View - T-Space - University of Toronto

358 Pages·2009·1.89 MB·English

by  Monica Aggarwal

Primary Care Reform: A Case Study of Ontario

by

Monica Aggarwal

A thesis submitted in conformity with the requirements
for the degree of Doctor of Philosophy
Department of Health Policy, Management and Evaluation
University of Toronto

© Copyright by Monica Aggarwal (2009)
Abstract
Primary Care Reform: A Case Study of Ontario

Doctor of Philosophy, 2009

Monica Aggarwal

Department of Health Policy, Management and Evaluation
University of Toronto

This dissertation examines the factors that have the most significant impact on the pace
of change in the primary care (PC) sector in Ontario. In Canada, there have been many
attempts to improve the PC system through the introduction of a variety of primary care
reform (PCR) models. Some say that there is insufficient movement in the PC sector
and that it is in a policy gridlock. Others assert that substantial progress has been made
and that transformational change is proceeding.

This dissertation demonstrates that PCR – the movement from PC to some form of
primary health care (PHC) – is multi-dimensional and complex. It identifies the multiple
dimensions of PHC and demonstrates that each dimension has implications for the
structural relationships between the state and the medical association in the PC sector
in Ontario.

The framework for this dissertation was derived from three bodies of literature: PC/PHC,
neo-institutionalism and professional autonomy. The research design used involves
qualitative and quantitative methods, including historical analysis, document analysis,
key informant interviews and qualitative data.
ii
The case study of PCR in Ontario demonstrates that while there have been some
changes in the methods of physician payment and in the organization and delivery of
PC, the majority of PCR models have not fundamentally altered the underlying
institutional and structural relationships that characterize the sector. This includes the
profession’s ability to control the political, economic and clinical aspects of care. Thus,
the PCR models that propose the greatest amount of reform – those that alter structural
relationships between the state and the medical association in a manner that results in
a significant impact on the balance of power in the PC sector- are less likely to be
adopted by physicians. This dissertation corroborates that the PCR models that have
the greatest impact on professional autonomy are those that remain at the margins of
the health care system, whereas the models that have little or no impact on autonomy
have been more readily adopted.

iii
Acknowledgements

The completion of this dissertation has been one of the most significant challenges that
I have endured in my life. I would like to begin by thanking the Canadian Institute for
Health Research (CIHR) and Medicare to Home and Community (MTHAC) for their
financial contribution to this research. I would also like to thank my colleagues, friends
and employers for their love, support, patience and encouragement during this journey.
In particular, I would like to acknowledge the following individuals since, without them,
this dissertation would not have been possible. To them all, I owe my deepest gratitude.

I would like to thank my esteemed supervisor, Dr. A. Paul Williams, for giving me an
opportunity to pursue doctoral studies and my passion for research. During the
development of this dissertation, Dr. Williams was always accessible to me. I have been
privileged to have a supervisor who has allowed me to work independently but who has
provided assistance when needed. His guidance, knowledge and wisdom have made
me strong as both an academic and as an individual.

I am thankful to my co-advisors, Dr. Eugene Vayda and Dr. Jan Barnsley, for their
advice and encouragement throughout this research. They have consistently provided
me with both timely and valuable feedback on the development of my research
dissertation and final drafts of my chapters. It was a sincere pleasure to work with them.

In life, one is fortunate to cross paths with a unique individual. For me, this person is Dr.
Raisa Deber. She is not just one of my professors but my mentor, advisor and friend.
Dr. Deber has been involved in my development throughout my academic journey. I
iv
have had the pleasure to learn and work with her on a variety of different research
projects at the university. I would like to thank Dr. Deber for her advice and feedback.
More importantly, I would like to express my gratitude for her consistent faith in my
abilities, her understanding and her ongoing support.

I am grateful to my younger brother, Vishnu Aggarwal, who is the foundation of my
family. Each day, I am encouraged by his strength, maturity and character. His attitude
toward life has inspired me to believe what Dr. R. Paush eloquently stated: “We cannot
change the cards we are dealt, just how we play the hand.”1 My brother has been my
inspiration for playing and successfully finishing my hand in the game of education.

My father, Ram Aggarwal, is my greatest motivator and supporter in life. He has always
inspired me to strive to the highest possible level in all aspects of life. He is the person
who encouraged me to pursue a career in academia, and he has supported me in every
imaginable way so that I could finish this journey. There were times when I was tired,
frustrated and ready to give up, but my father supported me with his own energy when I
was falling over from exhaustion. He has always stood by me. This dissertation is as
much my father's accomplishment as it is mine.

1 Pausch, R. (2008). The Last Lecture. New York: Hyperion (p.17).
v
Most importantly, I want to express my deepest gratitude to my late mother, Manju
Aggarwal. I lost my mother during my time working on this dissertation. Losing her
began the darkest time in my life. I cannot begin to list the sacrifices that she made so
that I could have a better life and complete this dissertation. Once she was gone, I did
not think I had the strength to finish this work. However, her dream to see me graduate
has been my greatest inspiration to continue working hard and to finish travelling down
the path on which she left me. I can never repay her for the unconditional love,
guidance and support she provided to my life. This dissertation is all I can offer you, my
dear mother. I dedicate this work to you – the love of my life. I miss you deeply.

vi
Table of Contents

1 Introduction .................................................................................................................. 1
1.1 The Case of Primary Care ..................................................................................... 5
1.2 Research Questions ............................................................................................ 12
1.3 Chapter Outline ................................................................................................... 12
2 Literature Review and Conceptual Framework .......................................................... 15
2.1 Literature Review ................................................................................................ 15
2.1.1 Primary Care and Primary Health Care ........................................................ 15
2.1.2 The Evidence for a Strong Primary Care System ......................................... 17
2.1.3 The Current State of Primary Care in Canada .............................................. 19
2.1.4 Key Elements of PCR ................................................................................... 24
2.1.5 The “Taxonomy” of Primary Care Reform Models ........................................ 36
2.1.6 Factors That Impact the Pace of Primary Care Reform ................................ 40
2.1.6.1 Political Factors ...................................................................................... 40
2.1.6.2 Technical Factors ................................................................................... 47
2.1.6.3 Political and Technical Factors ............................................................... 50
2.2 Conceptual Framework ....................................................................................... 51
2.2.1 Neo-institutionalism ...................................................................................... 51
2.2.2 Professional Autonomy ................................................................................. 58
2.3 The Application of Conceptual Framework to Proposed Elements of PCR ......... 65
2.4 Hypotheses ......................................................................................................... 69
3 Methodology .............................................................................................................. 71
3.1 Document Analysis .............................................................................................. 71
3.2 Key Informant Interviews ..................................................................................... 74
3.3 Quantitative Data ................................................................................................. 78
3.4 Analysis ............................................................................................................... 78
3.4.1 Historical Analysis ......................................................................................... 78
3.4.2 Document Analysis ....................................................................................... 78
3.4.3 Content Analysis ........................................................................................... 79
4 The Historical Evolution of Primary Care Reform Efforts in Canada .......................... 81
4.1 Pre-medicare ....................................................................................................... 84
4.1.1 Rise of Allopathic Medicine .............................................................................. 84
4.1.2 Pre-medicare – A First Attempt at Establishing State Financing of Health Care
............................................................................................................................... 86
4.1.3 Pre-medicare – Rise of Physician-Sponsored Insurance Plans .................... 88
vii
4.1.4 Establishment of the Federal Role in Financing of Hospital Insurance ......... 89
4.1.5 Establishment of Provincial Financing of Medical Insurance ........................ 91
4.1.6 Ontario Sault Ste. Marie Clinic ...................................................................... 94
4.2 Medicare – Establishment of Federal Financing of Medical Insurance ................ 97
4.3 Post-medicare ................................................................................................... 100
4.3.1 Quebec Local Community Service Centres ................................................ 100
4.3.2 Ontario Community Health Centres and Health Service Organizations ...... 103
4.3.3 The End of Extra-Billing – Canada Health Act ............................................ 122
4.3.4 Ontario Health Service Organizations and Comprehensive Health
Organizations ....................................................................................................... 124
4.3.5 Entrenchment of Political Power of the OMA .............................................. 130
4.3.6 Ontario Health Service Organizations ......................................................... 131
4.3.7 Ontario Primary Care Networks .................................................................. 134
4.3.8 Ontario Family Health Networks ................................................................. 143
4.3.9 Ontario Family Health Groups .................................................................... 149
4.3.10 Ontario Comprehensive Care Model ........................................................ 152
4.3.11 Ontario Family Health Teams ................................................................... 154
4.3.12 Ontario Family Health Organizations ........................................................ 159
4.4 Conclusion ......................................................................................................... 162
5 Factors That Impact on the Pace of Change in the Primary Care Sector ................ 166
5.1 The Politics of Power ......................................................................................... 170
5.2 The Nature of Organized Medicine .................................................................... 172
5.2.1 Ontario Medical Association ....................................................................... 173
5.2.2 Coalition of Family Physicians .................................................................... 175
5.2.3 Medical Reform Group and College of Family Physicians .......................... 175
5.3 Fee-for-Service Payment Model ........................................................................ 177
5.4 Changes in Government ................................................................................... 180
5.5 Distrust of Government ..................................................................................... 181
5.6 Political Will ....................................................................................................... 183
5.7 Liability Insurance .............................................................................................. 185
5.8 Conclusion ......................................................................................................... 187
6 Key Elements of Primary Care Reform .................................................................... 190
6.1 Alternative Payment Mechanism ....................................................................... 194
6.2 Community Involvement .................................................................................... 203
6.3 Health Care Teams ........................................................................................... 207
6.4 Rostering ........................................................................................................... 219
viii
6.5 Information Technology ..................................................................................... 224
6.6 Population Health Approach .............................................................................. 230
6.7 24/7 Access to Care .......................................................................................... 237
6.8 Collaborative Practice Setting ........................................................................... 242
6.9 System Coordination ......................................................................................... 244
6.10 Conclusion ....................................................................................................... 246
7 Discussion and Conclusions .................................................................................... 254
7.1 Strengths and Limitations .................................................................................. 256
7.2 Major Findings ................................................................................................... 257
7.2.1 Political versus Technical Factors ............................................................... 257
7.2.2 Primary Care Reform and the Key Elements .............................................. 262
7.2.3 PCR Models ................................................................................................ 265
7.3 Evaluating the Pace of Change in the PC Sector .............................................. 268
7.4 Policy Implications ............................................................................................. 269
7.4.1 Implications for PCR in Ontario ................................................................... 269
7.4.2 Implications for the Health Care System in Canada ................................... 273
7.5 Theoretical Implications ..................................................................................... 276
8 References .......................................................................................................... 277

ix
List of Appendices

9 Appendices .............................................................................................................. 310
Appendix A: Definitions of Primary Care and Primary Health Care ......................... 310
Appendix B: Proposed Elements of Primary Care Reform ...................................... 318
Appendix C: Cover Letter for Key Informants .......................................................... 334
Appendix D: Consent Form ..................................................................................... 336
Appendix E: Questions for Interview ....................................................................... 337
Appendix F: Questions for Respondents ................................................................. 338
Appendix G: Agreement by Stakeholder on Alternative Funding Model by Key
Informant Category .................................................................................................. 340
Appendix H: Agreement by Stakeholder on Community Participation by Key Informant
Category .................................................................................................................. 340
Appendix I: Support for Health Care Teams by Key Informant Category ................ 340
Appendix J: Agreement by Stakeholder on Rostering by Key Informant Category . 341
Appendix K: Disagreement by Stakeholder on Information Technology by Key
Informant Category .................................................................................................. 341
Appendix L: Agreement by Stakeholder on Disease Prevention/Health Promotion by
Key Informant Category .......................................................................................... 341
Appendix M: Disagreement by Stakeholder on Disease Prevention/Health Promotion
by Key Informant Category ...................................................................................... 342
Appendix N: Support for Population Health Approach by Key Informant Category . 342
Appendix O: Agreement by Stakeholder on Population Health Approach by Key
Informant Category .................................................................................................. 342
Appendix P: Disagreement by Stakeholder on 24/7 Access by Key Informant
Category .................................................................................................................. 343
Appendix Q: Support for Collaborative Practice by Key Informant Category ........... 343
Appendix R: Agreement by Stakeholder on Collaborative Practice by Key Informant
Category .................................................................................................................. 343
Appendix S: Disagreement by Stakeholder on Collaborative Practice by Key
Informant Category .................................................................................................. 344
Appendix T: Support for System Coordination by Key Informant Category ............. 344
Appendix U: Agreement by Stakeholder on System Coordination by Key Informant
Category .................................................................................................................. 344
Appendix V: Disagreement by Stakeholder on System Coordination by Key Informant
Category .................................................................................................................. 345

x