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])
In response to: G. Gibson; D. Wallik
Drs. Gibson and Wallik raise legitimate points which, because of space limitations, I was not able to address in my editorial.
One criticism of the HSO program as originally established was a lack of clear expectations.1 Nevertheless, the program was expected to promote some specific changes in the provision of primary care, such as the placement of greater emphasis on clinical prevention and health promotion. A 1988 study2 surveyed disease prevention and health promotion activities in HSOs, community health centres (CHCs) and fee-for service practices. At that time, HSO practice did not differ significantly from fee-for-service practices in terms of knowledge of or compliance with selected recommendations of the Canadian Task Force on the Periodic Health Examination. The increased use of nonphysician personnel was another aim. In general, the use of nonphysician health professionals has been modest.2
The important goal of reducing the rate of hospital admissions has received little study, but it is apparent, as Gibson states, that there are no significant differences between HSOs and fee-for-service practices, after physician and patient characteristics are taken into account.3
Difficulties with policies concerning the capitation rate, negotiation, arrangements for specialties and the Ambulatory Care Incentive Program had, by 1991, resulted in extraordinarily high costs. Contract changes instituted in 1993 have addressed many of these issues and have reduced the per capita cost for primary medical care to an amount only marginally greater than that for fee-for-service patients. I am unable, however, to verify Gibson's assertion4 that, within the current contract, capitation rates are based on the provincial average per capita costs.
Wallik mentions the scepticism associated with the HSO program; this may result from problems, especially with costs, that the program experienced before reforms were introduced in 1993. It would be unfortunate, as I attempted to point out in the original article, if this were interpreted either as evidence against capitation funding in general or as implying that there is no role for the CHC system in primary care reform.
David L. Mowat, MB, ChB, MPH
Assistant Professor
Department of Community Health and Epidemiology
Queen's University
Kingston, Ont.
References
- Ontario Ministry of Health. New beginnings [draft discussion paper by the Ministry of Health on the review of the HSO Program]. Toronto: The Ministry; 1991.
- Abelson J, Lomas J. Do health service organizations and community health centres have higher disease prevention and health promotion levels than fee-for-service practices? CMAJ 1990;142:575-81.
- Birch S, Lomas J, Harley J, Lomas L, Stratford-Devai F. Effect of a financial incentive to reduce hospital utilization in capitated primary care practice. Hamilton (ON): Centre for Health Economics and Policy Analysis; 1994.
- Gibson GA. Capitated practices. Do they work? [editorial]. Can Fam Physician 1996;42:589-92.
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