Clarifying Primary Care Networks.

There's been a lot of recent political and media discussion regarding Primary Care Networks in Alberta. I think a lot of it has been overly simplified, mischaracterized, and misses some of the real issues. I want to try to clarify some of that if I can.

Caveat. I'm not in the healthcare industry. My (excellent) family doc is part of a PCN though I've never used any of its services. I know a number of other people who work or have worked at various other PCN's, and observed enough of the workings of at least one PCN (and many other healthcare organizations, in Alberta and Ontario), and know a lot of doctors and how they run their businesses. I think I have a pretty good sense of things.

The PCN Motivation. For family care physicians, the benefit of the PCN's are that a group of clinics can get together and acquire some resources to provide services to their patients that any individual clinic wouldn't be able to afford/justify. For example, a single clinic may not have enough patients to put on a regular "stop smoking" group, but a group of clinics can.

Myth: Doctor's run PCN's. A widespread myth is that family physicians run the PCN's. Technically yes, in the same sense that board chairs run large corporations. The reality is doctors are already swamped with work with their own patients, generate hate administration, and frankly, aren't too good at it. So the doctors who (along with AHS) "own" the PCN's hire full-time administrators who actually run things and make most policy and implementation decisions.

Primary Clinics are More than Just Doctor's Offices. Sure, the idea is that the PCN's are really a "network" of clinics, but the aforementioned administrative responsibilities mean that each PCN has what amounts to a fully staffed "head office". A good chunk of the money that goes to funding PCN's covers these offices, and the administrative staff that works there. A full third of PCN paid staff can be just admin support people. And this doesn't include the admin support people (receptionists etc.) that work at each clinic in the PCN - they're funded as overhead like in any other doctor's office.

Now, that leaves a lot of other people that PCN's pay, including clinical staff. For example, most PCN's pay a certain number of mental health therapists, many who will spend part of their time at individual PCN clinics working with patients, and some time in the PCN "head office" e.g. doing groups, participating in team meetings, etc.

Nobody knows if PCN's are successful. The recent Auditor General report makes it clear that since we're not measuring anything, we have no idea what PCN's are actually accomplishing. That doesn't mean they aren't doing anything - they are. It's just hard to say what. Especially when it comes to clinical outcomes.

I think if there was a review, they'd probably find that there's too much centralized administration for the amount of services that they provide, there is no standard in what services are provided, and there's not enough information sharing and learning between each PCN and other organizations

Funding Model and Lack of Accountability Promote Bureaucracy. PCN's are paid per patient that are 'rostered' (e.g. officially under the care of a family physician who is a member of the PCN). With no accountability on how money is spent, there is no incentive to provide any particular programs or services, but there is an incentive to increase the number of rostered patients. Because of this, and because as mentioned earlier the PCN's are de facto run by full-time hired administrators, the temptation is to increase the size of administration, creating a self-sustaining bureaucracy. I believe many people in the know would agree this has been the result.

This is in marked contrast to the funding model proposed for the new Family Care Clinics, which would be largely funded based on the medical services provided, rather than number of patients. This produces incentives to maximize the amount of services and reduce the amount of administration (treating it like the overhead it is, which corresponds to how administration is treated in doctor's offices). Note the contrast with PCN's.

PCN's shouldn't compete with other health organizations. It's also the case that bureaucracy run amok becomes self serving, and needlessly competes with other areas of the healthcare system. Example, one of the PCN's has a good number of mental health coordinators, and access to one psychiatrist for med consults a half day every second week. When PCN administrators try to lean on family physicians to refer people who need mental health care through the PCN mental health coordinators, and actively discourage them from referring directly to a psychiatrist (outside the network), even when the outside psychiatrist can provide better and more appropriate care for the patient, that's just dysfunctional. And when the mental health coordinators are instructed not to get advice from outside specialists, well, that goes well beyond the realm of common sense.

Myth: Doctor's favour PCN's because they can be gatekeepers. The reality is that family doctors want access to resources for their patients. Having access to a mental health therapist, pharmacist or dietician through the PCN's is great for them and their patients. Frankly, I don't know how many would really care that much if their patients could access a dietician without them explicitly being referred by the doctor, as might be the case in the new Family Care Clinics. As long as their patient could access those resources, most would be mostly happy.

Government vs. the AMA. I think the real reason that the AMA is upset about the whole FCC idea is that there is a longstanding lack of trust, and a long history of poorly thought out government initiatives that have been imposed on them without any real thought of consultation (starting with Klein's cuts, through AHS, etc.). The FCC model may well be a decent one, but coming up with it in the panic of an election campaign without adequate consultation was not the best way to approach it. And ramming it through afterwards "as is" reaks of political expediency.

So I think the "docs have control" in PCN's and might have to give it up a bit in FCC's is way overblown. It's mostly a broader issue of trust.

As an aside, given what we know about the lack of accountability with the current PCN's, I'm not surprised the government removed any reference to them in their current contract negotiations. Again, not great in terms of the perception that things are being imposed rather than negotiated, but I sure wouldn't want that albatross around my neck if I were the health minister.

What everyone really wants. I think everyone (patients, government, family docs) wants funded, stable, predictable and hassle-free access to things like being able to see a family doctor in a timely manner, access a specialist, mental health care, programs like weight management, diabetes care, etc. And real accountability in terms of measurable patient care outcomes.

PCN, FCC, public health, whatever. But enough of the silos, turf wars and empire building for their own sake. Patients first.

As I said at the beginning, I'm no expert, so I'd welcome any corrections, clarifications or other interpretations.