You have probably heard the critique that you can’t improve what you don’t measure. In primary health care, part of our challenge is figuring out how to measure what matters, not just the things that are easily quantifiable.
A continuous relationship with a primary health care provider can positively affect health outcomes and reduce health system costs. So we need to find ways to measure those relationships.
To me, the most exciting measurement work going on in Canada is an Ontario project called D2D, or Data to Decisions. It started as the brainchild of an extraordinary family doctor from Oakville who is a self-declared data junkie. He’s made it his mission to drag us all into an era of enlightened measurement in primary care.
As a regular churchgoer who sings in the choir, Dr. George Southey had thought a lot about the parallels between music, spirituality, and family medicine. In his mind, all three were grounded in the importance of listening. And when he listened to his patients, the same themes emerged over and over: the importance of access, a caring experience, the competent delivery of medical services, and professional oversight of their health.
He’d read the research indicating that health care systems grounded in strong primary care do so much better than other systems at improving health and saving money. He called this the “Starfield observation,” named after Barbara Starfield, the researcher who had done the most important work on the topic. Like so many people who see patients in primary care, Dr. Southey was convinced that the reason primary care is so significant is relationships. So he set out to measure them.
Now the story switches from the spiritual to the geek domain. What can be measured and how does it reflect the relationship? Because the patient—doctor relationship is so broad in scope, he had to figure out how to measure many different elements. Some important measures could be body-part related, like screening rates for colon cancer or the proportion of patients whose blood pressure is under control. Dr. Southey began measuring these by drawing from the electronic records that most family doctors now use. Other measures assess things like whether patients can get an appointment in a timely fashion or their satisfaction with their doctor’s explanation of their symptoms.
These data can come from a simple survey. For example, if you were a patient in Dr. Southey’s practice, each year—in the month you were born—you’d receive a brief questionnaire from him about your experience as his patient. Not every patient responds, but enough of them do that he can develop a picture of how his practice measures up. And since we care about system costs, Dr. Southey uses administrative databases to look at his patients’ utilization of other health care services, like hospital services. With this, he’s able to calculate roughly how much money his patients cost the health care system overall.
Dr. Southey was able to measure a lot of things about his practice, but he struggled with the question of how much a given metric might reflect the quality of the thing he really cared about: the doctor–patient relationship. So he began to ask his patients how well any single indicator, like blood pressure control or whether they could get an appointment the same day they called, reflects broader aspects of the patient–provider relationship we all care about, like access, medical competence, or feeling listened to. Patients weren’t asked to choose between well-controlled blood pressure and a doctor who listened to them, but they were asked to reflect on how important each of those things was to them as a measure of a good relationship.
By asking hundreds of patients, Dr. Southey was able to learn about the relative importance of these things to his patients at that moment in time. The importance of each metric to the patients in his practice is what determines how much weight it’s given when they’re all rolled up together into a single measure of quality, on a score of 100.
Of course, as the priorities of the patients in Dr. Southey’s practice change, the relative significance of different aspects of the doctor—patient relationship will also change. Perhaps as his practice ages, chronic disease management will move to the fore. If he cuts back his hours, access to him will be more of a focus. His method of combining the indicators couldn’t remain static, so he periodically repeats the survey in order that he can shift the weight each of these issues carries in his quest to improve the quality of his care. By continuously monitoring his overall quality score, he learns what he needs to do better.
The D2D project builds on this work and is now starting to spread across primary care teams in Ontario. For the first time since I’ve been a family doctor, we have a way to measure quality of care that doesn’t feel meaningless or incomplete to me. It’s a measure that reflects more than body parts or lab results; it’s a measure of successful relationships.
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The idea that we’re finally measuring what matters to patients and changing the way we practise primary care is cutting edge. The urgent question then becomes how to align the way we pay doctors with the things that matter most.
Since the early days of medicare, most physicians have been paid on a piecework basis: the “fee-for-service” model pays your doctor for each encounter she has or procedure she does with a patient. She would bill the government for each individual interaction with you—say, $30 to assess you for a possible pneumonia, or $5 to immunize your child. But by its nature, fee-for-service rewards the volume of interactions rather than their complexity or quality.
Across Canada, “alternative” ways of paying family doctors have become much more common over the last decade; in fact, as of 2013, only about a third of family doctors were still receiving nearly all their earnings in a fee-for-service model. By contrast, I’m paid mostly through a capitation model. I receive a monthly payment that corresponds to the number of patients in my practice, with some adjustments for age and sex. This means that I don’t need to see you in order to get paid. In my view, that’s a good thing if we take advantage of it by conducting some of our appointments over the phone and by spending the necessary time in dealing with a long list of concerns during a single visit. On the other hand, you can imagine the perverse incentive here: if I make myself scarce, I can in theory collect my monthly amount without having to see you at all. Ontario’s auditor general found that some of this and other unsavoury behaviour does indeed exist in these models, though it’s not the norm.
There are other ways to pay doctors. Some countries, and to a small degree Canada, have experimented with a “pay-for-performance” method in which physicians are paid bonuses based on outcomes, such as whether they can bring their patients’ blood pressure under control or get them to quit smoking. It sounds appealing—pay for outcomes instead of, or in addition to, volume—but it hasn’t been convincingly shown to improve care. It can also provide an incentive for doctors to focus on signing up healthy, educated patients who will follow their advice rather than taking on vulnerable patients who may be less willing or able to comply.
We could put doctors completely on salary, which may work well for physicians with many complex patients requiring long visits. Yet there’s some evidence that paying doctors purely on salary—which frees us from the constraints of the clock—may eliminate the incentive to see many patients, which could jeopardize patient access and make waits for primary care longer.
In sum, there is no perfect way to pay family doctors. Every option encourages some behaviours we want to see yet also provides perverse incentives that we wish didn’t exist. On balance, I believe that fee-for-service is a barrier to the kind of primary health care we need. Fee-for-service promotes high-volume medicine by reimbursing doctors for the number of things they do rather than the quality or comprehensiveness of those things. For example, in some parts of the country it still happens that doctors limit their patients to “one problem per visit,” forcing patients to come back multiple times just to get their concerns addressed. Rapid visits for focused issues are rewarded in the fee-for-service structure, whereas spending forty-five minutes with a complex patient like Abida is a money loser.
What’s the solution? Probably a classic Canadian compromise. A base of capitation or salary could encourage doctors to do more telephone and email visits rather than requiring that patients always come in for a physical visit. In my view, perhaps 20 percent of family doctors’ incomes should be fee-for-service as a way to provide an incentive to see patients rather than just enrol them and then be unavailable. We also need some payments that reward group practices (rather than individual doctors) that score well on a relationship-based set of quality metrics—like the D2D model that Dr. George Southey pioneered and that has now been picked up in family health teams across Ontario.
As more and more doctors choose to practise in groups, those groups will need to take on accountability for their performance. And there’s a window of opportunity for this, given that just as our populations are changing, so is the face of family medicine.
Thirty years ago, over 40 percent of medical degrees were earned by women; today, women make up well more than half of our medical school graduates. Women practise medicine differently from men. On average, we see fewer patients per day and spend longer with each patient. During our reproductive years, we work fewer hours (in our paying jobs) per week. In fact, the newer generation of male family physicians is also working fewer hours than their predecessors, perhaps reflecting a greater commitment by men to participate in family obligations. These factors will influence how doctors practise in Canada, and the models we need to build for family doctors to practise in.
Furthermore, new physicians have little interest in the “business” side of medicine. The traditional model of hanging a shingle, hiring a secretary, and starting a filing system—the small business entrepreneur model of family medicine—is falling out of favour. Today, new graduates want less responsibility for the day-to-day running of their practices, and more flexibility to care for their patients and accommodate the other parts of their lives: in fact, only 1 percent of new family medicine graduates from Canadian medical schools want to enter traditional solo practice.
To me, this represents an opportunity. If we’re going to provide public support for family medicine in the form of clinic infrastructure or interprofessional teams, if we’re going to pay our family doctors well for the work they do, and if those family doctors want to practise differently than their predecessors did, we should provide the supports needed in primary care and demand accountability for the things patients deserve. In my view, some things should not be negotiable: team coverage for evenings and weekends, reasonable availability for urgent appointments, and the use of electronic medical records. Though this will take some time, those records should be deployed, through such enlightened metrics as those found in D2D, to proactively manage the health of one’s practice population.
Over time, we need to move to a system where we’re measuring what matters in family medicine and paying doctors and teams to achieve those standards. That is a much higher degree of accountability for the way we practise than Canadian family doctors are accustomed to. I don’t think this is a problem. I believe that most family doctors will find it entirely reasonable that our remuneration and the supports we get should depend on our provision of those aspects of relationship-based primary care we can control.
But some doctors may not want to be accountable to anyone but themselves for the hours they work or the way they choose to practise. They may not want to be told that they can’t take a vacation without arranging coverage for their patients, or that they have to cover a colleague’s patients when it’s her turn to go away. They may not feel it’s appropriate that they be obliged to prove they use electronic records or to have a mechanism for reaching out to women in their practice when they’re due for a Pap test. We’ll need to decide as a profession and as a society whether we’re prepared to continue to let that accountability be optional.
To decide that it isn’t optional would represent a big change. I think we’re ready. Without that accountability, I don’t see how we can achieve the goal of relationship-based primary care for every Canadian.
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The Big Idea here—population-wide, relationship-based primary care for Canada—is achievable. Our health care system would have many of the positive characteristics of a good public school system: greater consistency in the curriculum no matter which school you go to, an expectation that your local school will always have its doors open to you, and accountability for teaching the things that children need to learn. A population-wide primary care system wouldn’t force you into the local doctor’s practice, but it would ensure that there’s a doctor in your neighbourhood.
When this Big Idea has taken hold, payment models will make good use of our tax dollars by ensuring your access to the provider you need rather than steering you to a doctor every time. But you’ll also develop a relationship with a doctor or a nurse practitioner whom you regard as your personal care provider. It will be someone committed to developing a real human relationship with you, and we’ll pay for that rather than for each little interaction with you. We’ll also have well-established systems in place to get you access to specialty care or other resources in the community when you need them.
Building a health care system centred on primary care sounds like a simple idea. But as long as primary care remains mostly “outside” the health care system, provided by individual physicians or small groups unconnected in time, space, data sharing, and relationship from the rest of the system, we will struggle to achieve its potential. The most important building blocks are there already: a good supply of highly trained family physicians and other team members working in a single-payer system, and a population of citizens willing to engage with them. Now is the time to do even better by focusing on relationships.