Ontario Health Teams: Much promise, but not yet ready to launch

The model of the Ontario Health Team is the centrepiece of the latest generational health care reform here in Ontario. As such, there has been tremendous engagement from leadership at all levels. It is great to see collaborative energy like this, as this opens opportunities for good programs to scale while enabling others to be created through this new platform that is the local Ontario Health Team.

Ontario Health Teams have been well-summarized by others such as Dr. Darren Larsen, Dr. Bob Bell, and the excellent reporting in the Spectator. In essence they offer a renewed governance model that on paper attempts to include patients and primary care in unprecedented ways. Financial responsibility is different, as the broad strokes of a model-in-progress will follow the principles of value based care. Finally, the collaborative spirit behind the OHT model creates new relationships between various stakeholders and each other, but most importantly, to the anchor hospital of the OHT.

However, despite the promise, I believe the OHT model is still very raw and misses the mark. Here, I highlight ten major challenges our healthcare system left unaddressed in the current state. In my opinion, reform is an opportunity to eliminate, attenuate or mitigate the consequences of these ten challenges, and so a model for the province must purpose-built to address these challenges. While any individual OHT may be very successful within its microcosm, the provincial lens shows that the model itself has many problems which could have tremendous consequences for another generation. This list isn’t exhaustive, but is based on my experience as a family physician and digital health entrepreneur.

1. Unattached patients. An estimated 850,000 patients in Ontario do not have access to primary care. This problem is near and dear to my heart as a family doctor who has a roster, and works in walk-in, urgent care, and emergency room settings. The health experience for patients without primary care is categorically worse, their care is clearly compromised, and the cost effects downstream are large. We know about the cost savings of primary care, the humanity of providing good access to a caring primary care clinician and a responsive system, and the desire from patients to have their own doctor or NP. The OHT model does not yet ensure that every patient will have an administrative body responsible for their primary care needs and ensuring those needs are met.
2. Infrastructure for Primary Care. There are amazing initiatives in primary care that are happening all over the province. However, few are able to take root outside their environment of origin. Why is this the case? While this topic could fill a book, the problem is that primary care doesn’t have a pragmatic arm that manages a collective infrastructure. This could reduce the heterogeneity between settings, take up the challenges presented by shared roadblocks, and execute tactically towards a shared collective vision. This also takes us straight into the world of EMRs and how they facilitate or stunt scale, almost always the latter. The right organization for this could make it so that scaling e-consults isn’t such a resource intensive, poly-institutional scale effort; or that one clinic’s QI efforts could be dropped into another clinic with a few clicks, or that things like e-referrals that could reduce overhead and risk once taken up collectively. While all this can happen at an OHT level, why build in fragmentation from the outset? Primary care needs major infrastructure planning at the provincial level to provide the right foundation for regionally-led teams to thrive. There must be more attention paid to this than there is now.
3. Physician Payment. There are a few key issues within this challenge. The majority of doctors are paid by fee-for-service, which is a major problem. Many doctors find it dissatisfying, it is linked to the large gender pay gap, it can drive costs by biasing towards more tests and prescriptions, doesn’t account for quality, outcomes or effort, and ultimately it pays doctors to hurry rather than do the things natural to meaningful human interaction. Under value-based care models, FFS is hardly the go-to payment model for all the reasons listed above. OHTs cannot reach their full potential as a value based care model while using the remuneration tools of a bygone era.
4. Digital Health Modernization. It is intellectually dishonest to claim that our current system encourages and enables the adoption of digital health tools. Ontario has multiple companies that built solutions in e-referrals, e-booking, e-visits, and patient access to medical records. However, these solutions have hardly penetrated the marketplace. For one, it’s not clear who will pay for these services between patients, doctors, institutions and government. Secondly, new entrants likely have to integrate somehow with current EMRs and EHRs, which places incumbents in the role of gatekeeper, where they demand significant revenue share. This all makes the market less competitive, drives costs upwards, and keeps such “innovation” at the margins. Can this be solved at the OHT level? Perhaps, an OHT with the right digital health strategy can execute on a plan and modernize their microcosm. However, can this be done consistently across dozens of OHTs so that there’s homogenaety and equity across the province? This is less likely without an intelligent digital health strategy. This challenge is one for the province, and in my opinion OHTs need to lay out to the government what they need, and the government has to begin to bear its teeth with respect to the incumbents in this space. For those paying attention to Kaiser Permanente, they spent $4bn on a purpose built IT system, and other health systems have taken a similar approach to their IT. This is a far cry from what it appears the plan is in Ontario, though the much-anticipated digital health blueprint has yet to be revealed.
5. Democratizing Participation. I had tweeted recently that OHTs are like a better boat that only those with boats can get to. When the call for OHTs came out, you can imagine that those in local leadership knew who they would have to call to get on board, and could likely do so with ease. Importantly, there’s no OHT without a hospital (by design and by practicality — who else can provide the space, pro-bono resources, and is existentially challenged by this new reform?). As a family doc in a FHG in the shadows of multiple downtown Toronto hospitals, I know that there is no place for my kind in these naturally occurring teams. While this is not surprising, OHTs created an insider environment (with likely insiders among the insiders), and have already been met with some criticism around the inclusion of patients. The OHT model says the right things about participation, but the reality is still lacking.
6. Catchment Areas. If you’ve ever experienced the blood pressure rise in hearing a patient isn’t eligible for a service because of where they live, this problem needs no explanation. Catchment areas are an artifact of funding, and tying funding to geographical areas. LHINs and hospitals naturally produce catchment areas, especially where there is no fee for service arrangement but rather funding for a program for a population. Sure, if managing a program or budget, this makes sense. But if managing a provincial population with needs, or if one is a patient with needs, this is senseless and at times very cruel. How will OHTs manage this? The model creates a new map with new boundaries for patients to cross. Seamless portability is essential but only possible with province-level pre-planning and coordination. This isn’t a problem for individual OHTs to solve, but one that the model should be able to address intelligently at the outset. “We’ll figure it out later” is not that.
7. Geographic Health Inequities. Rural and urban health experiences differ greatly. Within urban settings, there are health deserts, as reported excellently in The Local, with consequences for important primary care things like screening for cancer. Does the OHT model address this by building around hospitals? Likely not. Addressing inequities and resource maldistribution requires a strong central body with good insight and an attitude of supporting rather than punishing. This also touches upon human resources allocation which again requires a provincial approach to coordinate efforts and avoid cannibalization.
8. Quality. Health care quality is incredibly important. Poor quality can be a cost driver and more importantly a humanitarian insult wrapped around real harms. Does the OHT model help us reach the quality we desire for our health care system? I don’t think so. We need something more transformative. Primary care must be at the centre, liberated from managing strain, to pushing into upstream, community-building and community-engaged care. Home care has the ability to radically change how we view health care, moving away from institutional models towards more responsive, human-focused ones like the Burtzorg model from the Netherlands that is being piloted here. Can we really move forward in a radical way if physician payments stay the same and our IT systems limit the horizon of what’s possible? I think this is an absolute no.
9. Cost. At the end of the day, the government has to find a way to contain costs, and reduce cost growth. Provincial budgets are essentially medical care, and everything else is just a social determinant of health. Medical care costs cannot continue to rise and steal away from portfolios that help contain costs (consider education, legal aid clinics, housing, and a host of other things ranging from the arts to climate action). OHTs must make the right kind of investment in primary care and mental health services, with appropriate resourcing of community programs and services which are the institutional equivalent of unpaid caregivers. This cannot be left to chance.
10. Worklife Experience. This one is very near and dear to my heart. Working in healthcare has amazing aspects but some very frustrating ones. As a new doctor 6 years ago I was shocked by the dysfunctional aspects, enough so that two other colleagues and I set out to change it by starting ConsultLoop. We felt, and I still feel to this day, that it’s ridiculous to work in an environment that cannot deliver excellence and furthermore, cannot competently improve itself. Despite 6 years in this system, little has changed in my work, and there’s a nagging feeling of defeat. Many of you will recognize the transition. Reform is an opportunity to re-energize the workforce, and re-introduce doctors, nurses, social workers, and all the other health care workers to the idealism that brought them to their field. OHTs can do this, but the model will need to solve the above challenges to rekindle that excitement. Can this be strictly personal and nobody else really feels this way? Perhaps, but the levels of burnout suggest that this is likely a widespread phenomenon. While everyone has their own personal narrative of what burnout is, OHTs have a chance to address structural issues in the workplace that can positively affect the physician workforce.

OHTs have succeeded in mobilizing the sector, and creating a window where some transformative changes can take hold. However, without building a model to purposefully address the issues listed here, we run the real risk of returning to more of the same culture and patterns that brought us to where we are today. As proud as we can be about the aspirational aspects of our healthcare system, we must be relentless in improving on its execution.

We can do better, but it begins with better planning from the Ministry. The model is not yet ready to launch.