4 Case Study in Public Policy and Administration

Chapters 2 and 3 provide examples of the worksheets being applied to the analysis of foundational texts in political philosophy and of particular situations in comparative politics in the US and Ukraine. But as shall be seen, it is also possible to use the worksheet method with case studies in public policy and administration. The chapter therefore expands the range of application of the worksheet method in political science. The present case study examines the introduction of new funding mechanisms in a public health care system in Ontario, Canada.

After a long history of solo family practice, many Canadian family physicians moved are moving towards working in groups (Devlin et al., 2013). About half of all of these now work in groups with other family physicians settings (Canadian Medical Association and Royal College of Physicians and Surgeons of Canada, 2004). Increases in the prevalence of group practices have been linked to demographic shifts in the workforce and to governmental primary care reforms (Schultz, Tepper, and Guttman, 2009). The Ontario government supported group practice models and alternative payment plans in order to address undersupply of physicians and maldistribution of services across the province (McKendry, 1999). Ontario began a pilot project in reforming primary health care services after a 1999 review by the Ministry of Health and Long Term Care (MOHLTC) (Health Services Restructuring Commission, 1999). That review, guided by the Primary Care Reform Steering Committee listed the following goals: improved access, improved quality and continuity of care; increased patient and provider satisfaction; and increased cost-effectiveness of health care services (Price Waterhouse Coopers, 2001). In response to a mailed questionnaire, family physicians spoke of demoralisation, cynicism, and a lack of trust in government. Overall, the respondents favoured use of practice guidelines and community care centres and said that the introduction of nurse practitioners had little impact. Family physicians considered early hospital discharge and consolidated hospital services as having an adverse impact (Brunk, 1999).

There were seven sites and thirteen groupings in the pilot study for a model based on a Primary Care Network (PCN) of physicians and other health care providers, who enrol patients for the provision and co-ordination of primary care services, including a telephone triage service and financial incentives for preventative interventions. There were two mechanisms tested to pay physicians: the capitation model, using by all but one, based the number of patients enrolled with the practice; and a reformed fee-for-service model, where they are paid based on the amount and type of service provided to patients. The pilot study included thirteen groupings, often formed around larger groups of physicians who shared office space and/or after-hours call groups; and a shared bank account for Ministry funding. They varied considerably in size and degree of collaboration. One of the key findings of the report was that in all groupings there was greater interaction among health care providers than prior to the pilot study (Price Waterhouse Coopers, 2001).

The pilot study specified that, to become a Family Health Network (FHN), at least five physicians collectively carrying at least 4000 patients would provide the Ministry with a completed application, agreements on governance between physicians, and the identity of the lead physician. Patients in a FHN had to: at the time of enrolment, an insured person by the province and reside within 100 kilometres of the location of the FHN. Patients could not be required to enrol, or be denied enrolment. Each physician received a payment on starting the enrolment process and a second payment within sixty days of the start date. Lead physicians provided information on insurance, signed agreements from all physicians with contact information, and on-call arrangements. Physicians were expected to provide and coordinate FHN services to the patient, including evenings and week-ends. The province arranged the provision of advice and referral information without charge to physicians or patients (Price Waterhouse Coopers, 2001).

In order to participate, physicians had to negotiate a contract that predictably took much more time to negotiate than they anticipated (Vogel 2012). Most physicians found enrolling patients for the capitation model to be the biggest challenge, because of the level of English required to complete the forms; the complexity of the consent forms; and the lack of understanding on the part of the patient with regard to the patient’s responsibility as an enrolled patient. On the other hand, there were funds for nurse practitioners, nurses, information technology, and administrative staff. There were a number of issues raised with the capitation funding mechanism: roster limits, particularly in underserviced areas of the province; rates for elderly, rate increases and on-call rates; and exclusion of services or procedures in the capitation rate (Price Waterhouse Coopers, 2001). The Ministry required budgets for the administration of the enrolment process, staff and information technology, but physicians were frustrated by delays in approval of funding and payment. The physicians participating cited their desire to improve quality of care for their patients and the offer of financial support for the acquisition of new information technology as reasons for participating. There occurred a strikingly higher proportion of physicians who had formerly practiced in health service organisations (30% in the study, provincial average 2.2%) (Donskov et al., 2010).

One of the striking outcomes of the pilot study was the high volume of calls for teletriage, over 200% of the planning estimate, with two thirds avoiding emergency care. Information technology was probably the most significant financial benefit to physicians, with a cost-sharing arrangement in place for the Ministry to pay two thirds. But this was also the second biggest challenge for physicians, who were not well prepared to assess their needs and choose systems. Integration of information technology varied from network to network and from physician to physician (Price Waterhouse Coopers, 2001). One of the key functions of capitation had been to transfer a type of risk from the payer (the province) to the primary care practice/physician (Sweetman, & Buckley, 2014).

There were a number of observations made in the pilot phase which contributed to the four primary care reform goals (Health Services Restructuring Commission, 1999). These observations were: improved access, improved quality and continuity of care, increased patient and provider satisfaction, and increased cost-effectiveness of health care services. In terms of improved access, all groupings provided extended hours and shared calls to ensure after-hours coverage; where available, nurse practitioners were sharing the patient load and reducing the burden on physicians; and the increased enrolment provided access to patients who previously did not have a family doctor (Price Waterhouse Coopers, 2001). With respect to improved quality and continuity of care, some physicians were using electronic medical records to identify trends or specific patient groups, templates for specific disease groups, electronic reminders of when patients were due for preventive interventions, etc. With respect to increased patient satisfaction, almost 90% of teletriage callers, reported they agreed with the advice provided by the nurse, and very few patients have had to de-enrol patients because of dissatisfaction. However, patients noticed little change in access, waiting time or quality of care. With respect to increased physician satisfaction, few have left groupings since they were introduced, and satisfaction has increased after the start-up phase. With respect to increased cost effectiveness, practice management software improved office efficiency, as did the use of electronic medical records (Price Waterhouse Coopers, 2001). Later evaluation of characteristics and patterns of care under both models showed that with similar demographic characteristics, patients in capitation practices had lower morbidity and morbidity indices (Sibbald, McPherson, & Kothari 2013). Comprehensiveness and continuity of care were similar between the two groups. Compared with patients in enhanced fee-for-service practices, those in capitation practices had less afterhours care and more visits to emergency departments. Overall, physicians in the capitation group enrolled fewer new patients than did physicians in the enhanced fee-for-service group. The same was true of new graduates (Glazier et al., 2009). Ontario’s doctors argued that they themselves are leaders in primary care reform, with more than 7500 doctors in collaborative care models in Ontario (Strasberg, 2010).

But groupings did not develop quickly as hoped. The barriers to greater progress included: implementation barriers like delays in various technological components or insufficient patient and public education; fundamental problems with the model such as the physician-centric approach and insufficient feedback to physicians on outside use; and barriers in the structure and nature of the health care system like physician shortages, and gaps in service (Price Waterhouse Coopers, 2001). However, Ontario’s move toward physicians paid through capitation or salaries might have been more financially rewarding for physicians but did not necessarily improve health outcomes, in comparison with community health centres with salaried doctors (Kondro, 2012).

Worksheet 4.1: Strategy

Worksheet 4.2: Key Actors

Worksheet 4.3: An Actor’s Actions and Tactics

Worksheet 4.5: Key Rules

Worksheet 4.6: Factors Outside Anyone’s Control

Worksheet 4.7: Do or Die Moments

Steps to Goal	Problem 1	Problem 2
Negotiate contract with MOHLTC
Enrol patients
Accept capitation method	Hire extra staff
	Recruit physicians	Call advice lines
		Complete budgets for enrolment of patients
		Complete budget for IT
		Complete budget for nurse practitioners
		Organise extended hours coverage
		Organise on call coverage
		Organise teletriage
		Organise IT
		Meet large number of requirements by MOHLTC

Use as many columns or rows as necessary. When the task is completed, bold or circle each do-or-die moment.

Worksheet 4.8: Tactics, Countervailing Tactics