Did GACOs help increase the enrolment of real orphan patients?
GACOs were originally set up with the objective of increasing enrolments of orphan patients while giving priority of access to vulnerable patients. In the first phase of the GACOs’ existence, the volume of patients enrolled through this mechanism was low. GACOs were introduced in 2008, and it took at least two years before they were implemented all across the province, which explains the small number of patients enrolled with a family physician through that mechanism during that period. Our results showed a slight increase in the number of patients over the period prior to the change in financial incentives. However, as can be seen in the graphs presented, after the financial incentives were changed, the number of patients enrolled with family physicians through GACOs more than doubled in one year. In 2011–2012, 140,434 patients were enrolled with family physicians through GACOs. That number increased to 291,676 in 2012–2013, after the change in incentives. However, after November 2011, patients enrolled with family physicians through GACOs were mainly non-vulnerable and non-priority patients coming through physician self-referrals.
According to the MSSS’s database, in 2011–2012 and 2012–2013, 4,821,216 persons and 5,030,019 persons, respectively, were enrolled with a family physician, out of a total population of 8 million. Changes in the overall number of patients enrolled with family physicians in the population reflect the fact that every year new patients are enrolled, some patients die or relocate, and some family physicians retire. Between 2011–2012 and 2012–2013, the number of patients enrolled with a family physician in the population increased by 208,803, and over that period 291,676 patients were enrolled with a family physician through the GACO mechanism. This unexpected result suggests that the majority of the new patients enrolled with a family physician during this period came from GACOs.
Another phenomenon observed was the registration in GACOs of many patients of retiring family physicians. Prior to the existence of GACOs, when family physicians retired, their patients were informally transferred to other physicians. The GACOs thus created a more formal and costly transfer of patients within the healthcare system. For patients who are “orphaned” after the retirement of their family physician, GACOs might be helpful. However, mechanisms should be developed to help such patients, particularly the most vulnerable ones.
Usually, family physicians enrol new patients each year in the course of natural patient turnover due to death, relocation, or other life events. In a way, GACOs reward family physicians for a task they were already doing: taking on new patients. The idea behind GACOs was to help orphan patients, based on a priority assessment. This raises new questions: What proportion of patients enrolled through GACOs were actually patients who did not already have a family physician, that is, were real orphan patients? Having a family physician and being formally enrolled with a family physician are different. The GACO system encourages the enrolment of patients. However, patients may declare themselves as having a family physician without having signed any formal enrolment agreement. The GACO system may have provided an opportunity to formally enrol patients who were already being followed without formal enrolment. Does the GACO system remunerate physicians for seeing patients they would have seen anyway? This raises important efficiency issues. We are not able to link those patients with the data we used. However, it will eventually be possible to analyze whether patients enrolled through GACOs had already received medical services from that family physician prior becoming enrolled by analyzing the RAMQ’s medical care insurance billing data. This kind of analysis will be an important contribution to the analysis of the GACO policy’s impact.
What explains the non-enrolment of vulnerable patients?
Even when the payment to family physicians for taking vulnerable patients doubled and was more than twice the amount for non-vulnerable patients, family physicians showed a preference for enrolling non-vulnerable rather than vulnerable patients. This may reflect the fact that non-vulnerable patients are more prevalent in the pool of patients waiting in the GACOs. So, while the objective of increasing enrolments with family physicians was achieved by changing the incentive system, that of giving priority to vulnerable patients was not. The intention had been to enrol vulnerable patients first, ahead of patients with no known health problems (non-vulnerable patients) who do not need frequent attention. After the new financial incentives were introduced, there was a substantial increase in the enrolment of non-priority patients, but the volume of patients considered vulnerable and of higher priority did not increase at the same pace. This presented a paradox, in that the two objectives—increasing the number of patients and prioritizing vulnerable patients—appeared to be incompatible, or at least not achievable through the same means. Our results suggest that physicians tend to prefer receiving a lower amount per patient while enrolling more patients who are less demanding and probably require shorter medical consultations, over receiving a higher amount for vulnerable patients who require more care. This observation is in line with results from other studies [
22,
23]. As such, patients who are unwell will have a harder time finding family physicians, leading to problems of equity in access to care. According to several stakeholders and physicians we encountered, some clienteles, such as those with mental health problems and drug addictions, waited longer in GACOs before being matched with a family physician, and those delays increased after the new financial incentives were implemented. Also, newspapers have reported cases of discrimination against certain vulnerable clienteles such as the elderly and persons with mental health problems and drug addictions [
24,
25]. Is this because physicians want to minimize the time spent in consultations in a fee-for-service system? Or is it for other reasons, such as their own perceived lack of expertise for treating patients with complex health conditions?