine the views of physicians were developed by the authors for this study and were not tested for their reliability and validity. Nevertheless, the questions were developed by the authors, whose expertise ranged from questionnaire design (DH), to primary care research (MG) and family medicine (SS, MG) and reflect the stated objectives of the Ontario initiative. We believe they had face validity. Interpretation of these results was based on the extent that responders agreed or strongly agreed with the statements. Depending on whether the "slightly agreed" category was included, interpretation of the results may differ – for example the majority agree with all but three statements (those about whether physicians expected to join the network and about capitation). A third limitation is that the survey was conducted a few months after the initiative was launched. The diffusion of innovations tends to have an initial latent phase before rapidly accelerating adoption. While it is possible that our survey only reflects this latency period, the fact that more than a year after the Network launch, only 5% of eligible physicians have joined, suggests that we have captured long-term intentions.
What are the implications of these findings for reform initiatives in Ontario? The majority of family physicians reported that they were unlikely to participate in the Network because they were opposed to capitation and patient rosters. In a study of the pilot phase of Ontario primary care reform physicians in Ontario's capitated Health Service Organizations were no more likely to join than fee-for-service physicians. In contrast, we found that a physicians support for capitation was associated with their intent to join the Network. Capitation payment is a key element in primary care restructuring not only in Canada but also in many foreign jurisdictions. It was the funding method officially endorsed by the Health Services Restructuring Commission in 1999 and is the dominant element in the Network remuneration scheme. Nevertheless, in Ontario almost 95% of physicians are currently paid by fee-for-service. For them, capitation may be associated with the unpopular principle in Ontario's Health Service Organizations where payment for patients attending a source of primary care outside the practice is withheld for that month. It has also been suggested that capitation may lead to loss of autonomy . Finally, it may be that Ontario family physicians disapprove of capitated practice because they just don't like change, a view supported by their reaction to many elements in contemporary health reform . Opposition to capitation is not confined to Ontario practitioners. In the USA, physicians who were introduced to partial capitation funding had strong negative views of the method and, while these views tended to moderate with time, capitation continued to be rated far below fee-for-service [17, 18].
Currently the vast majority of family physicians operate on a fee-for-service basis, with a significant number in solo practice. The decision not to be part of the network does not mean the physician will not be providing service. This may inhibit the incorporation of innovations, such as nurse practitioners or the electronic medical record, into existing practices with attendant implications for health human resources and quality of care respectively. Moreover, existing models of practice lack the capacity to address distributional issues. If all citizens were rostered to specific practices, there would be competition for patients. Some physicians now located in the urban south might be forced under such a capitated payment scheme to migrate to less serviced areas in order to acquire an adequate list of patients.
Many physicians reported that they did not fully understand the Network and may be unaware that it allows for a blended payment scheme including both capitation and fee-for-service. Since physicians may equate primary care reform largely with a switch to capitated payment, the successful recruitment to the Network will require the education of physicians about payment. Borrowing from strategy used to introduce Health Services Organizations, government suggested a process to compare the fee-for-service billings of potential recruits with their possible earnings under Network rules [1, 16]. Additionally, they need to emphasize that a selection of retained fee-for-service billing codes and the system of target achievement bonuses brings the Network's payment formula closer to a blended scheme favoured by many physicians [1, 19]. The key message, however, is that experience from many countries confirms that primary care reform does not succeed without the active support of the physicians involved . The alternative is to see the Network fail to attract widespread participation, as did its Health Services Organization and Community Health Centre predecessors [16, 20]. Since the launch of the Ontario Family Health Network, government has introduced a variant of fee-for-services with a number of incentives, known as family health groups that are proving more popular than the family health networks.
The results of this survey, conducted five months after the initial offering of primary care reform agreements to all Ontario physicians, suggest that a 80% enrolment target is unrealistic.
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