Ontario's HSOs have not failed!
CMAJ 1997;157:1509
Re: "Primary care reform: Is it time for population-based funding?" (CMAJ 1997;157[1]:43-4 [full text / résumé])
See response from: D.L. Mowat
It is uncertain whether the Ontario Ministry of Health articulated its objectives and methods of assessment when establishing the HSO program in the early 1970s, but it is clear that many view with scepticism the role of HSOs in Canada's evolving health care network.
A perception exists that HSOs are more costly than the fee-for-service model. HSO funding arises from 2 sources: capitation (a preset monthly amount based on numbers of patients in various age and sex categories) and program funding (a negotiated sum that does not constitute physician income and which enables the HSO to administer "enhanced care" by ancillary medical staff). On the basis of data submitted by the ministry to the OMA in 1996, it has been calculated that per capita capitation costs of the HSO program are slightly lower than the corresponding fee-for-service averages. When program funding costs are added, per capita costs are slightly higher for the HSOs. However, the enhanced care programs reduce use of hospital-based services, which are traditionally funded by global hospital budgets.
Having worked within an HSO for over 10 years, I have come to appreciate that the benefits are intertwined with challenges. The dissociation between remuneration and "office visit" has enabled me to practise in a way that I believe is appreciated by patients, while affording me greater flexibility. My willingness to use the telephone (and even email) to communicate with patients would be difficult to duplicate in a "reformed fee-for-service" milieu. Even if the ministry links fees to telecommunication-based "visits," the frequency, brevity and variety (in terms of time and location) of physician-initiated patient contact will make remuneration for this contact cumbersome. Likewise, the ability to rely on allied health care professionals during patient visits has enabled our office to use physicians' skills to better advantage.
Although I remain a strong advocate of physician choice in compensation, I have difficulty understanding why, as Ontario searches to evaluate new ways to deliver high-quality primary health care efficiently, the HSO program has not received the attention it deserves.
David Wallik, MD
Chair, OMA-HSO Executive
Burlington, Ont.
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