Commission on the Reform of Ontario's Public Services

Rather than draw patients into hospitals for care, we should strive to direct patients to the
most appropriate care setting for their problem — whether it is a doctor’s office, family care
centre or clinic, rehabilitation centre, long-term care centre or back home. Hospital financing,
traditionally based on historical costs and inflation, should move to a blend of base funding
and pay-by-activity, which would recognize the work of hospitals that take on the toughest and
most expensive cases. This would accompany a shift from hospitals that try to offer all
services to greater differentiation and specialization to reduce overlap and concentrate
expertise. A further transfer of management from the government to regional authorities
should accompany this.
Physicians and other professionals tend to work alone or in small groups where they are
not integrated with other sectors of the health care system; better that they become the
primary care hub for most patients by working in clinics that offer a variety of services and are
well connected with other parts of the care system. And rather than be paid primarily on a
fee-for-service basis, doctors should get a blend of salary, capitation (an annual fee for care of
a particular patient) and fee-for-outcomes. (Already across Canada, alternative payment
methods that include salary and capitation rather than pure fee-for-service account for
27 per cent of total clinical payments to physicians.) A recent report prepared by John Manley,
William Anderson and Peter Barnes for the Ontario Hospital Association recommends that the
compensation of hospital CEOs and senior executives should be tied to performance on
strategic hospital priorities. Further, performance pay should be linked to achieving strategic
health outcomes for each region across all types of health service providers in CCACs,
LTC facilities, FHTs, Community Health Centres and public health units. The Manley report’s
recommendation about transparency of CEO and senior executive compensation should also
be extended beyond hospitals and include LHINs, CCACs and LTC facilities. Evidence-based
guidelines for the care of specific maladies or conditions developed by quality councils and
used by physicians are needed to even out the wide variety of treatments — some more
effective than others — that are now used for the same problems. To its credit, the Ontario
government has established FHTs that go some way to meeting this goal, but they tend to
be too small, with too few physicians and cover too narrow a range of services. Currently,
it is unclear what objectives professionals are expected to meet and accountability is weak;
the former should be set by regional health authorities and the latter strengthened by
electronic record-keeping. In addition, where feasible, services should be shifted to
lower-cost care-providers.
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