Commission on the Reform of Ontario's Public Services

Evidence should drive policy. Medicine is ever-changing and it is difficult for doctors to keep
up with the latest research and best practices. They need research-based clinical guidelines
to help them stay current. In Ontario, these can come from the Institute for Clinical Evaluative
Sciences (ICES) and Health Quality Ontario (HQO). These agencies could also help the
government decide which procedures might be removed from public coverage. Health Quality
Ontario should become a regulatory body that would enforce evidence-based directives to
guide treatment decisions and OHIP coverage.
Hospitals are paid on the basis of average costs across the province so there is no incentive
to increase efficiency. The MOHLTC and LHINs should use HBAM data to set hospital
compensation for procedures. A blend of activity-based funding (i.e., funding related to
interventions or outcomes) and base funding would work best. Hospitals should be
encouraged to specialize. Hospitals should also make greater use of hospitalists — physicians
who co-ordinate inpatient care from admission to discharge. This role is crucial when dealing
with patients with complex cases where multiple specialists may be involved in their care.
Primary care, the domain of physicians, should be a focal point in a new, integrated health
model. Physicians’ primary goal should be prevention and keeping people out of hospitals.
The system should move away from the sole proprietorship nature of many doctors’ offices
and encourage more interdisciplinary integration. Physicians should be compensated through
a blend of salary/capitation and fee-for-service; the right balance is probably in the area of
70 per cent for the former and 30 per cent for the latter.
The government should firmly negotiate its next agreement with the OMA. Ontario’s doctors
are the best paid in the country, so it is reasonable to set a goal of allowing no increase in the
total compensation envelope. The negotiations must also address the integration of physicians
into the rest of the health care system.
Family Health Teams should become the norm for primary care. They need to be big enough
to support a wide range of care providers and the number of other staff needed to track people
through the system. They should offer better after-hours care and add more specialists to their
teams. The FHTs should also initiate discussions with their middle-aged patients about end-oflife
health care and “living wills,” so that patients and their families do not have to make such
critical decisions under duress. The MOHLTC should seek input from seniors’ advocacy
organizations to engage the public in an open dialogue on end-of-life care.
The government should remove perverse incentives that undermine care: physicians are
penalized when one of their patients goes to another walk-in clinic but not when the patient
goes to the emergency department of a hospital.
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