These models offer a range of different payment and care team makeups—from fee-for-service plus incentives to a fully salaried model, and from independent doctors to groups of three or more plus allied health professionals.
In the following years, these various primary care models have led to a few challenges:
- Population health management incentives limited to one part of the continuum: Each model incentivises population health management in some way or another—but primary care can't do this on its own, and the rest of the health continuum lacks the same incentives.
- Primary care lacks a cohesive voice: With these reforms came a handful of new models and incentives, splintering primary care into a number of bodies that care about different things.
Enter Ontario Health Teams
OHTs—Ontario's take on an accountable care organisation—are voluntary groups of three or more providers that will, at maturity, manage a population's health under a centralised, fixed budget.
Importantly, the government will not green-light an OHT unless primary care is an anchor partner. But for system leaders, partnering with primary care is an uphill battle.
For example, if a Family Health Organisation leader represents primary care at the OHT planning table, that means none of the other primary care models are technically represented, thus limiting primary care’s collective buy-in. Add in the fact that GPs are paid differently than acute and home care, and partnering with them becomes an even harder feat.
Generally, we see hospitals approaching GPs one by one to engage them in their OHTs. But in East York and North Durham, about 25 minutes from downtown Toronto, something different is happening.
Ontario's first 'GP Association'
The story starts with Dr. Alan Monavarri, a family physician who has been practicing in Ontario for more than 25 years. In 2014, he joined Markham Stouffville Hospital as the chief of Family Medicine, and became VP of Medical Operations in 2018.
When OHTs were announced, Monavarri, a system thinker at heart, leapt at the chance to help. He offered to step down from his VP role to serve as the physician lead for the East York Region and North Durham OHT. In this new role, he had a critical job: Gain physician buy-in.
He started by inviting local GP leaders to talk—he wanted to see if there was a chance GPs would organise into something more cohesive. He laid out a few options: a nonprofit corporation, a partnership model with care compacts between practices, or a loose GP association where participation was voluntary. Since the first two options were deemed too risky, they chose the association approach. After all, they could always adopt a more formal structure later.
Fast forward several months, 105 physicians have indicated they plan to sign on to the association—more than half of the area's GPs. In the next few weeks, the association will elect its own council and chair, who will sit at the OHT's leadership board. And delegates from the association will assist or lead each of the OHT's four action groups: access and navigation, strengthening primary care resources, digital connectivity, and community education.
In a recent interview, Monavarri shared his keys to success in engaging this critical mass of primary care partners:
- Start with your allies: The hospital already had long-standing relationships with two nearby Family Health Teams through past pilots and medical training programmes. This is the first place Monavarri looked for support, which gave him a base of about 30 doctors to start with.
- Don't underestimate the value of building support incrementally: There were another seven GP groups that each had eight to 10 doctors. Monavarri visited them one by one to pitch the idea, answer questions, and build trust. As each group indicated they would sign on, the base of support grew—a signal to others that this may be an idea worth joining in on.
- Prepare for the 'what's in it for me?' conversation: Physician buy-in is as much a sales job as it is a clinical one. Monavarri prepared for pushback with a clear message on why an association was the right way forward. Perhaps a GP would get better referral processes as a part of it, or the sector would gain more of a cohesive voice, or they could even help lead the system. Different messages resonated with different doctors.
- Show that you're in it for the right reasons: Monavarri discussed leadership more than any other principal. When asked how he fit all this work into his already busy schedule, his response was simple: "I deprioritised my income for the system." Not only did he take a step back from filling his GP schedule, he also stepped down from his VP role to help integration. And now, he will be replaced with another physician once the chair election occurs this month. All of this indicates that this work is not coming from a place of ego or resume building, but rather to make the system better for everyone.