Primary care providers performance re health promotion and illness prevention
Research findings
There has been limited research into the relative performance of fee-for-service (FFS) doctors and community health centres (CHCs), including the health promotion and illness prevention activities in these different settings. The following notes summarize the findings of three key studies on health promotion and illness prevention practice between different primary care providers.
1. Renaldo Battista and Walter Spitzer, “Adult Cancer Prevention in Primary Care: Contrasts Among Primary Care Practice Settings in Quebec” in the American Journal of Public Health (September 1983, Vol. 73, No. 9).
This study found that physicians in community health centres (known as CLSCs in Quebec) and Family Medicine Centers (FMCs) tend more than fee-for-service physicians to follow recommended patters of preventative practice and to pursue prevention in a wider spectrum of patient-physician encounters. The authors suggest two explanatory factors for these patterns of medical practice:
- CLSCs and FMCs are multidisciplinary, include more allied health professionals, and provide more preventive kits information pamphlets on health issues, and;
- fee-for-service payment does not adequately compensate preventive activities in private practice.
2. Marc Renaud et al., “Practice Settings and Prescribing Profiles: The Simulation of Tension Headaches to General Practitioners Working in Different Practice Settings in the Montreal Area” in the American Journal of Public Health (October 190, Vol. 70, No. 10).
Marc Renaud is one of Quebec’s leading intellectuals and a member of the National Forum on Health. In his 1980 study, he taught some of his graduate students to simulate tension-type headaches and sent them to CLSC and fee-for-service private doctors. The result: private doctors were twice as likely to prescribe an “inadequate” therapy. CLSC physicians imposed stricter time limits on their prescriptions, issued more explicit warnings about the chronic use of the prescribed drugs, and were more likely to explicitly suggest alternative therapies. Their examination procedure was more thorough and involved a lengthier encounter with the patient, a more complete investigation of the headache and the patient’s medical history, and a more supportive relationship with the patient.
3. Julia Abelson and Jonathan Lomas, “Do Health Service Organizations and Community Health Centres Have Higher Disease Prevention and Health Promotion Levels than Fee-For-Service Practices?” in Canadian Medical Association Journal (1990, Vol. 142, No. 6).
One of the studies often quoted is the Julia Abelson and Jonathan Lomas 1988 survey of Ontario primary care agencies. In fact, the study is being used by both FFS doctors and community health centre advocates to support their cases.
Doctors quote the sections which suggest that FFS doctors offer more preventive screening services, while promoters of the community health centre model refer to the findings that community health centres offer more health promotion services. The following comments on the Abelson and Lomas article are intended to counter the doctors’ claims against community health centres.
The Abelson and Lomas article concludes that CHCs provide more health promotion programs and tend to use non-physician providers more than do FFS doctors. Community health centres were also more likely to have an explicit policy on disease prevention. Nearly half of the FFS practices reported that the fee-for-service payment method limited their ability to deliver preventive services. In fact, the methodology used by Abelson and Lomas underestimates the true difference between community health centres and FFS physicians. Consider the following points:
- The article does not specify how “health promotion” was defined and whether it takes into account the full spectrum of services offered by community health centres. On page 578, it is reported that 90% of the community health centres offered health promotion services in addition to those listed in the researchers’ questionnaire, suggesting that the questionnaire was not designed to capture the scope and nature of community health centre programs.
- The article notes on page 578 that community health centres offer health promotion programs to the general public as well as to individual patients. Doctors in private practice, by contrast, interact mainly with individual patients and do not engage in community development and organizing. So while FFS doctors report engaging in health promotion activities, they reach fewer people than do community health centre providers.
- The researchers acknowledge that doctors who participated in the study may not be representative of FFS doctors. They note on the last page that FFS doctors who responded to the survey (only 58% of the canvassed FFS doctors agreed to participate in the study, compared to 92% of the CHCs and 86% of the HSOs) may be more likely than the average doctor to provide preventive and health promotion services. Because the letter of invitation included information on the nature of the study, it is possible that non-responding FFS practices were less interested in disease prevention and health promotion activities than the responding practices.
- The researchers do not explore the reasons for differing preventive practices between FFS doctors and community health centres. it seems logical that community health centres would be more judicious with regard to medical preventive procedures because many clinical screening procedures are considered unnecessary and hazardous. It may also be the case that community health centre patients are given more autonomy, information and power to decline medical procedures such as preventive testing.
- The chart on page 578 indicates that community health centres reported doing fewer colorectal cancer screening and routine lung cancer screening. On the next page, the researchers note that the main reasons for not performing those tests were perceived ineffectiveness and the high number of false positive results. This would seem to suggest that community health centres offer fewer clinical preventive procedures because some of those procedures are considered ineffective. While the researchers do report that CHCs tend to be less likely than FFS practices to undertake ineffective screening procedures, they downplay this point by concluding that providers from all practice types distinguish between effective and ineffective screening procedures. Studies need to examine more closely the type of preventive procedures and reasons for omitting certain procedures across practice types.
- The study is based on self-reported data. Given that doctors are aware of criticism regarding their failure to provide health promotion and illness prevention services, they would inclined to exaggerate those services or interpret their interventions, as “health promotion” and “illness prevention”. The researchers do, on page 580, refer to a study of physicians in the US which found that self-reports of disease prevention behaviour tend to overestimate actual behaviour. However, the researchers make a major assumption (page 580) that different practice types do not overestimate performance in a consistently different way. It may be that community health centres and doctors are equally honest in reporting performance, but this should be tested through examination of actual records (apparently unavailable to the researchers) rather than taken as a given.
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Community health centres
Description
Community health centres (CHCs) provide health and social services to a defined population with an emphasis on health promotion, disease prevention, and community development. Most CHCs offer primary physician and nursing services and may offer a range of social support services and health promotion programs. Some offer home support and home management services, and large CHCs have psychologists, nutritionists, and social workers on staff. For many of the CHCs, there was a gradual evolution of the service base, beginning with community development and expanding into health services.
CHC practitioners work together in multi-disciplinary teams to coordinate services. CHCs often target programs to persons with high burdens of ill-health and high health risks and to those who have difficulty accessing the system, for example immigrants, low-income people, and seniors. Community development and community participation in governance are also common features of CHCs.
History
Saskatchewan was the first province to see formal community health care programs. In the early 1960s, amidst a strike by physicians following the introduction of the Saskatchewan Medical Care Insurance Act, citizens pooled their resources and created clinics called community health cooperatives. The movement in Saskatchewan developed from grass roots involvement and interest in the “whole patient” medicine approach.
A number of other provinces have community health programs, though they vary significantly in terms of scope, size and status within the health care delivery framework. Manitoba has community clinics, British Columbia has health and human resources clinics, and Ontario has community health centres.
In the 1970s, Ontario’s CHC program had pilot status within the Ministry of Health and was responsible for providing support to 10 urban health centres, located in Ottawa and Toronto. Community health centres in Ontario were given permanent status with the acceptance of the Mustard Report in 1992. By 1995, 56 CHCs were funded throughout the province.
While community health care has evolved within the formal health care framework of many provinces, Quebec has by far the most extensive community health program. Local community service centres (CLSCs) evolved from the Quiet Revolution in the 1960’s as an alternative method for delivering primary health and social services in an integrated and accessible format. Quebec now has a network of 161 CLSCs across the province. The CLSC model is examined in a separate fact sheet.
There are fewer than 40 community health centres outside of Ontario and Quebec. Manitoba has fourteen community health centres, with the last having been opened in 1984. British Columbia has between six and nine community health centres, depending on how the model is defined. Saskatchewan has five CHCs, Alberta has three, and New Brunswick is testing the model in two sites. Nova Scotia has two community health centres receiving Ministry of Health funding, and two Prince Edward Island communities hope to establish centres in the near future.
Most provinces have a coordinating body representing community health centres. At a conference in October 1995, community health providers and activists from across Canada founded the Canadian Alliance of Community Health Care Associations.
Governance/Management
Community health centres are most commonly governed by non-profit boards of directors made up of community residents, centre users, providers, and others who are committed to the principles of community health. Boards differ in the way they are chosen, the extent to which they are accountable, and how they operate.
Some CHC boards are composed entirely of people who live and/or work in the community; others have a prescribed number of positions for community members. Many boards have members who use or are involved in the services and activities of the CHC.
In Quebec, paid staff members are represented on the board of directors of CLSCs. In most community health centres outside of Quebec, there is no formal representation for workers in the governance structure.
Funding
Community health centres are funded by different methods across Canada. Most CHCs serve a specific geographic catchment area for the purposes of planning and financing.
In Quebec, CLSCs are funded by global budgets determined by the number of people in the geographic area. They are funded almost entirely by the provincial Ministry of Health and Social Services.
In Ontario, CHCs receive an annual operating budget from the provincial Ministry of Health for primary care and health promotion services. The funding is program-based, with the budget for each program determined on a line-by-line basis. About two-thirds of Ontario CHCs receive small time-limited grants from other sources for specific activities. Approximately one-third are multiservice centres, receiving between 30 and 50 percent of their annual budgets from other sources, including the ministries of community and social service and skills development, municipal governments, the United Way, Health and Welfare Canada, and the Ontario Legal Aid Society. In addition, many centres engage in a variety of fundraising activities.
Community health centres in other provinces receive varying degrees of financial support from the government. Some are run entirely by volunteers and rely largely on fundraising from private sources.
Staff in community health centres, including doctors, are usually paid on a salary or sessional basis rather than a fee-for-service basis. Some physicians may have a contract in which their income varies with the financial viability of the organization or with other factors. Fee-for-service billing is not the primary source of revenue, but it does constitute an additional source of income for some physicians.
Labour
Rates of unionization vary for community health centre employees across Canada. Only about 2 percent of the approximately 1000 employees in centres affiliated with the Association of Ontario Health centres are unionized. In Manitoba, by contrast, 13 of the 14 community health centres are unionized. Virtually all of the 15,000 CLSC workers in Quebec are organized.
In Quebec, community health care workers employed by CLSCs bargain with other workers in the joint bargaining process and are covered by the same central agreement. As a result, their wages and benefits closely reflect those in the hospital sector.
CHC Performance
Probably the most scientifically rigorous study of community health care centres was an evaluation of the Saskatoon Community Clinic done in the early 1980s. This provincial government study showed that overall costs were 17% lower for patients attending the Saskatoon Clinic than for those treated in the fee-for-service system. The clinic’s patients had 24% fewer hospital admissions, and those who were hospitalized stayed, on average, nine percent fewer days. Drug costs at the clinic were 21% lower than the provincial average.
Most of the research which as been done to evaluate the effectiveness of community health centres has focused on non-physician providers and nurse practitioners in particular. One of the landmark studies on this topic, conducted by Lomas and Stoddart in the early 1980s, found that 20% to 32% of general practitioners in Ontario could have been replaced by nurse practitioners. Looking at the same time period but on a nation-wide scale, a group of researchers from McMaster University estimated that 10% of all medical costs and 15.9% of ambulatory costs could have been saved in 1980 had nurse practitioners substituted for physicians where safe and feasible. With national medical costs pegged at about $3 billion in 1980, this would have translated into $300 million in savings that year alone. The authors of both studies noted that their estimates were on the conservative side.
Less expensive care, in the case of community health, often means more appropriate care. A recent report from McMaster University describes how communities with nurse practitioners make less use of ambulatory and emergency services, hospital beds, radiology and lab services and drug therapy - all the while maintaining high standards of care and the same levels of health.
One of the features of community health care which makes it a cost effective method of improving health outcomes is an emphasis on health promotion and disease prevention. Providing health education to people in their homes, at school, and throughout the community is an integral part of community health centre practice, as are direct patient services such as prenatal care, regular medicals, and foot care for seniors.
A study by Battista and Spitzer found that physicians in CLSCs tend more than fee-for-service physicians to follow recommended patterns of preventive practice and to pursue prevention in a wider spectrum of patient-physician encounters. In another Quebec study, Marc Renaud compared CLSC and private fee-for-service doctors’ responses to patients with tension headaches. He found that CLSC physicians imposed stricter time limits on their prescriptions, issued more explicit warnings about the chronic use of the prescribed drugs, and were more likely to explicitly suggest alternative therapies. Their examination procedure was more thorough and involved a lengthier encounter with the patient, a more complete investigation of the headache and the patient’s medical history, and a more supportive relationship with the patient.
A more recent study by Abelson and Lomas compared the disease prevention and health promotion activities offered by community health centres, health service organizations and fee-for-service doctors in private practice. They conclude that CHCs provide more health promotion programs and tend to use non-physician providers more than do FFS doctors. Community health centres were also more likely to have an explicit policy on disease prevention. Nearly half of the doctors in private practice said that fee-for-service payment limited their ability to deliver preventive services.
Local community service centre (CLSC)
Description
The Local Community Service Centre (CLSC in French) offers primary health care and social services with a community orientation. As defined by law, CLSCs are:
Facilities other than a professional’s private consulting office in which sanitary, preventive and social services are ensured to the community, in particular by receiving or visiting persons who require current health services or social services for themselves or their families, by rendering such services to them, counselling them, or, if necessary, by referring them to the establishments most capable of assisting them.
CLSCs offer a range of primary health and social services, as well as home care and health education. A large share of CLSC resources goes to home care for the elderly and disabled. Community organizing and social action were core activities of CLSCs in the early days, but more recently established centres tend to put less emphasis on these activities. Since 1986, CLSCs have been mandated to provide six core programs: primary medical services, primary social services, home care services, services to families and children age 0-12 at risk, services to youth and young adults age 12-20 at risk, and front-line mental health services.
The CLSC is the only community health centre model in Canada which operates within a provincially planned regional network and under a comprehensive provincial statute that determines services, board membership, and relationships with other regional services. It is also the only CHC model that performs most of the functions performed in other provinces by public health units, and it is more closely related to a specific geographic area than most other examples. CLSCs tend to focus less on primary medical services than do community health centres elsewhere in Canada.
History
Local Community Service Centres were launched in Quebec in 1972 as a result of the Castonguay-Nepveu Commission. The long range plan was to establish one CLSC for every 10-40,000 people, or about 200 CLSCs for the whole province. Due to weak government support, coupled with opposition from the medical profession, the CLSC program has not reached that goal. In 1995, there were 160 CLSCs across Quebec employing over 16,000 staff, including 1,200 doctors (95% of whom are on salary).
The recent move to amalgamate health care facilities presents a serious threat to the CLSC network. Regional health boards have merged a number of CLSCs with long-term care hospitals in rural areas of the province. Community health providers believed that merging the budgets and administration of CLSCs and hospitals will compromise the community orientation and health promotion focus of CLSC programs.
Funding
CLSCs are funded by the provincial government on a global budget basis to serve a defined geographic area. The funding mechanism for Quebec CLSCs is sometimes referred to as capitation or needs-based funding, but it is important to note that funding is set according to the population of the catchment area and not according to the number of individual users of the centre. CLSCs do not roster members; they are automatically responsible for providing services to people who live in the catchment area. While people must use the CLSC in their neighborhood, they can choose a provider (doctor, social worker, homecare nurse etc) within that CLSC or elect to use a family physician outside of the CLSC network.
In the last budget, the Quebec Ministry of Health and Social Services reduced hospital funding by $207 million and overall health and social service spending by $386 million. Funding for CLSCs was increased by $57 million to a current allocation of $783 million or 6% of the total health and social services budget.
Governance/Management
CLSCs are government-owned and funded. The CLSCs are part of a larger framework of democratic governance which operates on a regional level.
Under the Quebec Act Respecting Health Services and Social Services (Section 132), there are eleven Board members governing Local Community Service Centres (CLSCs), with elections held every three years. The positions on CLSC Boards are as follows:
- Five people elected by and from users of the agency (defined as someone who has used the agency in the previous two years);
- Three people elected by and from medical staff and employees (physician, clinical, and non-clinical staff);
- The Executive Director of the agency;
- Two people appointed by the user representatives on the Board who are not employees of the Board in order to ensure that the Board properly reflects the gender, racial, ethnocultural, linguistic or demographic representation of the population serviced by the agency.
The Quebec legislation requires that health care facility Boards hold a minimum of ten meetings each year which have to be open to the public (unless a matter of confidential nature is being discussed). Boards must allow for a question period at each sitting. Documents submitted or transmitted to Boards as well as minutes of meetings are public information, subject to the protection of personal information. Every Board of Directors must hold a public information meeting at least once a year, where it must account to the public for decisions made with respect to priorities and new programs.
Staff representatives are not able to chair the Board or act as officers. Moreover, staff do not have the right to vote at the annual meeting where representatives from the general public are elected. Health care workers elected to the Board of a facility are not there officially as union representatives but rather are elected according to their occupational grouping - for example, nurses, doctors, and non-medical personnel. In advance of the Board elections, CUPE mobilizes locals to promote a candidate for the Board and to encourage members to vote for that person. CUPE has also developed a course which is delivered after the elections, designed to assist members in carrying out their Board duties and remaining accountable to the membership.
Labour
Virtually all non-physician personnel employed by CLSCs are unionized. CUPE and SEIU represent workers at about a dozen CLSCs each while the CSN represents the majority.
In Quebec, community health care workers employed by CLSCs bargain with other health and social service workers in a joint bargaining process and are covered by the same central agreement. As a result, their wages and benefits closely reflect those in the hospital sector.
CLSCs have a difficult time attracting enough physicians to work in the 160 centres across the province where salaries are below the fee-for-service average of physicians in private practice. This despite the fact that Bill 120 requires physicians with less than 10 years of service to work 12 hours a week in a public health care facility such as a CLSC or hospital. Physicians who do not comply with the provincial law face a 30 percent salary reduction.
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