Primary Care Networks: Alberta's Primary Care Experiment Is a Success – Now What?
Both Ontario and Alberta have undertaken fundamental health system changes in the past decade. Now, both provinces find themselves at a point where prudent consideration of the next steps is required. Ronson (2011) has summarized a prescription for Ontario's local health integration networks. Now, the same needs to be considered for Alberta's primary care networks (PCNs).
About Primary Care Networks
PCNs are Alberta's reform program for the province's primary care system. In 2003, Alberta Health and Wellness (AHW), the Alberta Medical Association and the then nine regional health authorities (now amalgamated into Alberta Health Services [AHS]) signed an eight-year trilateral master agreement to create PCNs (among other health programs) (Alberta Medical Association et al. 2003). Forty PCNs have since blossomed into nimble, effective healthcare organizations. Aggregately, PCNs receive just over $130 million per year in funding from public sources.
PCNs are funded through a capitation-based model. Using the four-cut method (Murray et al. 2007), AHW allocates patients to PCNs, paying them a fixed fee on a per-patient basis to operate locally developed programs. PCNs are joint ventures between the AHS local zone and local primary care physicians. Family doctors incorporate a private non-profit corporation to provide their suite of programs. The networks' day-to-day operations are governed by physician boards of the non-profit corporations at the city, town or county level. PCNs acquire approval for their funding by developing a business plan that describes the programs that physicians will put in place to improve local services. Programs most often focus on chronic disease management, mental health, women's health, and cancer care among many other programs. PCNs use most of their funding to hire an interdisciplinary team of nurses, pharmacists, dietitians, social workers and other professionals to deliver the programs. Business plans are renewed every three years by gaining approval from the provincial Primary Care Initiative Committee.
Many PCNs boast records demonstrating improvements in patients' health outcomes, reductions in wait times and improved integration with other local private and public health services (Alberta Medical Association 2011; Jones et al. 2011a, 2011b; Ludwick et al. 2010; R.A. Malatest and Associates Ltd 2011). Evidently, PCNs and their business plans are working. PCNs have facilitated significant improvements in patient attachment to family doctors, dramatic reductions in the use of emergency room services, better use of screening tools in health promotion and disease and injury prevention and far greater patient satisfaction with regards to wait times (R.A. Malatest 2011). With the end of the trilateral master agreement, the question now becomes, what's next for PCNs?
Source of Success
PCNs' source of success can be found in the province's governance model, which focuses on trilateral governance. Localized decision-making is devolved directly to local primary care physicians who have been practising in the community for years. This decentralized approach has led to the creation of cost-effective, relevant programs that make sense for the local population. The local AHS zone co-governs PCNs with the physician boards to integrate services with those already provided locally by AHS and to oversee the fiduciary use of public funds. AHW, as the payer, focuses on value for money. Its role has centred on the development of policy and the assurance of PCN accountability to the public as demonstrated through reporting, research and evaluation. Alberta PCNs' "local solutions to local problems" approach, facilitated through trilateral governance, has resulted in physician-led, interdisciplinary team–based programs that positively impact local health issues.
Source of Constraint
Despite their success, PCNs have been frustrated by fiscal limitations. PCNs have been limited to the same funding amount since the program's inception eight years ago. Of course, the healthcare sector is no stranger to fiscal restraint, and PCNs would seem to be no different in this regard. Nonetheless, if funding followed performance, the track record would warrant further prudent investment in the model.
So, What's Next?
The Alberta primary care reform model has proven to be successful. Local physician boards have developed programs that have improved the health of their patients while reducing wait times. Primary care programs have offloaded patients from busy emergency rooms by attaching patients to family physicians and improving office operations so that family doctors can accommodate new patients. In my opinion, Alberta should adopt the "if it ain't broke, don't fix it" approach. The trilateral governance model has resulted in agile, efficient healthcare companies operated by physicians and their teams who know the needs of the local population. Still, there is opportunity to wring more from this innovative approach to primary care reform. A funding model indexed to the cost of living would permit PCNs to compete for needed health human resources to grow their success. With greater funding, PCNs would have the financial resources to assume other parts of the primary care domain. PCNs have done well to provide chronic disease and mental health programs as well as integrating with other local public and private health services. There is opportunity to leverage PCNs' winning formula by delegating responsibility for public health, home care, localized addictions services, ambulance services and other programs to the networks.
The Timing Is Right
The 2003 trilateral master agreement expired in March 2011. Both the Alberta Progressive Conservative party and the Liberal party have new leaders. With party leadership now in place, negotiations for a new trilateral agreement empowering PCNs with more scope could extend their success to other parts of the primary care sector. With more funding and more responsibilities, more Albertans would benefit.
About the Author(s)
Dave A. Ludwick, PEng, MBA, PMP, PhD, is the general manager and chief operating officer of the Sherwood Park–Strathcona County Primary Care Network, in Sherwood Park, Alberta. He can be reached at firstname.lastname@example.org.
Alberta Medical Association. 2011. Primary Care Network (PCN) Backgrounder January 21, 2011. Edmonton, AB: Author. Accessed September 21, 2011 <http://www.albertadoctors.org/bcm/ama/ama-website.nsf/AllDoc/0612E868CC60A7238725782C007DB869/$File/PCN_Bkgder_Jan%2021_2011.pdf>.
Alberta Medical Association, Alberta Regional Health Authorities and Alberta Health and Wellness. 2003. Master Agreement Regarding the Tri-lateral Relationship and Budget Management Process for Strategic Physician Agreements. Edmonton, AB: Government of Alberta. Accessed September 21, 2011. <http://www.health.alberta.ca/documents/Trilateral-agreement-2004.pdf>.
Jones, D., D. Ludwick, N. Brass and C. Cutts. 2011a. "Suburban Cardiac Screening: Improving Access to Specialist Services within a Primary Care Network." Healthcare Management Forum 24(1): 20–24.
Jones, D.C, L.J. Carroll and L. Frank. 2011b. "After-Hours Care in Suburban Canada: Influencing Emergency Department Utilization." Journal of Primary Care and Community Health May. Accessed September 21, 2011. <http://jpc.sagepub.com/content/early/2011/05/25/2150131911408431.abstract>.
Ludwick, D., C. Lortie, J. Doucette, J. Rao and C. Samoil-Schelstraete. 2010. "Evaluation of a Telehealth Clinic as a Means to Facilitate Dermatological Consultation: A Pilot Project to Assess the Efficiency and Experience of Teledermatology Used in a Primary Care Network." Journal of Cutaneous Medicine and Surgery 14(1): 7–12.
Murray, M., M. Davies and B. Boushon. 2007. "Panel Size. How Many Patients Can One Doctor Manage?" Family Practice Management 14(4): 44–51.
R.A. Malatest and Associates Ltd. 2011. Primary Care Initiative Evaluation: Summary Report. Edmonton, AB: Alberta Medical Association. Accessed September 21, 2011. <http://www.albertadoctors.org/PresLetter/malatest_pci_eval>.
Ronson, J. 2011. "LHINs at Five Years – What Now?" Healthcare Quarterly 14(3): 6–7.
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