When Anne Lyddiatt’s family doctor retired, she went looking for a new one. The Ingersoll, Ontario resident thought she’d found one for herself, her two daughters, and her granddaughter, and they filled out application forms with their health information. But only one of the four was accepted: the daughter who had no chronic conditions.
“When we went back [to hand in the forms], the receptionist said ‘I’m sorry, she’s the only one who fits our profile,” says Lyddiatt. “I knew [cherry picking] went on, but I didn’t realize the extent of it until then.”
Family doctors are allowed to screen patients based on their scope of practice. But they can’t refuse people because they’re low-income or have complex health problems.
Lyddiatt isn’t the only patient who feels she’s been treated improperly: in a 2011 discussion with 25 members of the Toronto Health Policy Citizens’ Council – led by Andreas Laupacis, Healthy Debate’s editor-in-chief – some members believed they personally, or friends and family members, had been inappropriately screened out of a doctor’s practice. A recent study in Canadian Family Physician spoke to 18 Ontarians who had lost their family physicians, and found that many were frustrated with the process of getting a new family doctor. One said “I felt like I was applying for a job …. I knew already that there could be issues in terms of if you have too many problems, or … the burden that you’re going to put on the practice.”
The College of Physicians and Surgeons of Ontario has received 90 complaints since it began tracking them in 2008, after developing its policy on the issue. That only includes those who’ve come forward officially; the actual incidence is probably higher. Ken Gardener, assistant registrar at the College of Physicians and Surgeons of Alberta, says, “I don’t think we get lots of complaints [about cherry picking], but I know that if you go down and talk to a number of physicians practicing at the front line, they’re certainly aware that some clinics do not comply [with the rules around it].”
The issue has caused a debate over the common introductory meeting – is it a way for family doctors to present their practice and look for fit, or an invitation for some doctors to screen for more time-consuming patients? And new funding models may reward cherry picking more than old fee-for-service ones did. So how pervasive is the issue, and what can we do to counter it?
Who does it affect?
Trevor Theman, registrar of the College of Physicians and Surgeons of Alberta, says he’s also heard complaints about cherry picking, often against those with complex medical issues. “Commonly it appears to be the more difficult patients, patients with multiple chronic diseases, with chronic pain, those who may have some drug seeking behavior, or patients with mental health conditions,” he says.
Research has also found discrimination against a different category of patients. Last year, Stephen Hwang, a physician and scientist at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, studied the issue (Healthy Debate is also run out of the institute). Hwang looked at the effect socioeconomic and health status had on access to primary care physicians by having researchers call 375 family doctor’s offices in Toronto. They said they worked for a bank and had just been transferred to town, or that their welfare worker had told them to get a doctor, and also asked for regular check-ups or care for diabetes and back problems.
Contrary to popular perception, he found doctors actually were more likely to accept patients who needed more care, with 24% of those who said they had diabetes and back issues getting an appointment, versus 13% of those who only needed checkups. But there was a difference when it came to socioeconomic status: 37% of the callers who pretended to be bankers were accepted by family doctor versus only 24% of welfare recipients. Often, the ones in a lower socioeconomic status would be told the doctor wasn’t accepting new patients.
“Working with people who are marginalized or disadvantaged, what they often say is, ‘I think I got treated differently because I’m poor,” says Hwang. He suspects physicians may turn down lower-income people because of the perception that they take more time and energy.
Both the Canadian Medical Association’s code of ethics and The Ontario Human Rights Code prohibit discrimination based on things such as age, race or gender. The College of Physicians and Surgeons of Ontario’s 2009 policy on new patients is even more explicit, stating that patients should be accepted based on who’s first. “Physicians who are able to accept new patients into their practice should use a first-come, first-served approach,” it reads.
The policy does make exceptions for doctors who have decided to limit their practice to a certain specialty, such as sports medicine, or patients doctors don’t think they have the skills to treat (though the Toronto citizens’ council raised concerns this might be used as a loophole). Another exception: physicians can prioritize the sickest. “You can choose on the basis of picking someone who is more urgent than the person in front of them,” says Marc Gabel, president of the College of Physicians and Surgeons of Ontario.
The College of Physicians and Surgeons of Alberta has similar guidelines. “A physician who is accepting patients on anything other than a “first come first served basis” must establish criteria for patient selection, based on matters relevant to the physician’s scope of medical practice,” it reads.
The Ontario college’s guidelines recommend against introductory appointments, where family doctors meet with patients, explain the practice and hours of operation, and get a sense of the patient’s background. Hwang’s study looked at the rates of these introductory meetings – which he’s heard called “patient auditions.” It found in 9% of cases, patients were invited to one. “To me that’s kind of concerning, because [the CPSO] says in no uncertain terms you shouldn’t do that,” he says.
Those appointments are often where patients are rejected, says Theman, saying the College of Physicians and Surgeons of Alberta has had patients say they were explicitly told told they were too old or had too many conditions. However, he does believe meet-and-greets can be legitimate, when they’re used for a doctor who has a limited scope of practice or to clarify expectations between the physician and the patient.
Others also believe they have merit. The College of Family Physicians of Canada doesn’t have a policy surrounding patient screening, but believes that all family doctors need to be socially accountable. But Francine Lemire, executive director and CEO of the organization, believes that doesn’t mean they shouldn’t have introductory meetings, though they’re often precipated by an acute situation. “It offers an opportunity for us to communicate how the practice works, what our after-hours situation is, what the coverage for the practice is. We get appraised of their situation and can think through how is this practice going to be able to support them, and then they can also assess the same thing,” she says.
The College of Physicians and Surgeons of Alberta doesn’t discourage initial meetings, but believes that only the patient, not the physician, can look for fit (beyond the accepted exceptions). “If you have a meet and greet with a patient, then that is now your patient. You have established your relationship with that individual,” says Gardener.
Issues of compensation
The payment models for doctors may not be helping in Ontario, either. Capitation was introduced and has proven popular, with 4,000 of Ontario’s 9,000 family physicians on the system, which pays doctors per patient, per year, rather than per visit. “In the old traditional fee for service way of doing business, there wasn’t nearly as much incentive to cherry pick as there is with primarily capitation funding,” says Mark Dermer, a family doctor in Ottawa and author of Healthcare Insighter.
Under capitation, doctors get paid an adjusted rate depending on the patient’s age and gender – but not for how sick the person is. That means that physicians would be paid the same for a 40-year-old who came in once a year as for one who came in every month. “A payment system that creates sufficient incentive to cherry pick is flawed,” says Dermer.
Rick Glazier, senior scientist at the Institute for Clinical Evaluative Sciences, studied compensation and patient mix in a 2012 analysis. It found that doctors paid through capitation are more likely to be in suburban or rural areas, with patients who are healthier and richer. Those on fee-per-service are more likely to have lower income, less healthy patients. But those differences don’t necessarily mean doctors are cherry picking – rather, Glazier thinks those offices who would have benefited from capitation made the switch when it became available, and those who would have lost money stuck with the old fee-per-service program.
And the gap means the financial incentive to cherry pick is there. “The [patient] who never comes in is a winner financially, and the one who comes in all the time is a loser, financially” under the current system, Glazier says. He also has colleagues who began building practices from the ground up with Health Care Connect, which helps Ontarians find a family doctor and prioritizes those with complex health problems. “They’ve realized you can’t have an entire practice of those people, or you’ll have a third or half of the number that everybody else has [and make a lot less money],” he says.
The government has tried to address this problem by providing additional payments for illnesses such as diabetes, as well as services like prenatal care and smoking cessation. “They have recognized it as a problem… they are paying an acuity payment,” says Glazier. “They are attending to it, but so far it’s not anything like the size of the payment that would make you want to take on those patients.”
In the meantime, hopefully the ethical requirements of the profession are enough to keep doctors from screening out unhealthy or poorer patients. It’s important to treat everyone to maintain the public’s trust, says College of Physicians and Surgeons of Ontario’s Gabel. “Professionally we go into medicine to take care of people. Not to take care of only x or y, but to take care of the entire alphabet,” he says.