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Primary Care

Primary Care In Canada: So Much Innovation, So Little Change

Abstract

 
The development of Canadian primary care has been shaped by a series of policy legacies that continue to affect the possibilities for change in primary care through their cumulative effects on the health care system and the process of health policy development. The pursuit of radical systemwide change in the face of unfavorable circumstances (created in large part by those legacies) has resulted in missed opportunities for cumulative incremental change. While major changes in primary care policy seem unlikely in the near future, significant incremental change is possible, but it will require a reorientation of the policy development process.

We argue that the development of Canadian primary care has been shaped by a series of policy legacies that continue to affect the possibilities for change through their cumulative effects on the health care system and the process of health policy development. We also argue that the pursuit of radical, system wide change in the face of unfavorable circumstances (created in large part by those legacies) has resulted in missed opportunities for cumulative incremental change. Finally, we suggest that significant, although incremental, change is possible, but it will require a reorientation of the policy development process.

Primary Care In Canada

Top Primary Care In Canada Policy Legacies Innovations In Primary Care Taking Stock: What Has... The Starting Point For... Lessons For Policy Making NOTES

 
Primary care systems can be characterized in terms of organization/governance, funding/remuneration, and delivery. Canadian primary care is organized predominantly around family physicians and general practitioners (GPs) working in solo and small-group practices. Approximately one-third of primary care physicians are solo practitioners. Group practices average five physicians per group. The vast majority of primary care practices are owned and managed by physicians. Fee-for-service (FFS) payment is the dominant form of physician remuneration. For the 89 percent of Canadian family physicians/GPs who receive some FFS income, FFS payments account for an average of 88 percent of their total income.²

Delivery of primary care is physician-centered. Fewer than 10 percent of primary care physicians work in multidisciplinary practices. Primary care physicians’ average work week is just over fifty hours, excluding time spent on call. Fifty percent do house calls, and 72 percent participate in on-call activity for an average of twenty-six hours per week. Although provisions for off-hours coverage vary considerably, the usual arrangement is shared on-call coverage among groups of primary care physicians. One in five primary care physicians provides intrapartum obstetrical care, attending an average of forty births per year.³

Policy Legacies

Top Primary Care In Canada Policy Legacies Innovations In Primary Care Taking Stock: What Has... The Starting Point For... Lessons For Policy Making NOTES

 
As Paul Pierson has pointed out, "Political development is punctuated by critical moments or conjunctures that shape the basic contours of social life."⁴ Policies, once they are put in place, can be self-reinforcing through a process often referred to in the social science literature as "path dependence."⁵ This occurs through a variety of mechanisms, including the creation of institutions that support the policy, shaping the values of policymakers, stakeholders, and the public and adding over time to the social, political, and economic costs of shifting to another path. Because the costs of switching are usually immediate, while the benefits, if any, occur later, path dependence is supported by the short time horizons of political actors.⁶

Primary care innovations in Canada have been shaped—and to some extent bounded—by three policy legacies: (1) Canadian federalism, in which jurisdiction over health care is assigned primarily to provincial governments; (2) the principle of public payment for private medical practice on which Canada’s universal, publicly financed health insurance system is based; and (3) the limitation of compulsory coverage to hospital and physician service.

Federal/provincial division of powers. Under the British North America (Constitution) Act of 1867, jurisdiction over the design and management of health care services in Canada rests with the provincial governments. As a result, federal influence over health care is exerted mainly through the leverage of revenue transfers, and federal/provincial agreement is required to establish national standards or programs. At different times, the nature of Canadian federalism has both blocked and stimulated change in health care policy.⁷ For example, during the 1930s a limited federal government proposal for health insurance was overruled on constitutional ground, and, following World War II, proposals for compulsory health insurance foundered on the shoals of federal/provincial disagreement.

On the other hand, provincial jurisdiction over health care has also fostered experimentation and allowed pressure for change to develop at the provincial level. For example, both universal hospital and medical care insurance were introduced provincially by the social-democratic government of Saskatchewan several years in advance of the corresponding federal legislation.

The federal/provincial division of powers has encouraged a politics of blame assignment and avoidance in which the federal government accuses provincial governments of failing to manage the health care system in keeping with public needs and national standards, while the provinces complain about niggardly revenue transfers and federal meddling in provincial affairs. This dynamic has been particularly prominent since the economic recession of the early 1990s.

Private practice, public payment. Both the Saskatchewan Medical Care Insurance Act (1961) and its later federal counterpart, the Medical Care Act (1966), incorporated the principle of public payment for private medical practice, which had the effect of enshrining private FFS practice as the dominant mode of practice organization and physician payment in Canada.⁸ The passage in 1966 of federal legislation that provided for a federal/provincial cost-shared program of universal insurance for physician services was made possible by a confluence of conditions that included a minority government dependent on the support of the social-democratic New Democratic Party; fiscal buoyancy; a positive climate of federal/provincial relations; broad political support for the principle of access to health care on the basis of need, irrespective of personal financial resources; and physicians’ willingness to accept limitations on their "entrepreneurial discretion" in exchange for continued professional control over clinical decision making.⁹

A strong economy allowed governments to bring physicians into the Medicare program on generous terms, including the continuation of FFS remuneration, clinical autonomy, and control over the location and organization of medical practice. As Carolyn Tuohy has observed, this founding bargain or accommodation between the medical profession and the state "made no changes to the existing structure of health care delivery [and] placed physicians at the heart of the decision-making system at all levels."¹⁰ Federal and provincial policymakers were left with few and feeble policy levers to influence the organization and delivery of medical care and a reluctance to challenge the founding bargain for fear of jeopardizing the medical profession’s commitment to Medicare.

Privileging physician and hospital services. Health Act of 1984 clarified the standards to which provincial health insurance programs must conform in exchange for federal contributions: universality (coverage of the whole population on uniform terms and conditions); comprehensiveness (defined as health services provided by hospitals and physicians); accessibility ("reasonable access"); portability of coverage among provinces; and public administration. By defining the "comprehensiveness" standard as coverage of only hospital and physician services, the act had the important effect of reinforcing hospital- and physician-centered health care, limiting the potential for innovations in health care delivery based on alternative settings and providers, even in situations where they might be more appropriate or efficient.

Innovations In Primary Care

Top Primary Care In Canada Policy Legacies Innovations In Primary Care Taking Stock: What Has... The Starting Point For... Lessons For Policy Making NOTES

 
Primary care innovations have been introduced in three waves since the 1970s. Those innovations have almost invariably been at odds with the context-setting policy legacies we have described. The objectives and characteristics of these innovations have been largely driven by government responses to the economic times in which they occurred. With the exception of Quebec’s model of Centres locaux de services communautaires (CLSCs), all were conceived and implemented after the "golden age" of extraordinary economic growth from 1947 to 1973 had ended.¹¹ Although policy documents and political pronouncements have identified other objectives for primary care reform (for example, enhanced service integration, disease prevention, health promotion, and interdisciplinary team-based approaches to primary care delivery), these objectives have largely been derivative of the overriding goals of cost control and access. At best, quality of care has played third fiddle.

First wave: alternative organization and funding models (1970s). During this period, several alternatives to conventional solo and group general practice emerged. These included CLSCs in Quebec, Health Service Organizations (HSOs) in Ontario, and Community Health Centres (CHCs) in Ontario and, to a lesser extent, other provinces. All of these alternatives involved a change in funding and/or remuneration methods (to hybrid funding arrangements in Quebec, capitation funding in HSOs, and global funding in CHCs) and a change in delivery arrangements (most notably, the involvement of other health care providers, such as nurses and nurse practitioners). Organizational changes were more variable: CLSCs and CHCs have community governing boards, for example, while HSOs remained physician-led.

Introduced in 1972, CLSCs provide primary medical and social services to geographically defined populations. Some CLSCs, especially in rural areas, are vertically integrated with acute care hospitals and long-term care institutions. According to Luciano Bozzini, "The centres were born as the ‘vanguard institution’ of an ambitious health and social services reform whose objective was to set up an ‘integrated’ global system of care."¹² The network of CLSCs has gradually expanded to cover the entire Quebec population. There are currently 146 CLSCs employing about 1,500 salaried physicians (approximately 1,000 full-time equivalents, or FTEs) and more than 5,000 FTE nurses.¹³ Notwithstanding this growth, CLSCs are now considered either as alternative, competing models of primary care or merely as complementary to private practice.

Ontario HSOs had a slower birth process, coming into existence between the late 1970s and early 1990s. These physician-led, capitation-funded group practices provide medical care to rostered populations. A major objective of this program—especially during the period of rapid expansion between 1987 and 1991—was to move as many physicians as possible out of FFS payment. A Ministry of Health official described the deputy minister of the day as "thinking that eventually he would herd them into the gate and then close it behind them."¹⁴ Program expansions halted in the early 1990s in response to a growing government perception that the program had failed to achieve its intended objective of reducing health care costs while maintaining or improving health care quality. This moratorium continues. There are currently sixty-three HSOs with a total rostered population of 2.7 percent of the provincial population.

Initiated in the late 1970s as a complementary program to HSOs, Ontario’s CHCs are community-governed, globally funded primary health care organizations designed to improve access to health and health care for socially disadvantaged and hard-to-serve populations. Between 1987 and 1992 the number of CHCs increased from eleven to forty-nine. Program growth then slowed dramatically. There are currently 56 CHCs employing a total of 139 salaried physicians and 90 nurse practitioners. They provide primary health care to an estimated 2 percent of the Ontario population.

Second wave: broadening the range of primary care providers (mid-1980s). In pursuit of cost control and in response to advocacy by professional and consumer groups, several provinces undertook policy initiatives beginning in the mid-1980s and continuing into the 1990s to support an expanded role for nonphysician primary care providers. The Ontario government, for example, established a task force in the mid-1980s to recommend a plan for integrating midwives into Ontario’s health care system, although the relevant legislation was not proclaimed until 1994. Following Ontario’s lead, several other provinces legalized midwifery practice, and midwifery services are now publicly financed in Ontario, British Columbia, and Quebec. There are now about 350 registered midwives in Canada, the majority being in Ontario. Coincident with the legalization of midwifery in Ontario, legislation was passed that clarified and extended the scope of practice of other primary health care providers (for example, optometrists and physiotherapists).

Support for the role of nurse practitioners (NPs) in primary care delivery has been slower to develop. Legislation providing for the registration of primary care NPs was proclaimed in Ontario in 1998, and funding for approximately 220 primary care NP positions has been announced. Initiatives to train, license, or fund primary care NPs are under way in at least four other provinces and territories, although the total number of NPs remains small.

Third wave: primary care reform pilot and demonstration projects (mid-1990s). Since the mid-1990s all Canadian provinces have undertaken primary care pilot and demonstration projects, pursuing a variety of innovations in primary care organization/governance, funding/remuneration, and delivery arrangements, as one approach to dealing with the aftermath of dramatic downsizing and restructuring in the hospital sector during the early 1990s. Multisite projects in five provinces are being supported by federal funding, with the number of sites varying from one (in each of Prince Edward Island and the Northwest Territories) to twenty-six (in Alberta).

Consistent with provincial responsibility for health system design and management, arrangements vary considerably. This variation includes how and which stakeholders are involved in decision-making processes. In most jurisdictions the Ministry of Health or Regional Health Authority is the ultimate decisionmaker. In others (such as Ontario) primary care reform pilot projects have been planned and managed through a partnership between the Ministry of Health and the provincial medical association.

Variability also exists in the degree of autonomy given to the pilot and demonstration sites. Some are required to adhere to tightly defined requirements for the organization, funding, and delivery of care (such as in British Columbia and Ontario), while others have been given substantial latitude (Alberta). All but two jurisdictions (Alberta and Ontario) require interdisciplinary practice, and all but three (Alberta, British Columbia, and Ontario) require an expanded nursing role. Funding and remuneration methods for pilot and demonstration sites vary across and, in some cases, within jurisdictions. For physicians, salary and capitation are the most common remuneration methods. Global budgets and FFS are used less frequently.

An important sidebar to this discussion is that the modest innovations described here are proceeding largely in parallel to a much more significant reform that has swept the country since the late 1980s. Regionalization has introduced a new jurisdictional player to the health policy arena as governments in every province and territory except Ontario have devolved responsibilities for the funding, management, and delivery of health services to these new governing structures. Without exception, funding for physician services (and hence the bulk of primary care) has been excluded from the regional health authority budgets, once again leaving policymakers with little leverage over primary care organization and delivery.

Taking Stock: What Has Been Achieved?

Top Primary Care In Canada Policy Legacies Innovations In Primary Care Taking Stock: What Has... The Starting Point For... Lessons For Policy Making NOTES

 
Despite their wide variety and substantial numbers, innovations in the organization, funding, and delivery of primary care in Canada have been at the margins of primary care rather than at its core. Except in Quebec, where 20 percent of family physicians and GPs work in CLSCs, either full or part time, physicians participating in primary care reform projects or working in unconventional practice settings are in a tiny minority. In Ontario, with its long-established CHC and HSO programs and Canada’s largest provincial primary care reform scheme, only about 5 percent of physicians participate in alternative models of primary care funding and delivery.

Paradoxically, this absence of systemwide innovation has occurred despite a series of proposals for sweeping changes in primary care beginning with the 1973 report, The Community Health Centre in Canada, and continuing to the present. Government task forces, commissions, and policymakers charged with strengthening primary care have almost always advocated "big bang" reforms—the universal, more or less simultaneous, implementation of an "ideal" model for primary care organization, funding, and delivery. This approach virtually guarantees widespread opposition from physicians, the currently dominant primary care providers. Most physicians can be counted on to find at least one objectionable feature in any comprehensive model.

Proponents of "big bang" approaches often accompany their advocacy of radical change by crisis statements that are presumably intended to secure public and political support. Public statements by the chair of Ontario’s Health Service Restructuring Commission (HSRC) are illustrative:

Frankly, the greatest threat to "medicare" and access to health services...is failure to change the status quo. It is just not sustainable, not only because our provincial economy is out of money but because the present non-organization, non-coordination, non-integration of the sectors or elements of the health services non-system just do not make sense.¹⁵

The time for "pilots" is passed...It is time for the "big bang." I think we should just do primary care reform—do it everywhere, all at once and soon!¹⁶

The "politics of getting there" is often lost in the model-building exercise and in the model builders’ enthusiasm for their creations. Advocates of "big bang" change have paid insufficient attention to the starting point for primary care reform—a system dominated by small-group and solo FFS physician providers, which reflects the accommodation between physicians and government on which Canada’s publicly funded health care system is based.

Strategically, Canadian policymakers, analysts, and many health care stakeholders have focused their attention on funding and remuneration methods, seeing the elimination of FFS payment as a necessary, if not sufficient, condition for strengthening primary care. The identification of altered payment methods as an essential feature of primary care reform alienates many physicians from the reform process, including those reform elements that might otherwise be attractive to them. As a consequence of policymakers’ preoccupation with hard-to-sell funding and remuneration methods and the pursuit of "big bang" approaches to change, opportunities for cumulative incremental change that could enhance the effectiveness, efficiency, and responsiveness of primary care may have been forgone.

The Starting Point For Future Change

Top Primary Care In Canada Policy Legacies Innovations In Primary Care Taking Stock: What Has... The Starting Point For... Lessons For Policy Making NOTES

 
The lack of major change in primary care organization, funding, and delivery since the advent of Medicare has played out through the interacting effects on decision making of institutional arrangements (both formal and informal), information (including but not limited to research evidence), and values (including ideologies and interests), all of which have been heavily influenced by the policy legacies described at the beginning of this paper. This interplay not only helps to explain where we are now but also defines the opportunities and potential strategies for change and the limitations on what is achievable under current circumstances.

Institutional arrangements. The federal/provincial division of powers has provided thirteen provincial and territorial laboratories for innovation in primary care. However, unfavorable economic conditions and the politics of blame assignment and avoidance have combined to limit opportunities for significant systemwide change in primary care. Since the fundamentals of Canadian Medicare were established in the late 1960s, but particularly in the 1990s, provincial governments have faced a difficult fiscal climate, which led them to be either unwilling or unable to commit significant resources to effecting policy change—the principal policy lever available to them in the case of primary care. Dramatic reductions in transfer payments to the provinces, beginning in the 1980s and accelerating in the 1990s, reduced the federal government’s policy leverage in health care. Federal fiscal intervention to support primary care innovation has been limited to support of provincial primary care pilot and demonstration projects.

The policy legacies of the "founding bargain" between the medical profession and government of private practice based on FFS and negotiation of price and the privileging of both hospital-based and physician-provided care have created and reinforced institutional arrangements that serve as barriers to change.¹⁷ Policymakers have been left with few policy levers for reshaping the organization and delivery of primary care, other than the offer of additional dedicated funding to support desired innovations. Physicians occupy a privileged position in health policy formation with their associations often shaping, delaying, or preventing change. In some provinces the special status of physicians has been reflected in the development of joint management committees, while in other provinces the relationships have been less formal.¹⁸

More often than not, other stakeholders have been absent or had token involvement in the development of primary care policy. The exclusion of key stakeholders and failure to give due consideration to stakeholders’ responses to policy options under consideration risk making policy that is divorced from the real world. This may in part explain the recurring phenomenon of grand schemes for primary care reform that either are stillborn or meet an early demise.

Information. If institutional arrangements have been barriers to change, information has not provided the way to surmount them. Discussions of innovations in primary care invariably take place in an evidentiary vacuum. Strong evidence is lacking to support the superiority of any one model of organizing, funding, and delivering primary care and of many suggested model components, including group practice, multidisciplinary practice, and remuneration methods.¹⁹ (There is, however, growing evidence that quality improvement activities involving methods such as standard setting, patient and provider reminder systems, use of practice facilitators, and audit and feedback are of value in improving processes and outcomes of care)²⁰ Systematic, policy-informing evaluation of primary care innovations in Canada, including those that have been in existence for several decades, is remarkably limited, often narrowly focused, and not readily generalizable.²¹

The impact of primary care funding and remuneration methods on processes and outcomes of care is an area in which high-quality evidence is remarkably sparse. For example, the authors of a recent Cochrane Collaboration systematic review of primary care physician payment methods identified only four studies that met their rather liberal methodologic inclusion criteria (randomized controlled trial or controlled before/after study or interrupted time series).²²

As we assess the state of evidence regarding primary care physician payment methods based on the strongest, most relevant studies we have been able to identify, we see the following: (1) There is suggestive evidence that patients’ assessments of overall satisfaction and access/availability are more positive in settings with FFS as opposed to salary or capitation payment.²³ (2) There is minimal or conflicting evidence regarding patients’ assessments of continuity, comprehensiveness, coordination, technical quality, and interpersonal aspects of care.²⁴ (3) There is minimal evidence regarding practice patterns (for example, frequency of home visits and length of office visits).²⁵ (4) There is suggestive evidence that capitation payment results in higher rates of referrals to specialists.²⁶ (5) There is minimal or conflicting evidence regarding quality, utilization, and costs of care.²⁷ (6) There is minimal evidence regarding differences in use of nonphysician providers in FFS versus capitated practices.²⁸ (7) There is suggestive evidence of better preventive care performance by salaried and capitated physicians than by FFS physicians.²⁹

Effects of the range and mix of providers, working relationships and division of labor in multidisciplinary teams on health outcomes, patient and provider satisfaction, and cost-effectiveness with differing patient populations remain to be established. At best we have some research evidence about particular providers. For example, primary care NPs working in collaborative relationships with physicians can provide effective primary health care, although evidence regarding cost-effectiveness is scant and inconclusive.³⁰

Values. The absence of strong evidence to inform the development of primary care policy sets the stage for a cacophony of competing claims reflecting the concentrated (often economic) interests of stakeholders. We thus turn to values, which Jonathan Lomas describes as emerging from "a complex interaction of interests with beliefs and ideologies."³¹ Values are brought to policy making through the individuals and organizations who participate either directly or indirectly in the process.

Primary care reform proposals have typically addressed issues of managerial effectiveness and efficiency rather than core social values. This contrasts with the implementation of public medical care insurance in Canada, which responded to a deeply held public belief that access to medical care should be based on need, irrespective of personal financial resources. As a result, governments could count on strong public support for imposing change on unwilling physicians. Proposed primary care reforms may not address—and in some cases, such as patient rostering, triaging, and team-based approaches to care, may seem to compromise—important public values.

With no important social value at stake and the potential for primary care reforms to be seen as threatening health care access and choice, public and political support for fundamental change in the organization and delivery of primary care is likely to be soft. A perceived lack of public support may help to explain governments’ cautious approach to primary care innovation—as evidenced by waxing and waning support of innovative programs, a lack of investment in primary care infrastructure, and frequent recourse to pilot and demonstration projects.

Because Canadian Medicare was founded on the basis of an accommodation between governments and the medical profession, the interests of primary care physicians are especially salient. Physicians’ openness or resistance to proposed changes in primary care is shaped by how they think those changes will affect their professional autonomy, income, and conditions of work. Proposals for the mandatory adoption of new modes of primary care practice organization, funding, and remuneration that limit physicians’ choices regarding practice location, professional role, and payment method have met stiff resistance.

Physician surveys indicate that capitation payment is an anathema to most primary care physicians. For example, in the 1999 Canadian Medical Association Physician Survey, fewer than 1 percent of GPs identified capitation as their preferred method of payment.³² As well, anecdotally many family physicians worry that team-based approaches to primary care will greatly alter their scope of practice and undermine the continuity and closeness of their relationships with patients.³³ It is probably no coincidence that primary care reform pilot and demonstration projects require interdisciplinary practice everywhere but in Ontario and Alberta, the two provinces where medical associations have played the strongest role in shaping the projects.

Lessons For Policy Making

Top Primary Care In Canada Policy Legacies Innovations In Primary Care Taking Stock: What Has... The Starting Point For... Lessons For Policy Making NOTES

 
What can policymakers learn from the experience with innovation—and lack of innovation—in Canadian primary care? Perhaps the most important lesson is the importance of carefully assessing opportunities for change. The pursuit of "big bang" change under unfavorable circumstances may not simply be futile but may result in missed opportunities for cumulative incremental change.

If we are correct that "big bang" reform of primary care is currently unachievable in Canada, policymakers might, as an alternative, consider using two complementary approaches in parallel. The first of these is the identification of opportunities for progressive incremental change. The components of recently proposed models of primary care are largely divisible and capable of independent implementation. This unbundling of primary care models would allow early, systemwide implementation of those elements with broad stakeholder support (for example, enhanced clinical information systems). Action could be deferred on other elements while efforts are made to build consensus.

The second approach is to embrace (or at least tolerate) pluralism of organizational and funding models. Opportunities to move forward could be offered to those ready to embrace innovation, without attempting to impose change on the remainder. This approach to policy development—planned diversity and cumulative incremental change—if linked to thoughtful and rigorous evaluation, could lead to a primary care system that, over time, becomes increasingly effective, efficient, and responsive to patient and community needs while providing an acceptable work environment for primary care providers.

Potential pitfalls of an incremental and pluralistic approach to primary care policy development include a lack of system coherence, high administrative and transaction costs associated with multiple organization and funding models, and a change process that could become bogged down in the details of implementing a variety of reform elements independently. These risks need to be balanced against the alternative, which in the Canadian context appears to be policy gridlock.

Policymakers also need to reconsider their strategic emphasis on funding and payment methods as levers for change and their conceptualization of physician payment methods as mutually exclusive options. Blended funding arrangements provide a potential policy response to the unacceptability of capitation to most primary care physicians and the perverse incentives associated with the available physician payment options. Among the funding streams that could be incorporated into blended funding models are FFS, capitation, infrastructure funding, program funding, performance payments, and benefit packages.

As well as having the potential to address physicians’ resistance to capitation, blended funding could balance the competing perverse incentives of its components. For example, combining capitation with FFS payments could balance the incentive to stint on care under capitation with the incentive to overserve under FFS. Blended funding also could promote the achievement of specific policy objectives by targeting payments to support or reward desirable programs and activities.

Significant progress in primary care reform is unlikely in the absence of major investments by governments in primary care infrastructure. An era of fiscal stringency, together with almost exclusive reliance on FFS payments to fund primary care, has resulted in a striking lack of infrastructure in the areas of information technology, communication, coordination of care, quality improvement, and staffing. Investment in primary care infrastructure, which should be possible given more buoyant economic times, offers the possibility of enlisting the support of primary care physicians for reform. A process that has been viewed suspiciously as an exercise in cost reduction may come to be seen as one that offers primary care providers tools that will enhance their effectiveness and the quality of their working lives.

The case of primary care innovation in Canada illustrates the power of policy legacies in defining possibilities for change and, as a corollary, the limited role of research evidence and "good ideas" in the face of such legacies. It also suggests that fundamental change may be difficult to achieve when it fails to advance important social values, values that have themselves been shaped by policy legacies. Planning for the future requires knowing where you have been.

Editor's Notes

 
Brian Hutchison is a professor in the Department of Family Medicine and the Department of Clinical Epidemiology and Biostatistics, and acting director of the Centre for Health Economics and Policy Analysis, McMaster University, in Hamilton, Ontario. Julia Abelson and John Lavis are assistant professors in the Department of Clinical Epidemiology and Biostatistics and members of the center.

An earlier version of this paper was presented at the Commonwealth Fund International Symposium on Health Care Policy, "Quality and Innovation: Issues, Strategies, and Implications for Policy," in Washington, D.C., 11–13 October 2000.

NOTES

Top Primary Care In Canada Policy Legacies Innovations In Primary Care Taking Stock: What Has... The Starting Point For... Lessons For Policy Making NOTES

 

1. J.E.F. Hastings, The Community Health Centre in Canada (Ottawa: Information Canada, 1973); Federal/Provincial/Territorial Advisory Committee on Health Services, The Victoria Report on Physician Remuneration: A Model for the Reorganization of Primary Care and the Introduction of Population-Based Funding, A Discussion Document (Victoria: Advisory Committee, July 1995); National Forum on Health, Canada Health Action: Building on the Legacy—Final Report (Ottawa: National Forum on Health, 1997); and Health Services Restructuring Commission, Primary Health Care Strategy (Toronto: Health Services Restructuring Commission, December 1999).
2. College of Family Physicians of Canada, The CFPC National Family Physician Survey: Summary Report (Toronto: CFPC, October 1998).
3. Ibid.
4. P. Pierson, "Increasing Returns, Path Dependence, and the Study of Politics," American Political Science Review (June 2000): 251–267.
5. Ibid.; C.H. Tuohy, Accidental Logics: The Dynamics of Change in the Health Care Arena in the United States, Britain, and Canada (New York: Oxford University Press, 1999), 113, 123; and J.S. Hacker, "The Historical Logic of National Health Insurance: Structure and Sequence in the Development of British, Canadian, and U.S. Medical Policy," Studies in American Political Development (Spring 1998): 57–103.
6. Pierson, "Increasing Returns."
7. Tuohy, Accidental Logics; and Hacker, "The Historical Logic of National Health Insurance."
8. C.D. Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911–1966 (Kingston and Montreal: McGill-Queen’s University Press, 1986), 176–258.
9. Tuohy, Accidental Logics, 56.
10. Ibid.
11. E. Hobsbawn, Age of Extremes (London: Michael Joseph, 1994), 6.
12. L. Bozzini, "Local Community Services Centers (CLSCs) in Québec: Description, Evaluation, Perspectives," Journal of Public Health Policy 9, no. 3 (1988): 346–375.[Medline]
13. M. Dumont-LeMasson, Quebec Ministry of Health and Social Services, personal communication, 10 August 2000.
14. B. Hutchison, S. Birch, and J. Gillett, "Health Service Organizations: The Evolution of Capitation-Funded Physician Care in Ontario," Working Paper Series no. 96–11 (Hamilton, Ontario: Centre for Health Economics and Policy Analysis, McMaster University, September 1996).
15. D. Sinclair, chair, Health Services Restructuring Commission, "Notes for an Address to the Ontario Nurses’ Association 1996 AnnualMeeting" (19 November 1996).
16. D. Sinclair, "Action Plans to Further Primary Care Reform in Ontario," speech presented at Primary Care Reform in Ontario: Community and Academic Collaboration, Hamilton Convention Centre, Hamilton, Ontario, 24–26 September 1997.
17. Tuohy, Accidental Logics, 204.
18. Ibid., 207–210; J. Lomas, C. Charles, and J. Greb, "The Price of Peace: The Structure and Process of Physician Fee Negotiations in Canada," Working Paper Series no. 92–17 (Hamilton, Ontario: Centre for Health Economics and Policy Analysis, McMaster University, August 1992).
19. B. Hutchison and J. Abelson, Models of Primary Health Care Delivery: Building Excellence through Planned Diversity and Continuous Evaluation, Health Policy Commentary Series no. C96-3 (Hamilton, Ontario: Centre for Health Economics and Policy Analysis, McMaster University, 1996); and J. Abelson and B. Hutchison, "Primary Care Delivery Models: A Review of the International Literature," Working Paper Series no. 94–15 (Hamilton, Ontario: Centre for Health Economics and Policy Analysis, McMaster University, September 1994).
20. See, for example, "Medical Audit in General Practice, I: Effects on Doctors’ Clinical Behaviour for Common Childhood Conditions, North of England Study of Standards and Performance in General Practice," British Medical Journal 304, no. 6840 (1992): 1480–1484[Abstract/Free Full Text]; F. Buntinx et al., "Influencing Diagnostic and Preventive Performance in Ambulatory Care by Feedback and Reminders: A Review," Family Practice 10, no. 2 (1993): 219–228[Abstract/Free Full Text]; D.A. Davis et al., "Changing Physician Performance: A Systematic Review of the Effect of Continuing Medical Education Strategies," Journal of the American Medical Association 274, no. 9 (1995): 700–705[Abstract/Free Full Text]; and F.P. Bryce et al., "Controlled Trial of an Audit Facilitator in Diagnosis and Treatment of Childhood Asthma in General Practice," British Medical Journal 310, no. 6983 (1995): 838–842.[Abstract/Free Full Text]
21. See, for example, R.N. Battista, J.I. Williams, and L.A. MacFarlane, "Determinants of Primary Medical Practice in Adult Cancer Prevention," Medical Care 24, no. 3 (1986): 216–224[Medline]; M. Renaud et al., "Practice Settings and Prescribing Profiles: The Simulation of Tension Headaches to General Practitioners Working in Different Practice Settings in the Montreal Area," American Journal of Public Health 70, no. 10 (1980): 1068–1073[Abstract/Free Full Text]; Hutchison et al., "Health Service Organizations";; J. Abelson and J. Lomas, "Do Health Service Organizations and Community Health Centres Have Higher Disease Prevention and Health Promotion Levels than Fee-for-Service Practices?" Canadian Medical Association Journal 142, no. 6 (1990): 575–581[Abstract]; and B. Hutchison et al., "Do Physician-Payment Mechanisms Affect Hospital Utilization? A Study of Health Service Organizations in Ontario," Canadian Medical Association Journal 154, no. 5 (1996): 653–661.[Abstract]
22. T. Gosden et al., "Capitation, Salary, Fee-for-Service, and Mixed Systems of Payment: Effects on the Behaviour of Primary Care Physicians," Cochrane Review, The Cochrane Library 3 (2000).
23. A.R. Davies et al., "Consumer Acceptance of Prepaid and Fee-for-Service Medical Care: Results from a Randomized Controlled Trial," Health Services Research 21, no. 3 (1986): 429–452[Medline]; J.P. Murray, "A Follow-up Comparison of Patient Satisfaction among Prepaid and Fee-for-Service Patients," Journal of Family Practice 26, no. 5 (1988): 576–581[Medline]; P. Hjortdahl and E. Laerum, "Continuity of Care in General Practice: Effect on Patient Satisfaction," British Medical Journal 304, no. 6837 (1992): 1287–1290[Abstract/Free Full Text]; and D.G. Safran, A.R. Tarlov, and W.H. Rogers, "Primary Care Performance in Fee-for-Service and Prepaid Health Care Systems: Results from the Medical Outcomes Study," Journal of the American Medical Association 271, no. 20 (1994): 1579–1586.[Abstract/Free Full Text]
24. Davies et al., "Consumer Acceptance of Prepaid and Fee-for-Service Medical Care"; Murray, "A Follow-up Comparison of Patient Satisfaction"; and Safran et al., "Primary Care Performance."
25. I.S. Kristiansen and K. Holtedahl, "Effect of the Remuneration System on the General Practitioner’s Choice between Surgery Consultations and Home Visits," Journal of Epidemiology and Community Health 47, no. 6 (1993): 481–484[Abstract/Free Full Text]; and I.S. Kristiansen and G. Mooney, "The General Practitioner’s Use of Time: Is It Influenced by the Remuneration System?" Social Science and Medicine 37, no. 3 (1993): 393–399.
26. A. Krasnik et al., "Changing Remuneration Systems: Effects on Activity in General Practice," British Medical Journal 300, no. 6741 (1990): 1698–1701[Abstract/Free Full Text]; and T. Iverson and H. Luras, "The Effect of Capitation on GPs’ Referral Decisions," Health Economics 9, no. 3 (2000): 199–210.[Medline]
27. See, for example, I.S. Kristiansen and P. Hjortdahl, "The General Practitioner and Laboratory Utilization: Why Does It Vary?" Family Practice 9, no. 1 (1992): 22–27[Abstract/Free Full Text]; Hutchison et al., "Do Physician Payment Mechanisms Affect Hospital Utilization?";; A. Krasnik et al., "Changing Remuneration Systems"; and A.L. Hillman, M.V. Pauly, and J.J. Kerstein, "How Do Financial Incentives Affect Physicians’ Clinical Decisions and the Financial Performance of Health Maintenance Organizations?" New England Journal of Medicine 321, no. 2 (1989): 86–92.[Abstract]
28. Abelson and Lomas, "Do Health Service Organizations?"
29. Ibid.; W.G. Manning et al., "A Controlled Trial of the Effect of a Prepaid Group Practice on Use of Services," New England Journal of Medicine 310, no. 23 (1984): 1505–1510[Abstract]; R.N. Battista and W.O. Spitzer, "Adult Cancer Prevention in Primary Care: Contrasts among Primary Care Practice Settings in Quebec," American Journal of Public Health 73, no. 9 (1983): 1040–1041[Abstract/Free Full Text]; S.R. Cummings et al., "Smoking Counseling and Preventive Medicine: A Survey of Internists in Private Practices and a Health Maintenance Organization," Annals of Internal Medicine 149, no. 2 (1989): 345–349; and B. Hutchison et al., "Provision of Preventive Care to Unannounced Standardized Patients," Canadian Medical Association Journal 158, no. 2 (1998): 185–193.[Abstract]
30. S.A. Brown and D.E. Grimes, "A Meta-Analysis of Nurse Practitioners and NurseMidwives in Primary Care," Nursing Research 44, no. 6 (1995): 332–339[Medline]; F. Crosby, M.R. Ventura, and M.J. Feldman, "Future Research Recommendations for Establishing NP Effectiveness," Nurse Practitioner 12, no. 1 (1987): 75–79; U.S. Congress Office of Technology Assessment, Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (Washington: U.S. Government Printing Office, 1986); and H.C. Sox, "Quality of Patient Care by Nurse Practitioners and Physician’s Assistants: A Ten-Year Perspective," Annals of Internal Medicine 91, no. 3 (1979): 459–468.[Medline]
31. J. Lomas, "Connecting Research and Policy," Canadian Journal of Policy Research (Spring 2000): 140–144.
32. Canadian Medical Association, "1999CMA Physician Resource Questionnaire Results," 19 October 1999, <cma.ca/cmaj/vol-161/issue-8/prq/index.htm> (7 March 2001).
33. Ontario College of Family Physicians, Implementation Strategies: Protecting Trust in the Patient-Physician Relationship (Toronto: OCFP, 19 June 2000).

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