Building the Patient-Centered Medical Home in Ontario

The concept of the patient-centered medical home is gaining traction in debates about expanding access, improving quality, and restraining the cost of health care. These homes include physician-led multidisciplinary teams that provide comprehensive primary care, expanded hours (with possible open-access scheduling), integrated evidence-based quality measurement, better communication for the patient experience, and modern health information technology. The timing seems right in the United States and a proof-of-concept project has shown promising change.¹ Yet concerns are being raised about slow uptake² and whether this concept will withstand the test of health care reform.³ Some authorities suggest that the Ontario experience with medical homes could be a blueprint for reform in US primary care.⁴ Ontario offers tangible real-world lessons for both countries about the consequences of decisions made in the course of home construction.

The Ontario medical homes are one of the world's largest experiments in primary care reform. From 2002 to 2010, about 75% of the region's 13 million residents and 10 000 primary care physicians joined medical home models with patient rostering, after-hours coverage, incentives for preventive health care, and payments for chronic disease management.⁵ The single most notable change (involving almost 4 million patients) was to switch from predominantly fee-for-service to predominantly capitation practices. Close to half of the capitation practices also had multidisciplinary clinician teams. These large-scale changes came about incrementally with the introduction of several new models through government negotiations with organized medicine.

One outcome has been increased primary care physician incomes. As medical homes were introduced voluntarily, inducements were needed for physicians to leave the traditional fee-for-service model. Stabilizing and enhancing the primary care workforce was a government goal, for which increased funding was knowingly committed. Ontario patient-centered medical homes have yielded improved work satisfaction and financial benefits to primary care physicians with typical annual net earnings increasing from about Can$162 000 to about Can$207 000.⁶ Government negotiators likely underestimated the distinct popularity of capitation, which is now expected to overtake all other models during 2010. The estimated annual incremental total direct physician expenditures for capitated medical homes has been at least Can$160 million.

Publicly funded health care aims to support patients in most need, but negotiations in Ontario resulted in models that somewhat compromised this outcome. Parties involved in the negotiations could not agree on case-mix or socioeconomic adjustments (in turn, capitation payments were adjusted for age and sex alone). Without finer case-mix adjustment, practices in the healthier and wealthier areas obtained attractive revenue projections with capitation, and the majority chose this model⁷ in accordance with economic theory. Conversely, physicians treating sicker patients had no incentive to join a capitation model and enjoyed relatively few financial incentives for providing better fee-for-service care.

Such adverse risk selection and “cherry picking” was accentuated because capitated medical homes were allowed to de-roster patients who sought outside primary care. This provided a strong incentive for some medical homes to drop precisely those patients with higher health needs and complex care. Such off-the-roster patients could continue to receive fee-for-service care within their original home but were not tracked, did not receive reminders for needed care, were not included in most incentives for chronic disease management, and may have missed out on other benefits of a medical home including access to nonphysician health professionals.

Demographic diversity also led to other economic inequities. That is, policy makers funding capitation did not want to pay twice for the same service from fee-for-service physicians who were contacted by a patient living in a capitated medical home. In Ontario, that translated into financial penalties for out-of-group primary care visits. Such duplication was most likely to occur in urgent care clinics, walk-in centers, or other facilities typical of urban settings. In contrast, rural settings had few such alternatives. Hence, rural practices gained the most with capitation. Conversely, major cities with urban poor and recent immigrants were much less likely to be served by primary care physicians working in a capitated medical home.⁷

Medical homes have the potential to reduce emergency department use by providing timely access to primary care. In particular, expanded clinic hours were required of Ontario's medical homes; however, entire groups were exempted if the majority of physicians provided hospital-based services. As a consequence, one survey found that less than a third of medical homes mentioned extended-hour clinics on their telephone messages despite the general requirement to hold such clinics.⁸ Medical homes, furthermore, had no requirement for open-access scheduling or other timely access strategies despite the benefits of such patient-centered processes.⁹

Limiting emergency department care is typically a public relations nonstarter, so Ontario's medical homes were designed with no direct disincentives against emergency department care. Administrative data showed that blended capitation was associated with 30% fewer after-hours visits and 20% more emergency department visits than blended fee-for-service practices.⁶ Of note, this pattern of emergency department care existed prior to capitation, indicating a strong attraction of such practices to the medical home model. Regardless of explanation, Ontario's medical homes did not appear to reduce emergency department use.

A timely and transparent evaluation of medical homes in Ontario would have allowed for mid-course corrections and adjustments. Instead, the government-funded evaluation of team-based capitation practices began 2 years after the model was established. Moreover, the results of the evaluation will be made public only under “terms and conditions which the Minister, in his sole discretion considers appropriate” (Service Agreement, Section 11.8, Intellectual Property Rights). Such confidentiality agreements would generally not be tolerated in medical science. A rigorous evaluation of Ontario medical homes, therefore, may never be made public, receive external scrutiny, or become available to policy makers elsewhere.

Ontario's medical homes are laudable in their innovation, scope, and workforce stabilization. They are a step forward in bringing change to a situation “exemplified by individuals making personal heroic efforts to compensate for the absence of systems and support.”¹⁰ Political negotiations, however, resulted in policies that favored self-selection of healthier patients, disincentives in major cities, gaps for vulnerable groups, and suboptimal access to care. Improved primary care income is always welcome, but the lack of an open evaluation mechanism is troubling. Others may want to examine the Ontario blueprints for large-scale primary care reform. However, they will want to consider their political landscape, choose locally appropriate construction methods, and carefully select building materials for patient-centered medical homes in the United States.