Canada’s primary healthcare system is in … quite a state. Primary care is the first entry point into the healthcare system for many and provides foundational services that support health and well-being. The pressures on primary care have been accelerated by the COVID-19 pandemic; this is only a part of the strain seen across the global primary care landscape by factors such as consumer behavior, labor shortages, demographic shifts, and digital disruption. Healthcare organizations should focus on three fundamental actions to protect and strengthen the state of Canadian primary care: invest in technology, encourage workforce growth, and accelerate alternative funding models.
The gap between the need for care and the supply of licensed physicians is a growing problem. Shockingly, just under one in five Canadians do not have a family doctor; this represents more than six million Canadian adults who lack regular access to primary care. Fewer medical school graduates are picking family medicine as their top choice for residencies, and more family physicians are choosing to retire, exacerbating the problem. Many practicing physicians are burned out and overwhelmed with increasing administrative burdens and an overall lack of a workforce to help lighten the load.
A perfect storm is threatening the sustainability of our health system. Without robust primary care, other parts of the healthcare ecosystem are bearing the brunt, with hospitals and emergency departments stepping in to provide non-emergency care. This places even more strain and cost on an already overburdened system.
Delivery and funding models continue to be hotly debated. Despite some movement to value-based healthcare in various parts of the country, most primary care continues to be delivered through physician practices operating as small businesses, with fee-for-service (FFS) tending to be the predominant compensation model.
Many family doctors have reported that FFS payments are not keeping pace with their own costs. They also face increasing pressure from the growing complexity of patient’s medical needs driven by an aging population beset by chronic illnesses that are starting earlier in life than ever before. The growing complexities of implementing, protecting, and maintaining a digital health infrastructure in each individual primary care practice add additional expenses or stresses, pulling physicians away from the bedside and affecting patient outcomes.
Some FFS physicians are showing interest in alternate payment models, e.g., those that offer a salary or pay for each rostered patient, etc. In British Columbia (BC), one study found that 40% of established family physicians would prefer alternative compensation models; that number jumped to 70% for newer graduates.
It comes as no surprise that the BC government recently moved in this direction, announcing a new compensation model worth millions of dollars for its province’s primary care physicians. Many have characterized this as a step in the right direction; others worry about accountability for outcomes.
Across Canada, though there has been progress over the last decade to address some of these challenges, it has not been done fast enough or with the scale or adoption that is needed to realize the changes that are required. There are three main areas Canadian healthcare should consider improving upon to address these challenges.
Invest in technology advancements
It’s time to move beyond electronic health record (EHR) adoption (which is still an essential, foundational component) and embrace advances in technology that can dramatically improve patient experience and clinical outcomes, and which help to expand access. There was considerable growth of various networks and digital channels of care during the pandemic, and this needs to be even further accelerated. Models of care are moving from clinics to homes, retailers, and digital platforms, and these shifts should be encouraged to address health inequities and workforce shortages.
Virtual primary care saw tremendous growth during the pandemic. This is an effective and efficient way to enable access, especially for lower-risk, healthier patients, as part of a multi-channel approach to care delivery. Expansion of virtual care options emphasizes patient choice, respect for the patient/provider relationship, and the importance of continuity of care.
Innovation in primary care must leverage digital tools and networks to improve integration and expand capacity and access. The burden of understanding and piecing together electronic tools should not fall on clinicians. A comprehensive platform should be a one-stop shop for individual practices. Additionally, leveraging innovative tools, such as speech recognition, automatic scribing, and AI tools to script suggested assessments and plans or perform administrative tasks, will also improve clinician time at the bedside. Canadian governments must both fund and partner with technology leaders in this space to deliver these solutions across our health system.
Although comprehensive technology solutions are a great start, they are not enough. Physicians need education and coaching on how to incorporate these new tools into their work. Traditional models of continuing medical education are not keeping pace with the speed of technology advancement. Physicians need guidance to incorporate chronic disease management apps and patient generated data into their care process.
Expand the workforce
Governments and their partners should leverage new approaches to encourage the employment of more primary care providers. This includes shifting the traditional physician-centric models to a team-based model allowing nurse practitioners and other multi-disciplinary providers to share the load with family doctors. This allows clinicians to work at the top of their license, decreasing stress and burden, while increasing workplace happiness.
Taking an integrated approach to medical, behavioral, and social determinants of health, working in multi-disciplinary teams, and maximizing scopes of practice will be essential to respond to physician labor shortages and meet increasing demand. This approach can help advance care delivery and improve patient outcomes, including promoting health equity, which will be an increasing focus for funders over time.
Consider shifting to alternate funding models
Beginning with those provinces with limited alternatives to FFS models, governments, physician associations, and other healthcare partners should work together to develop alternative funding models, even if it does require more up-front investment (which it will).
A shift from sole FFS must be one of the most significant sources of innovation in primary care over the next several years. In some jurisdictions, this is already happening in the form of blended models, such as FFS and capitation or salary-based models with defined accountabilities to ensure patients have appropriate access to primary care, regardless of the model.
Evidence suggests that these models demonstrate better clinical outcomes, lower overall cost of care, and carry a potential upside for physicians.
The road to solving the primary care crisis in Canada should not and cannot be another decades-long journey. A rapid transformation involving people, technology, and funding needs to occur to ensure the long-term health of both the Canadian people and healthcare system. Let’s expedite the mission by bringing a collaborative coalition together to get the job done.