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Family physician views about primary care reform in Ontario: a postal questionnaire

Family physician views about primary care reform in Ontario: a postal questionnaire Background: Primary care reform initiatives in Ontario are proceeding with little information about the views of practicing family physicians. Methods: A postal questionnaire was sent to 1200 randomly selected family physicians in Ontario five months after the initial invitation to join the Ontario Family Health Network. It sought information about their practice characteristics, their intention to participate in the Network and their views about the organization and financing of primary care. Results: The response rate was 50.3%. While many family physicians recognize the need for change in the delivery of primary care, the majority (72%) did not expect to join the Ontario Family Health Network by 2004, or by some later date (60%). Nor did they favour capitation or rostering, 2 key elements of the proposed reforms. Physicians who favour capitation were 5.5 times more likely to report that they expected to join the Network by 2004, although these practices comprise 5% of the sample. Conclusions: The results of this survey, conducted five months after the initial offering of primary care reform agreements to all Ontario physicians, suggest that an 80% enrollment target is unrealistic. reform has been advocated by provincial and national Background Since the inception of Canadian medicare in the late commissions in Canada as fundamental to health system 1960s there have been recurrent cycles, albeit largely fruit- restructuring [3-6]. In Ontario, two main models of less, of demands for innovation to primary care delivery reformed primary care (reformed fee-for-service and glo- models [1]. Increasingly, however, the need to review and bal capitation) have been initiated as pilot projects and revise the delivery of primary care has assumed new evaluated[7]. In 2001 the Ontario government launched urgency and is currently seen as a core health policy issue the Ontario Family Health Care Network, intended to in the developed world and beyond [2]. Primary care enlist 80% of practitioners by the year 2004 into a Page 1 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 redesigned model of delivering primary care. The key ele- month later. The questionnaire sought information about ments in this model include: patient rostering, capitation physicians (age, sex, years in practice), practice character- payment with added incentives for prevention and other istics (type, size, remuneration, percent of time spent in targeted services, provision of out-of-hours service and clinical practice, use of computer, out-of-hours service) tele-triage, and extensive use of electronic medical records and their level of agreement with several statements and linkages[8]. related to primary care reform in Ontario (Table 1). The level of agreement ranged from: strongly agree, agree, The move towards changes in the delivery of primary care slightly agree, slightly disagree, disagree, to strongly disa- appears to be a top-down process driven by provincial gree. The wording of statements is presented in Table 1. To Ministries of Health. What do 'grass-roots' practitioners test for sampling bias, responder characteristics (age, sex, feel about change? A study in 2001 found that only five years in practice) were compared with the Ontario percent of Ontario family physicians, in practice eight to responses to the 2001 National Family Physician Work- ten years, believed primary care reform would have a force Survey [11]. favourable effect on their practices[9]. A subsequent study of physicians who were eligible for, but did not participate Data analysis consisted of frequency distributions and the in, a primary care reform pilot project identified many calculation of odds ratios. The variables were re-coded as concerns about the impact of a new system on: practice follows: age-group [less than 44 vs. 45+ years], years in routines, working conditions, financial arrangements and practice [less than 9 years vs. 10 years or greater], type of loss of autonomy[10]. practice [solo vs. group, community health centre, health services organization, other], remuneration [fee-for-serv- Currently in Ontario the long-standing Community ice vs. capitation, salary, other], size of practice [less than Health Centre and Health Services Organization pro- 1500 vs. 1500 or more patients], percent time in clinical grams, and recent primary reform sites, account for only practice and [less than 75% vs. greater than 75%]. Level of about five percent of family physician practices[1]. This agreement was re-coded as either agreement [strongly small number, along with evidence that practitioners are agree, agree, slightly agree] or disagreement [slightly disa- sceptical about current reforms, suggests that the recruit- gree, disagree, strongly disagree]. ment target may be unrealistic. The aims of this study are: 1) to determine whether family physicians intended to All analyses were conducted using procedures written in participate in the Ontario Family Health Care Network; SAS[12]. Ethics approval was received from the Queen's and 2) to identify factors that may influence their University Health Sciences and Affiliated Teaching Hospi- decision. tals Research Ethics Board. Methods Results A cross-sectional survey of family physicians in Ontario Of the 1200 family physicians sent a questionnaire, 50 was carried out in July 2002. A two page questionnaire, were not in practice so the final study population was along with a covering letter and a pre-paid return enve- 1150. 565 questionnaires were not returned and a further lope, was sent to 1200 family physicians, randomly 8 were returned without a response so that the final selected from a list of 5200 members of the Ontario Col- response rate was 50.2% (577/1150). The mean age of lege of Family Physicians. The college represents 65% of responders was 44 years, with the majority of responders all practicing family physicians in the province of Ontario. (39%) aged between 35–44 years (Table 2). There were Non-responders were sent a second questionnaire one Table 1: Statements used to elicit family physician views about primary care reform in Ontario. I understand the Ontario Family Health Network well enough to make informed decisions about my involvement I expect to be part of the Ontario Family Health Network by 2004 I expect to be part of the Ontario Family Health Network at some time after 2004 The current system for the organization of primary care delivery in Ontario needs to be changed The current system for the financing of primary care delivery in Ontario needs to be changed A capitation based formula for funding physician services would improve primary care in Ontario A roster that links a patient to a single care provider would improve primary care in Ontario Appropriate financial incentives would enhance preventive interventions in primary care Patients should always have access to extended weeknight and weekend office hours A telephone health line staffed by a qualified nurse is a good resource to direct patients to appropriate care I would like to see computer systems replace most of the paper systems in my practice Page 2 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 Table 2: Characteristics of respondents and their practices, family physicians in Ontario, 2002. Characteristic N (%) Age group (missing = 66) 25–34 years 101 19.8 35–44 years 198 38.8 45–54 years 155 30.3 55–64 years 57 11.2 Sex Females 259 44.9 Males 318 55.1 Years in practice (missing = 90) 0–9 years 186 38.2 10–19 years 168 34.5 20–29 years 107 22 30–39 years 26 5.3 Practice tyype (missing = 4) Solo 169 29.5 Group 318 55.5 Community Health Centre 27 4.7 Health Services Organization 18 3.1 Other 41 7.2 Primary Clinical Income (missing = 4) Fee for service 464 81 Capitation 29 5.1 Salary 58 10.1 Other 22 3.8 Size of practice (missing = 25) <500 patients 21 3.8 500–1000 patients 61 11.1 1001–1500 patients 116 21 1501–2000 patients 144 26.1 2001–2500 patients 90 16.3 >2500 patients 120 21.7 Percent time in clinical practice (missing = 2) <25% 12 2.1 25–50% 29 5.1 51–75% 103 17.9 76–100% 431 75 Use computer (missing = 12) Billing only 169 29.9 Billing, scheduling & registration 337 59.5 Full electronic record 59 10.4 Out of hours service* Use on-call physician 357 61.9 Sign-out to emergency 180 31.2 Sign-out to walk-in clinic 154 26.7 Week-day evening hours 155 26.9 Week-end evening hours 84 14.6 * More than one response allowed, so numbers don't add up to 577. slightly more men (55%) than women (45%). Respond- vey. Responders to the present survey were more likely to ers had practiced for an average of 15 years, with 38% of be younger, to be women and to have practiced for less family physicians reporting that they had practiced for less time than the Ontario responders to the national survey. than 9 years. Most practices differed from the type pro- posed by the Network (72%). Table 3 shows a compari- The frequency distribution of practice characteristics is son of sample characteristics with those of the Ontario presented in Table 2. The majority of family physicians portion of the National Family Physician Workforce Sur- (56%) worked in group practices, while the remainder Page 3 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 Table 3: Comparison of responders characteristics with the Ontario component of the National Family Physician Workforce Survey, Characteristic N (%) N (%) Age 25–34 years 101 19.8 760 8.7 35–44 years 198 38.8 2629 29.7 45–54 years 155 30.3 2958 33.5 55–64 years 57 11.2 1606 18.4 65+ -- -- 781 8.9 Missing 66 214 Sex Females 259 44.9 2778 31.8 Males 318 55.1 5951 68.2 Missing 0 112 Years in practice 0–9 years 186 38.2 1699 19.4 10–19 years 168 34.5 2827 32.3 20–29 years 107 22 2424 27.7 30–39 years 26 5.3 1297 14.8 40+ years -- 497 5.7 Missing 90 98 worked in solo practices (30%), 'other' practices (7%), care requires change. Nevertheless, few responders agreed community health centres (5%), or health services organ- with the statement that capitation (10%) or rostering izations (3%). A substantial majority (81%) reported that (23%) would improve primary care in Ontario. Many they were remunerated on a fee-for-service basis – of the responding physicians (68%) believed that appropriate remainder, 10% were salaried, 5% were paid on a capita- incentives would enhance prevention. Thirty percent of tion basis and 4% were 'other'. Practice sizes were: less responders agreed or strongly agreed that patients should than 500 patients (4%); 500–1000 patients (11%), 1001– always have access to extended office hours, while 42% 1500 patients (21%), 1501–2000 patients (26%), 2001– agreed or strongly agreed that patients should have access 2500 patients (16%) and greater than 2500 patients to a telephone health line. Half the responders (51.9%) (22%). The majority of family physicians (75%) spent agreed or strongly agreed that they would like to see com- between 76–100% of their time in clinical practice. All puter systems replace papers systems in their practice. family physicians reported using a computer in their prac- tice; 60% for billing, scheduling and registration; 30% for Odds ratios and their associated 95% confidence intervals billing and only 10% reported that they kept full elec- are presented in Table 5. Younger physicians were less tronic records. likely (OR = 0.62) to agree that rostering would improve primary care and that patients should have access to The level of agreement with statements about primary extended hours (OR = 0.49). Physicians in practice 9 years care reform is presented in Table 4. A substantial majority or less, were 1.6 times more likely to expect to join the (72%) of physicians did not expect to join the Network by Network by 2004, or after 2004 (OR = 1.67). Solo practice 2004 or by some later date after 2004 (60%). If the inter- physicians were less likely (OR = 0.65) to agree with the mediate category, 'slightly disagree' was included, these idea of extended hours and of computers replacing paper estimates rose to 84% and 76% respectively. The propor- systems (OR = 0.41). Physicians in small practices were tion of persons who reported that they never expected to less likely (0.64) to understand the reforms and to favour join the network was 82%. Thirty six percent of respond- telephone health lines (OR = 0.65). They were 1.49 times ers either agreed or strongly agreed with the statement that more likely to report that they expected to join the Net- they did not understand the Network well enough to work after 2004. Those physicians remunerated on a fee- make an informed decision about it. Forty eight percent of for-service basis were less likely to agree with statements responders agreed or strongly agreed that the current sys- about joining by 2004 (OR = 0.25), or after 2004 (OR = tem for the organization of primary care delivery required 0.47), that the organization required changing (OR = change and many responders (60%) agreed or strongly 0.29), favour capitation (OR = 0.27), rostering (OR = agreed with the statement that the financing of primary 0.34), financial incentives for prevention (OR = 0.41), or Page 4 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 Table 4: Percent level of agreement with statements about primary care reform. Statement Strongly Agree Slightly Slightly Disagree Strongly agree agree disagree disagree %% %%% % I understand the Ontario Family Health Network well 8.9 27.7 18.3 9.1 24.4 11.7 enough to make informed decisions about my involvement (n = 574) I expect to be part of the Ontario Family Health 3.1 4.3 8.7 12.1 33.3 38.6 Network by 2004 (n = 562) I expect to be part of the Ontario Family Health 1.8 5.8 16.4 16.4 27.7 31.9 Network at some time after 2004 (n = 549) The current system for the organization of primary care 14.4 33.1 26.8 7.8 12.7 5.3 delivery in Ontario needs to be changed (n = 568) The current system for the financing of primary care 25.2 34 19.6 6.2 10.2 4.8 delivery in Ontario needs to be changed (n = 567) A capitation based formula for funding physician services 3.4 6.5 17.3 14.6 31.7 26.6 would improve primary care in Ontario (n = 556) A roster that links a patient to a single care provider 6 16.5 27.5 9.6 22.2 18.3 would improve primary care in Ontario (n = 564) Appropriate financial incentives would enhance 23.5 44.4 19.6 3.4 6.4 2.8 preventive interventions in primary care (n = 567) Patients should always have access to extended 4.4 25.9 22.2 13.2 24.5 9.9 weeknight and weekend office hours (n = 568) A telephone health line staffed by a qualified nurse is a 9 33.2 28.3 8.6 13.9 7 good resource to direct patients to appropriate care (n = 569) I would like to see computer systems replace most of 22.6 29.3 20.4 8.5 13 6.2 the paper systems in my practice (n = 563) extended access for patients (OR = 0.58). Those who financing of primary care, the majority of physicians do derived less than 75% of their income from clinical prac- not expect to join the Network, and half of them do not tice, were less likely to understand the reforms (0.65), understand the Network enough to make an informed much more likely to agree that the financing of primary decision about participating. Physicians are divided on care required changing (OR = 2.38), agree with both cap- issues such as patient rostering and extended hours, itation (OR = 1.83) and rostering (OR = 1.77), and favour although many support the idea of financial incentives for extended access for patients (OR = 1.58). preventive interventions or a telephone health line. Whether or not a physician was remunerated on a fee-for- Three possible explanations for a physicians intention to service basis strongly influenced their views on reform. join the Network were assessed. Neither a lack of under- Physicians on fee-for-service were less likely to: report that standing of the reform initiative (OR = 1.5, 95% C.I.s they would join the Network; believe that the organiza- 0.96–2.3), nor the possibility that physicians were already tion of primary care required changing; support rostering practising in a manner similar to that proposed by the or capitation; favour financial incentives for prevention; Network, were statistically significant explanations for the or support extended access for patients. Physicians who stated intention to join the Network (OR = 1.3, 95% C.I.s spent less than 75% of their work in clinical practice were 0.6–2.9). The main factor associated with a physicians more likely to agree that the financing of primary care intent to join by 2004 was related to method of payment required changing, and to favour both capitation, roster- – physicians who favour capitation were 5.5 times more ing and extended access for patients. Physicians who likely to report that they expected to join the Network by favour capitation were 5.5 times more likely to report that 2004 (O.R. = 5.5, 95% C.I.s 3.5–8.7). they intended to join the Network by 2004. Although many responders did not understand the Network, the only statistically significant explanation was that physi- Discussion This study has described the views of physicians about pri- cians did not support capitation. mary care reform in Ontario. While many physicians rec- ognize the need for change in both the organization and Page 5 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 Table 5: Statistically significant relationship between characteristic of family physicians and their level of agreement with statements about primary care reform, odds ratios with their 95% confidence intervals. Age group Years in Practice type Size of Primary Percenttime practice practice clinical in clinical Incomee practice < 44 vs. 45+ 0–9 vs. 10+ Solo vs. all <1500 vs. Fee-for- <75% vs. 75%+ years years others * 1500+ service vs. all patients others** Understand the network 0.64 (0.46–0.90) 0.65 (0.45–0.95) enough to make informed decision about involvment Expect to be part of network 1.60 (1.03–2.50) 0.25 (0.16–0.40) by 2004 Expect to be part of network 1.67 (1.14–2.45) 1.49 (1.03–2.16) 0.47 (0.31–0.73) afer 2004 Oorganization of primary 0.29 (0.15–0.55) care needs changing Financing primary care needs 2.38 (1.37–4.14) changing Capitation would improve 0.27 (0.17–0.41) 1.83 (1.24–2.72) primary care Rostering would improve 0.62 (0.45–0.87) 0.34 (0.27–0.53) 1.77 (1.21–2.56) primary care Financial incentives would 0.41 (0.18–0.93) preventive care Patients should have 0.49 (0.35–0.69) 0.65 (0.45–0.93) 0.58 (0.38–0.89) 1.58 (1.08–2.33) weeknight and weekend access Telephone health line is a 0.65 (0.45–0.95) good resource Favours computer systems 0.41 (0.28–0.61) to replace paper * All other type of practices includes: group, community health centre, health services organization and other. ** All other type of primary income includes:capitation, salary and other. The limitations of this study ought to be considered responded (53%) to the Ontario portion of the National before any conclusions be drawn. These results may be Family Physician Workforce Survey. While, we acknowl- limited by the representativeness of the sample and by the edge the possibility of sampling bias, we feel that the reliability and validity of the questions used to determine views of younger physicians may be more relevant views about reform. The representativeness of this sample because they are more likely to be the ones who are targets is influenced by sampling bias and response bias. Our sur- of the reform initiative. The low response rate (50%) was vey was based on a 20% random sample of the Ontario expected as it is well known that busy clinicians frequently College of Family Physicians, that represents 65% of prac- do not complete questionnaires. Nevertheless, our ticing family physicians in Ontario. This sampling frame response rate is comparable to that of the National Family excluded general practitioners who are not certified in Physician Workforce survey (53%) and a recently pub- Family Medicine, but who are eligible to participate in the lished survey of Ontario family physicians (47%) [11,13]. reforms. These physicians are likely to be older than certi- fied family physicians and may hold different views from Second, the way that the questions were phrased could those sampled in this study. The extent that this exclusion bias the results. The questions used to determine the views may bias these results is unknown, although that it may of physicians were developed by the authors for this study be minimal is suggested by the finding that non-certified and were not tested for their reliability and validity. Nev- general practitioners were equally likely to join a pilot pri- ertheless, the questions were developed by the authors, mary care reform site as those who were members of the whose expertise ranged from questionnaire design (DH), Ontario College of Family Physicians [10]. Responders in to primary care research (MG) and family medicine (SS, our survey were more likely to be younger, to be women MG) and reflect the stated objectives of the Ontario initi- and to have practised for less time, than physicians who ative. We believe they had face validity. Interpretation of Page 6 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 these results was based on the extent that responders ver, existing models of practice lack the capacity to address agreed or strongly agreed with the statements. Depending distributional issues. If all citizens were rostered to spe- on whether the "slightly agreed" category was included, cific practices, there would be competition for patients. interpretation of the results may differ – for example the Some physicians now located in the urban south might be majority agree with all but three statements (those about forced under such a capitated payment scheme to migrate whether physicians expected to join the network and to less serviced areas in order to acquire an adequate list about capitation). A third limitation is that the survey was of patients. conducted a few months after the initiative was launched. The diffusion of innovations tends to have an initial latent Many physicians reported that they did not fully under- phase before rapidly accelerating adoption. While it is stand the Network and may be unaware that it allows for possible that our survey only reflects this latency period, a blended payment scheme including both capitation and the fact that more than a year after the Network launch, fee-for-service. Since physicians may equate primary care only 5% of eligible physicians have joined, suggests that reform largely with a switch to capitated payment, the suc- we have captured long-term intentions. cessful recruitment to the Network will require the educa- tion of physicians about payment. Borrowing from What are the implications of these findings for reform ini- strategy used to introduce Health Services Organizations, tiatives in Ontario? The majority of family physicians government suggested a process to compare the fee-for- reported that they were unlikely to participate in the service billings of potential recruits with their possible Network because they were opposed to capitation and earnings under Network rules [1,16]. Additionally, they patient rosters. In a study of the pilot phase of Ontario pri- need to emphasize that a selection of retained fee-for-serv- mary care reform physicians in Ontario's capitated Health ice billing codes and the system of target achievement Service Organizations were no more likely to join than bonuses brings the Network's payment formula closer to fee-for-service physicians[10]. In contrast, we found that a a blended scheme favoured by many physicians [1,19]. physicians support for capitation was associated with The key message, however, is that experience from many their intent to join the Network. Capitation payment is a countries confirms that primary care reform does not suc- key element in primary care restructuring not only in Can- ceed without the active support of the physicians involved ada but also in many foreign jurisdictions[14]. It was the [14]. The alternative is to see the Network fail to attract funding method officially endorsed by the Health Services widespread participation, as did its Health Services Restructuring Commission in 1999 and is the dominant Organization and Community Health Centre predeces- element in the Network remuneration scheme[15]. Never- sors [16,20]. Since the launch of the Ontario Family theless, in Ontario almost 95% of physicians are currently Health Network, government has introduced a variant of paid by fee-for-service[1]. For them, capitation may be fee-for-services with a number of incentives, known as associated with the unpopular principle in Ontario's family health groups that are proving more popular than Health Service Organizations where payment for patients the family health networks. attending a source of primary care outside the practice is withheld for that month. It has also been suggested that Conclusions capitation may lead to loss of autonomy [16]. Finally, it The results of this survey, conducted five months after the may be that Ontario family physicians disapprove of cap- initial offering of primary care reform agreements to all itated practice because they just don't like change, a view Ontario physicians, suggest that a 80% enrolment target is supported by their reaction to many elements in unrealistic. contemporary health reform [9]. Opposition to capitation is not confined to Ontario practitioners. In the USA, phy- Competing interests sicians who were introduced to partial capitation funding None declared. had strong negative views of the method and, while these views tended to moderate with time, capitation continued Authors' contributions to be rated far below fee-for-service [17,18]. DH was the principal investigator of the study and takes responsibility for the integrity of the work as a whole. Currently the vast majority of family physicians operate SEDS, PW, and MG made substantial contributions to the on a fee-for-service basis, with a significant number in conception and design of the study, to the acquisition of solo practice. The decision not to be part of the network data, and to the analysis and interpretation of data. All does not mean the physician will not be providing service. authors critically reviewed drafts of the manuscript and This may inhibit the incorporation of innovations, such as have approved the final version. nurse practitioners or the electronic medical record, into existing practices with attendant implications for health References 1. Hutchison B, Abelson J, Lavis J: Primary care in Canada: So much human resources and quality of care respectively. Moreo- innovation, so little change. Health Aff 2001, 20:116-131. Page 7 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 2. World Health Organization: Primary health care: A framework for future strategic directions. Geneva 2003. 3. Commission on Medicare: Caring for medicare: Sustaining a quality system. Regina 2001. 4. Premier's Advisory Council on Health: A framework for reform. Edmonton 2001. 5. Standing Senate Committee on Social Affairs, Science and Technol- ogy: The health of Canadians the federal role. Issues and options. Ottawa 2001, 4:. 6. Commission on the Future of Health Care in Canada: Shape the future of health care. Ottawa 2002. 7. PricewaterhouseCoopers: Ontario Ministry of Health and Long- Term Care: Evaluation of Primary Care Reform Pilots in Ontario; Phase 2 Interim Report. Toronto 2001. 8. PricewaterhouseCoopers: Ontario Ministry of Health and Long- Term Care: Evaluation of Primary Care Reform Pilots in Ontario; Phase 1 Final Report. Toronto 2001. 9. Cohen M, Ferrier B, Woodward CA, Brown J: Health care system reform, Ontario family physicians' reactions. Can Fam Physician 2001, 47:1777-1784. 10. Neimanis IM, Paterson JM, Allega RL: Primary care reform: Phy- sicians' participation in Hamilton-Wentworth. Can Fam Physician 2002, 48:306-313. 11. The JANUS Project, College of Family Physicians of Canada: The 2001 CFPC National Family Physician Workforce Survey Database. Mississauga 2001. 12. SAS Institute Inc: Proprietary Software Release 8.2 (TS2M0). Cary . 1999–2001 13. Delva MD, Kirby JR, Knapper CK, Birtwhistle RV: Postal survey of approaches to learning among Ontario physicians: implica- tions for continuing medical education. BMJ 2002, 325:1218. 14. Mable AL, Marriott J: Opportunities and potential: A review of international literature on primary health care reform and models. Ottawa: Health Canada 2000. 15. Health Services Restructuring Commission: Primary health care strategy. Advice and recommendations to the honourable Elizabeth Witmer, Minister ofHealth. Toronto 1999. 16. Gillett J, Hutchison B, Birch S: Capitation and primary care in Canada: financial incentives and the evolution of health serv- ice organizations. Int J Health Serv 2001, 31:583-603. 17. Tyrance PH Jr, Sims S, Ma'luf N, Fairchild D, Bates DW: Capitation and its effects on physician satisfaction. Cost Qual Q J 1999, 5:12-18. 18. Nadler ES, Sims S, Tyrance PH Jr, Fairchild DG, Brennan TA, Bates DW: Does a year make a difference? Changes in physician satisfaction and perception in an increasingly capitated environment. Am J Med 1999, 107:38-44. 19. Rosser WW, Kasperski J: Argument for blended funding. Can Fam Physician 2002, 48:236-237. 20. Suschnigg C: Reforming Ontario's primary health care system: one step forward, two steps back? Int J Health Serv 2001, 31:91-103. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2296/5/2/prepub Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 8 of 8 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Family Practice Springer Journals

Family physician views about primary care reform in Ontario: a postal questionnaire

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Springer Journals
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Copyright © 2004 by Hunter et al; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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15070426
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Abstract

Background: Primary care reform initiatives in Ontario are proceeding with little information about the views of practicing family physicians. Methods: A postal questionnaire was sent to 1200 randomly selected family physicians in Ontario five months after the initial invitation to join the Ontario Family Health Network. It sought information about their practice characteristics, their intention to participate in the Network and their views about the organization and financing of primary care. Results: The response rate was 50.3%. While many family physicians recognize the need for change in the delivery of primary care, the majority (72%) did not expect to join the Ontario Family Health Network by 2004, or by some later date (60%). Nor did they favour capitation or rostering, 2 key elements of the proposed reforms. Physicians who favour capitation were 5.5 times more likely to report that they expected to join the Network by 2004, although these practices comprise 5% of the sample. Conclusions: The results of this survey, conducted five months after the initial offering of primary care reform agreements to all Ontario physicians, suggest that an 80% enrollment target is unrealistic. reform has been advocated by provincial and national Background Since the inception of Canadian medicare in the late commissions in Canada as fundamental to health system 1960s there have been recurrent cycles, albeit largely fruit- restructuring [3-6]. In Ontario, two main models of less, of demands for innovation to primary care delivery reformed primary care (reformed fee-for-service and glo- models [1]. Increasingly, however, the need to review and bal capitation) have been initiated as pilot projects and revise the delivery of primary care has assumed new evaluated[7]. In 2001 the Ontario government launched urgency and is currently seen as a core health policy issue the Ontario Family Health Care Network, intended to in the developed world and beyond [2]. Primary care enlist 80% of practitioners by the year 2004 into a Page 1 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 redesigned model of delivering primary care. The key ele- month later. The questionnaire sought information about ments in this model include: patient rostering, capitation physicians (age, sex, years in practice), practice character- payment with added incentives for prevention and other istics (type, size, remuneration, percent of time spent in targeted services, provision of out-of-hours service and clinical practice, use of computer, out-of-hours service) tele-triage, and extensive use of electronic medical records and their level of agreement with several statements and linkages[8]. related to primary care reform in Ontario (Table 1). The level of agreement ranged from: strongly agree, agree, The move towards changes in the delivery of primary care slightly agree, slightly disagree, disagree, to strongly disa- appears to be a top-down process driven by provincial gree. The wording of statements is presented in Table 1. To Ministries of Health. What do 'grass-roots' practitioners test for sampling bias, responder characteristics (age, sex, feel about change? A study in 2001 found that only five years in practice) were compared with the Ontario percent of Ontario family physicians, in practice eight to responses to the 2001 National Family Physician Work- ten years, believed primary care reform would have a force Survey [11]. favourable effect on their practices[9]. A subsequent study of physicians who were eligible for, but did not participate Data analysis consisted of frequency distributions and the in, a primary care reform pilot project identified many calculation of odds ratios. The variables were re-coded as concerns about the impact of a new system on: practice follows: age-group [less than 44 vs. 45+ years], years in routines, working conditions, financial arrangements and practice [less than 9 years vs. 10 years or greater], type of loss of autonomy[10]. practice [solo vs. group, community health centre, health services organization, other], remuneration [fee-for-serv- Currently in Ontario the long-standing Community ice vs. capitation, salary, other], size of practice [less than Health Centre and Health Services Organization pro- 1500 vs. 1500 or more patients], percent time in clinical grams, and recent primary reform sites, account for only practice and [less than 75% vs. greater than 75%]. Level of about five percent of family physician practices[1]. This agreement was re-coded as either agreement [strongly small number, along with evidence that practitioners are agree, agree, slightly agree] or disagreement [slightly disa- sceptical about current reforms, suggests that the recruit- gree, disagree, strongly disagree]. ment target may be unrealistic. The aims of this study are: 1) to determine whether family physicians intended to All analyses were conducted using procedures written in participate in the Ontario Family Health Care Network; SAS[12]. Ethics approval was received from the Queen's and 2) to identify factors that may influence their University Health Sciences and Affiliated Teaching Hospi- decision. tals Research Ethics Board. Methods Results A cross-sectional survey of family physicians in Ontario Of the 1200 family physicians sent a questionnaire, 50 was carried out in July 2002. A two page questionnaire, were not in practice so the final study population was along with a covering letter and a pre-paid return enve- 1150. 565 questionnaires were not returned and a further lope, was sent to 1200 family physicians, randomly 8 were returned without a response so that the final selected from a list of 5200 members of the Ontario Col- response rate was 50.2% (577/1150). The mean age of lege of Family Physicians. The college represents 65% of responders was 44 years, with the majority of responders all practicing family physicians in the province of Ontario. (39%) aged between 35–44 years (Table 2). There were Non-responders were sent a second questionnaire one Table 1: Statements used to elicit family physician views about primary care reform in Ontario. I understand the Ontario Family Health Network well enough to make informed decisions about my involvement I expect to be part of the Ontario Family Health Network by 2004 I expect to be part of the Ontario Family Health Network at some time after 2004 The current system for the organization of primary care delivery in Ontario needs to be changed The current system for the financing of primary care delivery in Ontario needs to be changed A capitation based formula for funding physician services would improve primary care in Ontario A roster that links a patient to a single care provider would improve primary care in Ontario Appropriate financial incentives would enhance preventive interventions in primary care Patients should always have access to extended weeknight and weekend office hours A telephone health line staffed by a qualified nurse is a good resource to direct patients to appropriate care I would like to see computer systems replace most of the paper systems in my practice Page 2 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 Table 2: Characteristics of respondents and their practices, family physicians in Ontario, 2002. Characteristic N (%) Age group (missing = 66) 25–34 years 101 19.8 35–44 years 198 38.8 45–54 years 155 30.3 55–64 years 57 11.2 Sex Females 259 44.9 Males 318 55.1 Years in practice (missing = 90) 0–9 years 186 38.2 10–19 years 168 34.5 20–29 years 107 22 30–39 years 26 5.3 Practice tyype (missing = 4) Solo 169 29.5 Group 318 55.5 Community Health Centre 27 4.7 Health Services Organization 18 3.1 Other 41 7.2 Primary Clinical Income (missing = 4) Fee for service 464 81 Capitation 29 5.1 Salary 58 10.1 Other 22 3.8 Size of practice (missing = 25) <500 patients 21 3.8 500–1000 patients 61 11.1 1001–1500 patients 116 21 1501–2000 patients 144 26.1 2001–2500 patients 90 16.3 >2500 patients 120 21.7 Percent time in clinical practice (missing = 2) <25% 12 2.1 25–50% 29 5.1 51–75% 103 17.9 76–100% 431 75 Use computer (missing = 12) Billing only 169 29.9 Billing, scheduling & registration 337 59.5 Full electronic record 59 10.4 Out of hours service* Use on-call physician 357 61.9 Sign-out to emergency 180 31.2 Sign-out to walk-in clinic 154 26.7 Week-day evening hours 155 26.9 Week-end evening hours 84 14.6 * More than one response allowed, so numbers don't add up to 577. slightly more men (55%) than women (45%). Respond- vey. Responders to the present survey were more likely to ers had practiced for an average of 15 years, with 38% of be younger, to be women and to have practiced for less family physicians reporting that they had practiced for less time than the Ontario responders to the national survey. than 9 years. Most practices differed from the type pro- posed by the Network (72%). Table 3 shows a compari- The frequency distribution of practice characteristics is son of sample characteristics with those of the Ontario presented in Table 2. The majority of family physicians portion of the National Family Physician Workforce Sur- (56%) worked in group practices, while the remainder Page 3 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 Table 3: Comparison of responders characteristics with the Ontario component of the National Family Physician Workforce Survey, Characteristic N (%) N (%) Age 25–34 years 101 19.8 760 8.7 35–44 years 198 38.8 2629 29.7 45–54 years 155 30.3 2958 33.5 55–64 years 57 11.2 1606 18.4 65+ -- -- 781 8.9 Missing 66 214 Sex Females 259 44.9 2778 31.8 Males 318 55.1 5951 68.2 Missing 0 112 Years in practice 0–9 years 186 38.2 1699 19.4 10–19 years 168 34.5 2827 32.3 20–29 years 107 22 2424 27.7 30–39 years 26 5.3 1297 14.8 40+ years -- 497 5.7 Missing 90 98 worked in solo practices (30%), 'other' practices (7%), care requires change. Nevertheless, few responders agreed community health centres (5%), or health services organ- with the statement that capitation (10%) or rostering izations (3%). A substantial majority (81%) reported that (23%) would improve primary care in Ontario. Many they were remunerated on a fee-for-service basis – of the responding physicians (68%) believed that appropriate remainder, 10% were salaried, 5% were paid on a capita- incentives would enhance prevention. Thirty percent of tion basis and 4% were 'other'. Practice sizes were: less responders agreed or strongly agreed that patients should than 500 patients (4%); 500–1000 patients (11%), 1001– always have access to extended office hours, while 42% 1500 patients (21%), 1501–2000 patients (26%), 2001– agreed or strongly agreed that patients should have access 2500 patients (16%) and greater than 2500 patients to a telephone health line. Half the responders (51.9%) (22%). The majority of family physicians (75%) spent agreed or strongly agreed that they would like to see com- between 76–100% of their time in clinical practice. All puter systems replace papers systems in their practice. family physicians reported using a computer in their prac- tice; 60% for billing, scheduling and registration; 30% for Odds ratios and their associated 95% confidence intervals billing and only 10% reported that they kept full elec- are presented in Table 5. Younger physicians were less tronic records. likely (OR = 0.62) to agree that rostering would improve primary care and that patients should have access to The level of agreement with statements about primary extended hours (OR = 0.49). Physicians in practice 9 years care reform is presented in Table 4. A substantial majority or less, were 1.6 times more likely to expect to join the (72%) of physicians did not expect to join the Network by Network by 2004, or after 2004 (OR = 1.67). Solo practice 2004 or by some later date after 2004 (60%). If the inter- physicians were less likely (OR = 0.65) to agree with the mediate category, 'slightly disagree' was included, these idea of extended hours and of computers replacing paper estimates rose to 84% and 76% respectively. The propor- systems (OR = 0.41). Physicians in small practices were tion of persons who reported that they never expected to less likely (0.64) to understand the reforms and to favour join the network was 82%. Thirty six percent of respond- telephone health lines (OR = 0.65). They were 1.49 times ers either agreed or strongly agreed with the statement that more likely to report that they expected to join the Net- they did not understand the Network well enough to work after 2004. Those physicians remunerated on a fee- make an informed decision about it. Forty eight percent of for-service basis were less likely to agree with statements responders agreed or strongly agreed that the current sys- about joining by 2004 (OR = 0.25), or after 2004 (OR = tem for the organization of primary care delivery required 0.47), that the organization required changing (OR = change and many responders (60%) agreed or strongly 0.29), favour capitation (OR = 0.27), rostering (OR = agreed with the statement that the financing of primary 0.34), financial incentives for prevention (OR = 0.41), or Page 4 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 Table 4: Percent level of agreement with statements about primary care reform. Statement Strongly Agree Slightly Slightly Disagree Strongly agree agree disagree disagree %% %%% % I understand the Ontario Family Health Network well 8.9 27.7 18.3 9.1 24.4 11.7 enough to make informed decisions about my involvement (n = 574) I expect to be part of the Ontario Family Health 3.1 4.3 8.7 12.1 33.3 38.6 Network by 2004 (n = 562) I expect to be part of the Ontario Family Health 1.8 5.8 16.4 16.4 27.7 31.9 Network at some time after 2004 (n = 549) The current system for the organization of primary care 14.4 33.1 26.8 7.8 12.7 5.3 delivery in Ontario needs to be changed (n = 568) The current system for the financing of primary care 25.2 34 19.6 6.2 10.2 4.8 delivery in Ontario needs to be changed (n = 567) A capitation based formula for funding physician services 3.4 6.5 17.3 14.6 31.7 26.6 would improve primary care in Ontario (n = 556) A roster that links a patient to a single care provider 6 16.5 27.5 9.6 22.2 18.3 would improve primary care in Ontario (n = 564) Appropriate financial incentives would enhance 23.5 44.4 19.6 3.4 6.4 2.8 preventive interventions in primary care (n = 567) Patients should always have access to extended 4.4 25.9 22.2 13.2 24.5 9.9 weeknight and weekend office hours (n = 568) A telephone health line staffed by a qualified nurse is a 9 33.2 28.3 8.6 13.9 7 good resource to direct patients to appropriate care (n = 569) I would like to see computer systems replace most of 22.6 29.3 20.4 8.5 13 6.2 the paper systems in my practice (n = 563) extended access for patients (OR = 0.58). Those who financing of primary care, the majority of physicians do derived less than 75% of their income from clinical prac- not expect to join the Network, and half of them do not tice, were less likely to understand the reforms (0.65), understand the Network enough to make an informed much more likely to agree that the financing of primary decision about participating. Physicians are divided on care required changing (OR = 2.38), agree with both cap- issues such as patient rostering and extended hours, itation (OR = 1.83) and rostering (OR = 1.77), and favour although many support the idea of financial incentives for extended access for patients (OR = 1.58). preventive interventions or a telephone health line. Whether or not a physician was remunerated on a fee-for- Three possible explanations for a physicians intention to service basis strongly influenced their views on reform. join the Network were assessed. Neither a lack of under- Physicians on fee-for-service were less likely to: report that standing of the reform initiative (OR = 1.5, 95% C.I.s they would join the Network; believe that the organiza- 0.96–2.3), nor the possibility that physicians were already tion of primary care required changing; support rostering practising in a manner similar to that proposed by the or capitation; favour financial incentives for prevention; Network, were statistically significant explanations for the or support extended access for patients. Physicians who stated intention to join the Network (OR = 1.3, 95% C.I.s spent less than 75% of their work in clinical practice were 0.6–2.9). The main factor associated with a physicians more likely to agree that the financing of primary care intent to join by 2004 was related to method of payment required changing, and to favour both capitation, roster- – physicians who favour capitation were 5.5 times more ing and extended access for patients. Physicians who likely to report that they expected to join the Network by favour capitation were 5.5 times more likely to report that 2004 (O.R. = 5.5, 95% C.I.s 3.5–8.7). they intended to join the Network by 2004. Although many responders did not understand the Network, the only statistically significant explanation was that physi- Discussion This study has described the views of physicians about pri- cians did not support capitation. mary care reform in Ontario. While many physicians rec- ognize the need for change in both the organization and Page 5 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 Table 5: Statistically significant relationship between characteristic of family physicians and their level of agreement with statements about primary care reform, odds ratios with their 95% confidence intervals. Age group Years in Practice type Size of Primary Percenttime practice practice clinical in clinical Incomee practice < 44 vs. 45+ 0–9 vs. 10+ Solo vs. all <1500 vs. Fee-for- <75% vs. 75%+ years years others * 1500+ service vs. all patients others** Understand the network 0.64 (0.46–0.90) 0.65 (0.45–0.95) enough to make informed decision about involvment Expect to be part of network 1.60 (1.03–2.50) 0.25 (0.16–0.40) by 2004 Expect to be part of network 1.67 (1.14–2.45) 1.49 (1.03–2.16) 0.47 (0.31–0.73) afer 2004 Oorganization of primary 0.29 (0.15–0.55) care needs changing Financing primary care needs 2.38 (1.37–4.14) changing Capitation would improve 0.27 (0.17–0.41) 1.83 (1.24–2.72) primary care Rostering would improve 0.62 (0.45–0.87) 0.34 (0.27–0.53) 1.77 (1.21–2.56) primary care Financial incentives would 0.41 (0.18–0.93) preventive care Patients should have 0.49 (0.35–0.69) 0.65 (0.45–0.93) 0.58 (0.38–0.89) 1.58 (1.08–2.33) weeknight and weekend access Telephone health line is a 0.65 (0.45–0.95) good resource Favours computer systems 0.41 (0.28–0.61) to replace paper * All other type of practices includes: group, community health centre, health services organization and other. ** All other type of primary income includes:capitation, salary and other. The limitations of this study ought to be considered responded (53%) to the Ontario portion of the National before any conclusions be drawn. These results may be Family Physician Workforce Survey. While, we acknowl- limited by the representativeness of the sample and by the edge the possibility of sampling bias, we feel that the reliability and validity of the questions used to determine views of younger physicians may be more relevant views about reform. The representativeness of this sample because they are more likely to be the ones who are targets is influenced by sampling bias and response bias. Our sur- of the reform initiative. The low response rate (50%) was vey was based on a 20% random sample of the Ontario expected as it is well known that busy clinicians frequently College of Family Physicians, that represents 65% of prac- do not complete questionnaires. Nevertheless, our ticing family physicians in Ontario. This sampling frame response rate is comparable to that of the National Family excluded general practitioners who are not certified in Physician Workforce survey (53%) and a recently pub- Family Medicine, but who are eligible to participate in the lished survey of Ontario family physicians (47%) [11,13]. reforms. These physicians are likely to be older than certi- fied family physicians and may hold different views from Second, the way that the questions were phrased could those sampled in this study. The extent that this exclusion bias the results. The questions used to determine the views may bias these results is unknown, although that it may of physicians were developed by the authors for this study be minimal is suggested by the finding that non-certified and were not tested for their reliability and validity. Nev- general practitioners were equally likely to join a pilot pri- ertheless, the questions were developed by the authors, mary care reform site as those who were members of the whose expertise ranged from questionnaire design (DH), Ontario College of Family Physicians [10]. Responders in to primary care research (MG) and family medicine (SS, our survey were more likely to be younger, to be women MG) and reflect the stated objectives of the Ontario initi- and to have practised for less time, than physicians who ative. We believe they had face validity. Interpretation of Page 6 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 these results was based on the extent that responders ver, existing models of practice lack the capacity to address agreed or strongly agreed with the statements. Depending distributional issues. If all citizens were rostered to spe- on whether the "slightly agreed" category was included, cific practices, there would be competition for patients. interpretation of the results may differ – for example the Some physicians now located in the urban south might be majority agree with all but three statements (those about forced under such a capitated payment scheme to migrate whether physicians expected to join the network and to less serviced areas in order to acquire an adequate list about capitation). A third limitation is that the survey was of patients. conducted a few months after the initiative was launched. The diffusion of innovations tends to have an initial latent Many physicians reported that they did not fully under- phase before rapidly accelerating adoption. While it is stand the Network and may be unaware that it allows for possible that our survey only reflects this latency period, a blended payment scheme including both capitation and the fact that more than a year after the Network launch, fee-for-service. Since physicians may equate primary care only 5% of eligible physicians have joined, suggests that reform largely with a switch to capitated payment, the suc- we have captured long-term intentions. cessful recruitment to the Network will require the educa- tion of physicians about payment. Borrowing from What are the implications of these findings for reform ini- strategy used to introduce Health Services Organizations, tiatives in Ontario? The majority of family physicians government suggested a process to compare the fee-for- reported that they were unlikely to participate in the service billings of potential recruits with their possible Network because they were opposed to capitation and earnings under Network rules [1,16]. Additionally, they patient rosters. In a study of the pilot phase of Ontario pri- need to emphasize that a selection of retained fee-for-serv- mary care reform physicians in Ontario's capitated Health ice billing codes and the system of target achievement Service Organizations were no more likely to join than bonuses brings the Network's payment formula closer to fee-for-service physicians[10]. In contrast, we found that a a blended scheme favoured by many physicians [1,19]. physicians support for capitation was associated with The key message, however, is that experience from many their intent to join the Network. Capitation payment is a countries confirms that primary care reform does not suc- key element in primary care restructuring not only in Can- ceed without the active support of the physicians involved ada but also in many foreign jurisdictions[14]. It was the [14]. The alternative is to see the Network fail to attract funding method officially endorsed by the Health Services widespread participation, as did its Health Services Restructuring Commission in 1999 and is the dominant Organization and Community Health Centre predeces- element in the Network remuneration scheme[15]. Never- sors [16,20]. Since the launch of the Ontario Family theless, in Ontario almost 95% of physicians are currently Health Network, government has introduced a variant of paid by fee-for-service[1]. For them, capitation may be fee-for-services with a number of incentives, known as associated with the unpopular principle in Ontario's family health groups that are proving more popular than Health Service Organizations where payment for patients the family health networks. attending a source of primary care outside the practice is withheld for that month. It has also been suggested that Conclusions capitation may lead to loss of autonomy [16]. Finally, it The results of this survey, conducted five months after the may be that Ontario family physicians disapprove of cap- initial offering of primary care reform agreements to all itated practice because they just don't like change, a view Ontario physicians, suggest that a 80% enrolment target is supported by their reaction to many elements in unrealistic. contemporary health reform [9]. Opposition to capitation is not confined to Ontario practitioners. In the USA, phy- Competing interests sicians who were introduced to partial capitation funding None declared. had strong negative views of the method and, while these views tended to moderate with time, capitation continued Authors' contributions to be rated far below fee-for-service [17,18]. DH was the principal investigator of the study and takes responsibility for the integrity of the work as a whole. Currently the vast majority of family physicians operate SEDS, PW, and MG made substantial contributions to the on a fee-for-service basis, with a significant number in conception and design of the study, to the acquisition of solo practice. The decision not to be part of the network data, and to the analysis and interpretation of data. All does not mean the physician will not be providing service. authors critically reviewed drafts of the manuscript and This may inhibit the incorporation of innovations, such as have approved the final version. nurse practitioners or the electronic medical record, into existing practices with attendant implications for health References 1. Hutchison B, Abelson J, Lavis J: Primary care in Canada: So much human resources and quality of care respectively. Moreo- innovation, so little change. Health Aff 2001, 20:116-131. Page 7 of 8 (page number not for citation purposes) BMC Family Practice 2004, 5 http://www.biomedcentral.com/1471-2296/5/2 2. World Health Organization: Primary health care: A framework for future strategic directions. Geneva 2003. 3. Commission on Medicare: Caring for medicare: Sustaining a quality system. Regina 2001. 4. Premier's Advisory Council on Health: A framework for reform. Edmonton 2001. 5. Standing Senate Committee on Social Affairs, Science and Technol- ogy: The health of Canadians the federal role. Issues and options. Ottawa 2001, 4:. 6. Commission on the Future of Health Care in Canada: Shape the future of health care. Ottawa 2002. 7. PricewaterhouseCoopers: Ontario Ministry of Health and Long- Term Care: Evaluation of Primary Care Reform Pilots in Ontario; Phase 2 Interim Report. Toronto 2001. 8. PricewaterhouseCoopers: Ontario Ministry of Health and Long- Term Care: Evaluation of Primary Care Reform Pilots in Ontario; Phase 1 Final Report. Toronto 2001. 9. Cohen M, Ferrier B, Woodward CA, Brown J: Health care system reform, Ontario family physicians' reactions. Can Fam Physician 2001, 47:1777-1784. 10. Neimanis IM, Paterson JM, Allega RL: Primary care reform: Phy- sicians' participation in Hamilton-Wentworth. Can Fam Physician 2002, 48:306-313. 11. The JANUS Project, College of Family Physicians of Canada: The 2001 CFPC National Family Physician Workforce Survey Database. Mississauga 2001. 12. SAS Institute Inc: Proprietary Software Release 8.2 (TS2M0). Cary . 1999–2001 13. Delva MD, Kirby JR, Knapper CK, Birtwhistle RV: Postal survey of approaches to learning among Ontario physicians: implica- tions for continuing medical education. BMJ 2002, 325:1218. 14. Mable AL, Marriott J: Opportunities and potential: A review of international literature on primary health care reform and models. Ottawa: Health Canada 2000. 15. Health Services Restructuring Commission: Primary health care strategy. Advice and recommendations to the honourable Elizabeth Witmer, Minister ofHealth. Toronto 1999. 16. Gillett J, Hutchison B, Birch S: Capitation and primary care in Canada: financial incentives and the evolution of health serv- ice organizations. Int J Health Serv 2001, 31:583-603. 17. Tyrance PH Jr, Sims S, Ma'luf N, Fairchild D, Bates DW: Capitation and its effects on physician satisfaction. Cost Qual Q J 1999, 5:12-18. 18. Nadler ES, Sims S, Tyrance PH Jr, Fairchild DG, Brennan TA, Bates DW: Does a year make a difference? Changes in physician satisfaction and perception in an increasingly capitated environment. Am J Med 1999, 107:38-44. 19. Rosser WW, Kasperski J: Argument for blended funding. Can Fam Physician 2002, 48:236-237. 20. Suschnigg C: Reforming Ontario's primary health care system: one step forward, two steps back? Int J Health Serv 2001, 31:91-103. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2296/5/2/prepub Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 8 of 8 (page number not for citation purposes)

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Published: Mar 1, 2004

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