OMA Submission to the. Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario. Discussion Paper Consultation

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1 OMA Submission to the Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario Discussion Paper Consultation February, 2016

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3 OMA Submission to the Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario Discussion Paper Consultation Background and Context The Ontario Medical Association (OMA) welcomes the opportunity to comment on the Patients First: A Proposal to Strengthen Patient-Centred Health Care in Ontario Discussion Paper (referred to as the Discussion Paper) in order to identify opportunities to address structural issues that create inequality and identify the critical role physicians play in ensuring effective patient care in an integrated health care system. The OMA is committed to ensuring that physicians are at the forefront of building a stronger, higher quality and sustainable health care system for patients. To achieve this, Ontario needs to focus its efforts on building a patient-centred health care system that enables integration between physicians, other health service providers, patients and families. The goal is a collaborative network of care centered on the patient. These integrated relationships will look different in each community, as they will reflect the unique mix of patients, physicians and other health care providers, resources and geography. As the timelines for consultation on the Discussion Paper were short, the OMA was unable to consult with Ontario s physicians in the way we wished. Considering the breadth and extent of the content within the government s paper, the OMA feels two months was insufficient time and will not take into account important discussions taking place after the February 29 th deadline. It is the OMA s view that as the government moves forward with reforms within the health system, they should do so within the context of a negotiated Physician Services Agreement that establishes the foundation for meaningful and sufficient dialogue and engagement with Ontario s physicians. Comments that follow are based on this context. Page 1 of 11 March 2, 2016

4 LHIN capacity, role and function The Discussion Paper proposes changes be made to the primary health care system to provide for care that is more integrated and responsive to local needs. This is proposed to occur through a substantial change to the mandate of the 14 LHINs in Ontario. The OMA recognizes that the Local Health Integration Networks (LHINs) as regional structures have an important role to play in the health care system, but they can only be effective if they commit to ensuring a collaborative partnership with all physicians. A great deal of the government s proposed transformation relies on the LHINs for implementation. The OMA is unaware of any evidence demonstrating that the LHINs are equipped to effectively manage an expanded role. In 2014, the government began a legislated review of the Local Health System Implementation Act, but regrettably this review remains incomplete. The legislative review represented an opportunity to assess the role and performance of the LHINs to date, to identify their strengths and weaknesses and to address their future role in the health system. Without this review, it is unclear how the LHINs are performing in relationship to their original mandate and whether they are positioned to accept even greater responsibility for health system planning and accountability. We note that the Auditor General reviewed some key performance areas of the LHINs and made substantial recommendations for LHIN improvements. LHINs are an untested resource in the broader primary health care system. The government s proposal outlined in the Discussion Paper raises concerns with respect to how LHINs will effectively engage with family doctors, whose self-funded practice settings represent the largest source of primary patient care services in Ontario. These practice environments and the patient care provided within them are key to the success of any reforms to how patient care is organized and delivered in Ontario. However, to date the LHINs have not been effective in engaging, collaborating or understanding the variable and unique needs of these practice settings. Any transition of planning and accountability to the LHINs for primary health care must be done after a meaningful consultative process that involves family doctors. It cannot be overstated how important it is that the LHINs gain a deep and meaningful understanding of how family doctors Page 2 of 11 February 25, 2016

5 organize their family practices and how these practices differ based on patient health service need, physician payment model, geographic location and access to nursing and interprofessional services. The current LHIN consultations, occurring in the absence of a broad government plan for primary care does not give physicians the information they need to effectively participate in a planning exercise. Sub-LHIN Organization The OMA supports the notion that publicly-funded health care services should be coordinated and organized better to support and improve patient care. The sub-lhin concept proposed within the Discussion Paper offers some potential. However, many important implementation details remain unknown. It is unclear what governance structure the government is considering for the sub-lhin planning and organization of services. Currently, most family doctors and their practices are organized within Patient Enrolment Models (PEMs), and some family doctors work in Community Health Centres (CHCs) or in affiliation with Family Health Teams (FHTs). Each of these organizations and the mix of community and social care agencies that serve patients have their own governance agreements. Any new accountability to the LHINs or to a sub-lhin will require consultation to determine what the added value is to the provision of patient health care services. If there are new accountability agreements, any existing governance structures, contractual agreements and service commitments will need to be purposeful and effectively harmonized. Inequity of access to services is a structural problem in Ontario s health care system. The availability of services for some patients is derived by geography, economic circumstances, government program funding and policy, health human resources distribution and patient need. Provincial policy is required to ensure that LHIN and Sub-LHIN planning for primary health care is mandated to identify these inequities. This policy is required to begin the necessary work to fill the gaps in patient care that are leading to inequitable access, experience and outcomes for patients throughout Ontario. Implementing a solution to this problem requires flexible and adaptable policy, and program and funding approaches that address the population health needs and service delivery capacity of the community. Family doctors will be essential in this regard; their role as the most responsible provider for nearly all patients in Ontario uniquely positions Page 3 of 11 March 2, 2016

6 them to lead in the design of meaningful solutions to patient care issues at the LHIN, sub-lhin and provincial policy levels. The ability of physicians to respond to local need will not be achieved through a command and control relationship with LHINs and the Ministry of Health and Long-Term Care. This approach has been proven not to work. A mutually defined partnership that is established among physicians, the OMA, the LHINs and the Ministry is what is required if Ontario is to develop a health care system that puts patients first. Physician Leadership at the LHIN and sub-lhin level LHINs are envisioned within the Discussion Paper as partnering with local clinical leaders, who would take responsibility for planning and performance management. LHINs would set clear principles for successful clinical change, including the clinical leader engagement structure. LHINs currently employ a number of physician leads, whose engagement with physicians has varied in approach, role and success. Evidence shows that physician commitment is critical to sustainable change. Local clinical leaders play an integral role in local planning and implementation because they support individual clinicians in fulfilling their accountabilities. LHINs have, to date, relied heavily on their physician leads and a small cadre of like-minded clinical leaders. LHINs will need to establish an engagement strategy that works with all physicians, including those that view the needs of the health care system differently. A collaborative partnership requires that practicing physicians feel that they have a voice in the system and that the physician leads are accountable to both the LHIN and to the profession. The current employed physician model used by the LHINs should be replaced with a new approach in order to achieve the changes envisioned within the Discussion Paper. Building meaningful partnerships between the LHINs and physicians will require a collaborative shared approach that addresses program and service issues at the LHIN, sub-lhin and local or practice level. At present, the Local Health Systems Integration Act (LHSIA) prohibits physicians from being appointed to LHIN Boards. This deprives the LHIN of the contributions of some of the most knowledgeable actors in the system. Further, if the LHINs are to effectively engage with independent community physicians, there will need to be a table at which they can come together as system partners. The OMA recommends that LHSIA be amended to allow physicians to be Page 4 of 11 February 25, 2016

7 eligible for appointments to LHIN Boards and that sub-lhin physician leaders be empowered, resourced and supported to partner within their local community to engage with physicians and other providers to identify successes and barriers to better delivery of integrated patient care. Access and Equity Improving access to interprofessional teams for patients that need it most, facilitating care plans, and supporting an integrated and coordinated patient-centred experience are all proposed to become roles of the LHINs. LHINs would also become responsible for improving health equity and reducing health disparities. The OMA has long advocated for improved access to interprofessional care, be it through formal teams or less formal approaches such as networks and shared care models. There are two key elements to defining a more accessible and equitable health system. The first is recognition of the established role of the family doctor in integrated, continuous care in family practice. This includes the utilization of interprofessional providers, clinical and hospital based clinical programs and services in addition to community and social supports. Secondly, an important element often over-looked in primary care discussions is the key role in access played by focussed practice physicians and community and consultant specialist physicians. Family doctors and their patients often benefit from focussed practice physicians and specialist consultants to support the best quality and accessible care. Focussed practice physicians, family doctors, and consultant specialists work alongside each other to address the needs of our most vulnerable patients (e.g. children, addictions, mental health, and care of the elderly). System planning must take this component of care into account from the outset in order to ensure that all physician services are effectively integrated throughout the primary health care system. Patients require timely and appropriate access to a family doctor. While many patients still remain unattached from a family doctor, access to physician services is well established in most communities. It is important that government respect the patient s right to choose his/her provider as outlined in the Health Insurance Act. Further, LHINs must not enforce enrolment requirements on family doctors absent the necessary supports and resources required to provide for the additional care. This includes the ability for family doctors to access the optimal payment model Page 5 of 11 March 2, 2016

8 and publicly funded interprofessional health provider resources. Through collaboration agreements there are opportunities for LHINs and the OMA to better leverage the existing physician and patient care services within the community, including services provided by focussed practiced physicians, urgent care clinics, walk-in clinics, community lab and diagnostic services and specialist consultants. Failure to do so will result in an over-demand for family physician services and a reduction in their ability to see patients in a timely way. Linkages with Hospitals There is a trend in the primary care field to view primary health care in isolation of the rest of the health care system. This tendency towards primary care isolationism appears to be carried forward in the Discussion Paper, as little mention is made of integration outside of the primary and community care sectors. If the government is to succeed in transforming the health care system, the OMA believes that effective links between primary medical care, medical specialists and hospitals are critical. Family doctors are unique, as their work spans a variety of practice environments, and three quarters have hospital privileges. The OMA believes that the relationship built at the sub-lhin level must include physicians and hospitals as partners. In addition to building necessary continuity across the system, hospitals are sophisticated players in the system in terms of governance, management and performance management. They also have important infrastructure resources and linkages to community and outpatient speciality care that might be shared with community based primary care health services. Public Health Ontario s Medical Officers of Health are critical to the success of our public health system. In the Patients First Discussion Paper, the government proposes to give LHINs more authority for local health planning and responsibility for managing accountability agreements with health units. This change proposes to better integrate the public health system within primary care and the broader heath care system in the province. Key factors to success will be ensuring that Medical Officers Page 6 of 11 February 25, 2016

9 of Health and Associate Officers of Health positions are fully filled by full-time, properly credentialed physicians and that public health nursing is better integrated into the family doctors practice. This should be a requirement of any accountability agreement signed between the LHIN and the Public Health Unit. Home Care As home care becomes a more integrated part of primary health care services in Ontario, any reforms to home care services should be structured such that the care coordinator is accessible to physicians for patient updates and communication regarding patient care plans. The OMA believes that this approach offers value to patients. The OMA is willing to partner with the Ministry and LHINs to further explore how to beneficially link care coordination and case management with physician practices. Transfer of CCAC The OMA is concerned about the plan to transfer responsibility for service delivery of home care to the LHINs. The Discussion Paper proposes to transfer full responsibility for service management and delivery of CCACs to the LHIN. LHIN management of the health system and delivery of community care services is a conflict of interest and contrary to good governance. The LHINs were not designed to be service delivery agents. In addition there are conflicts of interest with the LHINs acting as both the manager of the health system and a service delivery body within it. Improving community based home care and delivery through collaboration and integration within the health system is an important area for focussed reform, however, it should be done through broad and deliberate dialogue with all providers and designed to enhance patient experience, outcomes and equitable access to care based on mutually agreed upon service delivery design. Changing the structure for home care service delivery from CCACs to LHINs should be a separate and comprehensive discussion that includes relevant stakeholders, notably physicians, home care providers, hospitals and patients. Page 7 of 11 March 2, 2016

10 OMA Representational Rights The Discussion Paper states that LHINs will play a greater role in primary care health human resources planning and accountability for clinical service delivery. It also asserts that physician contracts would still be negotiated by government and that OMA representational rights would continue to be respected. The Representative Rights Agreement (RRA) provides that the OMA is recognized as the exclusive representative of physicians practising in Ontario. It states that; The Minister and the OMA will consult and negotiate in good faith with each other for the purpose of entering into Physician Services Agreements to establish physician compensation for physician services and related accountability in the publicly funded health care system. Physician accountability is a term to be negotiated between the OMA and the Government, as described in the RRA. Accordingly, the Discussion Paper is misleading in implying that LHINs will develop physician performance accountabilities. Any such accountability must be negotiated between the Government and the OMA with possible local implementation at the LHIN or sub- LHIN level. Preserving Physician Remuneration Models The Discussion Paper indicates the Ministry would continue to be responsible for physician remuneration. Family doctor practices are self-funded. This is a unique arrangement not found in the other providers and organizations impacted by the reforms proposed within the Discussion Paper. To be successful, physicians require access to a supportive structure and financial sustainability within the full range of physician remuneration models currently available. No one payment model will enable the reforms proposed within the Discussion Paper and it is imperative that due to the evolving demands on physician services that are being considered, the Ministry of Health and Long-Term Care recognize the critical importance of ensuring the financial viability of family doctor services throughout Ontario. Page 8 of 11 February 25, 2016

11 Role and Function of the Ministry The role of the Ministry is described within the Discussion Paper as negotiating physician remuneration agreements and primary care contracts. The OMA is supportive of this approach and its respect of the Representative Rights Agreement. However, it is proposed that LHINs will be responsible for implementing some accountability requirements. It will be important to ensure that this arrangement is not cumbersome, is specific and not duplicative, brings added value, and that physicians are not excessively burdened by more data collection and reporting requirements. The Discussion Paper also speaks of the LHINs engaging in health human resource planning. A stable health human workforce is one of the pillars of our health system and must be preserved. It is important the Ministry not allow regional service delivery strategies to evolve into competing regional plans. In the past, the government and the OMA have successfully negotiated Physician Services Agreements with the understanding that rural family practice has unique demands and requirements. The Discussion Paper does not address this. Irrespective of where a physician practices within the province, they must have equitable access to incentives, bonuses and payment models that allow them to maintain a viable and rewarding medical practice. Use of Performance Metrics in an Accountability Framework As noted previously, the OMA s Representation Rights Agreement requires that indicators that will be used for accountability purposes be negotiated with the OMA. The OMA recognizes, however, that performance information can be used for a variety of purposes, including local quality improvement. It will, therefore, be important to be very clear in determining the purposes for which data is collected. Physicians have limited access to real time patient, provider and group data as well as resources such as coaches, mentorship, and education, and EMR interoperability. Family doctors should be consulted on which performance measures are important in their sub-lhin region and within their practice setting. With local determination of priorities, uptake on the necessary work flow changes will receive greater buy-in from front-line physicians. Page 9 of 11 March 2, 2016

12 Measuring performance at a sub-lhin level will rely on the capacity to measure all providers, where currently, measurement is focussed on physician services. Additionally, it is important to note the variation in resources available to physicians to effect change. Physicians connected with FHTs and CHCs, or those whose practice is located in well serviced communities will have greater access to the necessary resources and supports that will improve their ability to meet local system performance priorities. For those physicians practicing alone, in rural or isolated communities, or in areas where sufficient resources are unavailable it is important that accountability and performance standards be adapted to reflect these limitations. Role of E-Health It is evident to the OMA that while the Discussion Paper does not directly address the use of electronic health tools. These tools will be critical to any successful reform of the health system. Widespread adoption of EMRs among community based physicians is an important opportunity to advance the horizontal and vertical integration of patient information across the continuum connecting primary, community and acute care. Physician use of EMRs and the development and implementation of programs to interface with certified EMR products are necessary to integrate additional sources of patient information. OntarioMD has deployed many of these programs including Hospital Report Manager (HRM), enotifications, and econsult, and continues to develop new programs such as ereferral, ebooking and the EMR Physician Dashboard. Each of these programs supports meaningful changes to the performance of Ontario s health care system. Conclusion The Ministry of Health and Long-Term Care has provided very little time to provide feedback on the Discussion Paper. The reforms proposed in the Discussion Paper are complex, in some cases untested, and most cases lacking in sufficient detail as to make concrete recommendations. Command and control does not work. We expect that the Ministry of Health and Long-Term Care and the LHINs will commit to establishing the necessary structures for collaboration that will Page 10 of 11 February 25, 2016

13 ensure an on-going and effective opportunity for physicians and the OMA to contribute towards addressing health system reform in the best interest of patients. The OMA shares the government s interest in improving health promotion and prevention, better access for patients, and effectively integrated services and public health. Physicians are essential to the successful implementation of these shared interests and require a Physician Services Agreement that reflects the valuable role physicians play in delivering patient care. Page 11 of 11 March 2, 2016

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