The Form and Context of the PCNs
Alberta, a landlocked western province in the Canadian federation, is the nation’s fourth most populous jurisdiction and home to approximately 4.1 million residents spread over 640,000 square kilometers. This population is concentrated in two major cities: Calgary (1.285 million) and Edmonton (972,000). As elsewhere in the federation the province of Alberta, aligning itself with the Canada Health Act, seeks “to facilitate reasonable access to health services without financial or other barriers” (16) to Albertans, and is responsible for the delivery of care. Alberta’s particular policy approaches to delivering care have, arguably, been subject to one of the most radical administrative shifts in Canada: in 2008, nine regional health authorities were centralized into the province’s largest single employer, Alberta Health Services (AHS).(33) With 110,000 staff, but a very limited role in the delivery of primary care, AHS’ central focus is the province’s acute care system. It is Alberta Health – the provincial Ministry of Health (MoH) – which has tended to engage with, and has always paid, family physicians on an almost exclusively FFS basis.(34) Fee schedules are determined through negotiations between the Alberta Medical Association (AMA) and the MoH.(35) The potential for the expansion of highly successfully alternative payment models(36) as well as the outright elimination of FFS have been introduced by the most recent provincial budget(37) but, for the moment, it remains Alberta’s foundational approach to funding primary care and its ongoing transformation towards PHC.
In 2003, drawing on the federal Primary Health Care Transition Fund mandate, the PCNs were created through an agreement between the AMA, the MoH, and the regional health authorities that would eventually be merged into AHS. The three parties signed an 8-year (2003-2011) Trilateral Master Agreement to support Local Primary Care Initiatives (LPCIs). The initial relationship between the AMA, the MoH, and AHS was one of equals that required consensus on the form of, and priorities for, what would come to be called the PCNs. That consensus tended, in the early years, to be driven by the grassroots concerns of family physicians working through the AMA. However, between 2008 and 2011, the MoH became pre-eminent and began exerting, in concert with AHS, greater central control over the PCNs.(33, 38, 39)
Alberta’s PCNs are positioned between the MoH and front line family physicians. More often than not, they operate at the supra-clinic level, joining together practices with one or more physicians. Membership is voluntary, with approximately 84.3% of Alberta’s family physicians choosing to sign a contract with a PCN (40). Each PCN – of which a small minority are single clinics, and most are multi-clinic partnerships – is established through a joint venture agreement between AHS and a group of family physicians who have formed themselves into a non-profit corporation. This joint venture is devoted to collaboratively identifying local priorities and developing programs and services. The PCN that emerges from the joint venture is accountable to the MoH under the terms of a three-year grant agreement that flows money from the ministry according to a visit-based algorithm that attributes patients to physician members of the originating non-profit corporation. In 2019, the capitation grants were valued at C$62 per patient per year. PCNs direct this funding towards: 1) non-physician health professionals and administrative staffing, 2) chronic disease management, 3) providing 24/7 access to care, 4) expanded office hours, and 5) premises and equipment. In this way the PCNs use pooled resources to cover their own administrative costs and provide a range of services to their members.
From their position as an intermediate layer in Alberta’s healthcare policy eco-system, the PCNs operate in three directions. Looking upwards from their perspective, they deliver funding from, and extract accountability for, the MoH. Looking laterally towards their co-venture partners, they provide a point of contact with, and co-planning capacity to, AHS, the manager and operator of the broader system. And finally, looking downwards to their membership, they provide financial, administrative, technical, planning and PHC-transformation-management support to individual primary care providers.
FIGURE 1 HERE
History and evolution of PCNs
Our interviews and documentary analysis revealed two distinct periods in the evolution of Alberta’s PCNs: The Frontier Era (2003-2012), and The Era of Accountability (2013-Present). We describe each of these periods, focusing on the interactions between people, time, and culture as they shaped the implementation of the PCNs.
The Frontier Era (2003-2012):
This initial era was characterized by a number of features: 1) the grass roots nature of the priorities and policies that the PCNs adopted; 2) clashes between the values and norms of the province’s powerful acute care system and the relatively uncoordinated primary care sector; 3) the universality of a problem for which local and highly variable solutions were sought; 4) the selective and limited use of evidence to build and measure progress for the PCNs, and; 5) the level of autonomy and independence afforded to the PCNs by AHS and the MoH.
In 2003, Alberta received $100 million of the Primary Health Care Transition Fund with the province opting to follow the five objectives the federal government had established at the time the fund was formed.(18) In this way, the LPCI program emerged and the three parties – the AMA, the MoH, and AHS – began fielding ideas, and designing programs. While there were conversations amongst all three, the AMA broadly, and a few committed individuals within the general practice section of the AMA specifically, took the lead. As one policy-maker described it:
[One family doctor] and his group of senior thinkers… said, “We’re up to the challenge, but you gotta help us. You gotta help us create a playing field where [the RHAs / AHS] will work with the PCNs rather than try to consume us. And you gotta help us with the other health professions so that we deliver integrated care through the PCNs rather than fragmented care.” [A politician]…had already started some fairly detailed discussions with [that same family doctor]. (P1)
The family physician’s concern that AHS would consume the nascent PCNs was one grounded in the functional, financial and political realities of Alberta’s healthcare system. While mandated with the organization and delivery of all healthcare in the province, the regional health authorities and eventually AHS, were and are heavily focused on the acute care system. As another of our key stakeholders noted, while primary care may be the preferred policy locus for broader PHC transformation, it is peripheral to existing healthcare operations in Alberta. He described how AHS has a relatively small group of staff focused on primary care,
I’m going to say about 100 strong within our large organization of [110,000 employees]…We’re a little bit like that glue that helps tie the [primary and acute care systems] together. (P4)
He went on to note how, in addition to primary care being peripheral to the core work of AHS, there was also the issue of culture:
What we’ve got here are two different cultures …operating from two completely different perspectives. And…the two aren’t even talking the same language, often. (P4)
A key cultural or linguistic difference to be bridged here is centered in the family physicians’ professional and vocational identities. On the one hand, the province’s legal and payment structures mark them as ‘independent contractors’ who provide care, hire and pay their own staff, purchase their own space, and bill the MoH on a FFS basis. And on the other, the broad scope of their work combined with their sustained, one-on-one relationships with their patients mark them as lone, long-term generalists. With both of these identities emphasizing longitudinal entrepreneurial self-reliance, it is perhaps unsurprising that there is a perceived gap with AHS’ acute, specialized, bureaucratic, system-reliant culture and language. Understanding this gap in the thinking and values of the two parties who enter into the joint venture that creates a PCN is essential to understanding the original formation of these organizations.
At a time of significant upheaval for the RHAs – they were in the throes of amalgamating into AHS – a small group of independent, lone, long-term generalists working in a field technically and culturally peripheral to what was seen as core healthcare operations, began talking to one another and directly to politicians. Out of these LPCI conversations came a vision, and the technical details of the PCNs. As one policy-maker noted, the vision coalesced
around local solutions for local problems. The local PCN basically got the dollars…in order to meet the needs of the local community. (P9)
Another participant from AHS repeated the mantra and emphasized,
there has to be flexibility, because PCNs were created [to deliver] local solutions for local problems. (P7)
In this way the independent professional and vocational identities of family physicians guided the initial vision for the PCNs. The technical details were also worked out in a culturally concordant manner. A physician leader described the homey conditions under which the PCN concept was drafted:
it was so small-town…We would sit on some guy’s living room carpet – two of us, with one person from the AMA – starting to sort of draft this [idea]. You know, go through this process. That’s literally how it started. (P6)
Down on the carpet, alongside the physicians, was an economist from the AMA who, as another participant described it
looked very much at the economic literature – at the papers and the books that were being published at the time, saying, “Here’s what the economic evidence might suggest.” To the best of my knowledge, he didn’t dig in to the medical literature. (P3)
In this way, the initial structures for the PCNs tended to focus on finance and economic issues, with the PCNs’ potential to tap into the QI, health services, care management, and primary care literatures laying dormant. As one of the physicians on the carpet noted,
I had no idea, really. I didn’t have the [QI] vision at that time, at all. (P6)
Another policy-maker participant used an Albertan cultural trope to describe not just these originating discussions on people’s floors, but the early years of PCN operations:
It was the wild west. (P3)
Another participant echoed this frontier image, emphasizing a key feature of the PCNs’ operational environment in the early years.
There were no…strings attached… So the PCNs [existed in a] kind of wild west sort of landscape. (P5)
At a high level, the cultural trope expresses a western Canadian narrative generally – one focused on frontier town initiative taking and small scale communitarianism in an atmosphere of few or no central rules. At a lower level, closer to the ground from which the PCNs were emerging, the wild west image was also concordant with the independent professional and vocational identities of family physicians.
Emerging out of these layers of culture, the PCNs were, as the previous policy-maker noted,
…pretty much just launched and left …and not followed through in an organized way by government until very recently (P5)
Another policy-maker participant concurred, noting,
Until we [developed] the [new] governance structure in 2017, each individual PCN was pretty much on their own. (P9)
PCN leaders affirmed the extent to which independence was a feature of their inception.
In the early days, we were pretty much left to our own devices. (P2)
In my recollection, there wasn’t a lot of “You should do this. You shouldn’t do that.” (P11)
The result of this culturally concordant approach was that, in a frontier environment with few rules, bottom up policy innovation became the norm.
It was truly a grassroots movement…Very quickly, we got to a place where there’s a bunch of us that recognized there’s a real opportunity here, and we have to saddle this horse and ride it properly. (P6)
As part of attempting to saddle the horse, there were initially calls for the creation of a few model PCNs, however, this approach did not survive the first years of innovation. As one participant described it,
There was a belief amongst some that Alberta would be able to identify [a] handful of Centres of Excellence …and everybody else would copy them” (P11)
Instead, as a policy-maker noted,
the first PCN went live in 2005. And then, over the course of just a few years, we ended up with like 21 of them or something. That wasn’t the intent. So instead of having a couple [of] stellar examples, what happened was a lot of spread of PCNs across the province. (P9)
In this way the independent frontier environment supported a focus on locally adapted solutions and produced a wide range of sizes and organizational forms in what would, by 2019, become 41 PCNs across the province.
This structural heterogeneity reflected significant variations in the way the PCNs interpreted and sought to make good on the five federal objectives – subsequently adopted by the province – of the Primary Health Care Transition Fund. Where those objectives stressed PHC issues of access, health and wellness promotion, interdisciplinary team-based care delivery, and health and social services integration, the local priority for many PCN member physicians was the care of complex chronic patients. As one participant described it, if you had asked physicians at the time the PCNs were forming up ‘what’s the biggest problem in your practice?’ their answer would focus on one group:
It was the complex patients. The ones that take a lot of time, more than a standard fee-for-service window would allow – whatever that may be. Some doctors may allow 10 or 15 minutes, some want to triple book every five. So whatever their definition of a standard window was, those populations were [seen as] problematic … (P2)
As such, in many cases,
The PCN money [came to be] viewed as a supplement to the compensation of the family physicians. And that a lot of the per capitation money was re-distributed among the family physicians. (P1)
The FFS system of remuneration of the day was, in the case of complex patients with chronic diseases, seen as failing physicians and so the PCN capitation funding came to be seen as
a way to pay family doctors for all those things that they did that they weren’t being paid for” (P6)
While some PCNs merely funneled capitation money to their members, others took a more active, systems oriented approach to the challenges of delivering care to complex, chronic patients. Again, the approaches
varied quite dramatically. Some places set up chronic pain clinics that still live today. [Others] looked at cardiac rehab [services] that still exist today. [Some] have foot care clinics that still exist today…We [also] saw a lot of PCNs say, “There’s gotta be a better way to get patients into specialty services. Maybe we’ll set up a Navigation Service, or a Referral Service that will help ease that burden on the primary care clinic and help patients more successfully make that transition.” (P3)
In this way the mantra of ‘local solutions to local problems’ was functionally converted into one that sought local solutions to what was, essentially, a universal problem (i.e., complex chronic patients).
Their degree of success in solving this ‘universal problem’ through their wide range of approaches was not something that was measured. The diversity of locally driven emphases and organizational arrangements, combined with no formal measurement or accountability requirements, meant the effects of the various innovations were virtually unknown. As one participant noted, the PCNs were, in the early years, a
completely evidence-free zone.
[Various stakeholders] had feelings, and they cited the evidence that supported their feelings. So, the pro [PCN] faction cited [the results of successful PCNs] saying, “Look at the wonderful things these PCNs are doing!” The anti [PCN] faction cited some of the scams that were going on, and said, “These people are just ripping off the Treasury!”
Did anybody say, “Well, here’s the percentage that are doing good, and the percentage that are scamming?” No, there was no objective analysis. The only actual analysis of it was done by the Auditor General. (P5)
In 2012, Alberta’s Auditor General (AG) delivered a report directly questioning the value that the province was receiving for its ongoing investment in the PCNs. At that point the federal money from the Transition Fund had been exhausted and so the capitation payments were now coming from the provincial treasury. The AG’s report, coming as it did amid the drafting of a new province-wide strategy for PHC, was generally accepted by our participants as ushering in a new era for the PCNs. It signaled the end of the Frontier Era and the arrival of Accountability.
In sum, the first decade of the PCNs was one rich in locally driven innovations and poor in accountability. With the professional vocation of primary care, the FFS arrangements under which the province’s family doctors operate, and Alberta’s frontier culture all valorizing and incentivizing independence, a profusion of PCN forms, sizes, and approaches to improving quality emerged in the early years. Steadfastly local in their outlook, and concerned, on behalf of their memberships, at the acute care system’s intentions towards them, the PCNs focused their diverse energies on the universal challenge of caring for complex chronic patients. From funneling per capita money directly to physicians, to setting up new patient services, their solutions ranged significantly and their ability to track, formally, success or failure was virtually non-existent.
Table 2 HERE
The Era of Accountability (2013-2019):
The current era of PCN evolution has seen the continuation and evolution of features from the Frontier Era. Specifically, autonomy and culture clashes have persisted and come to be addressed through new mechanisms and structures of accountability. In addition, the present era has developed policy implementation characteristics of its own including the introduction of 1) PCN-level performance indicators; 2) governance and co-planning structures, and 3) Quality Improvement (QI) as a goal. We elaborate on these new features, noting developments and continuations.
The Arrival of Accountability
The Frontier Era was officially ushered out by the AG’s 2012 report, although it was, arguably, already in motion as the MoH had been taking greater control over the form, if not the development and size, of the PCNs since 2008. As one policy maker speaking in 2019 noted, the problem of accountability was a foundational one.
The lack of clarity in exactly what those performance accountability requirements are …has been the challenge for the last 12 years. (P7)
This was a sentiment echoed by at least some of the PCNs for whom evidence of their successes and shortcomings was an important missing element. In the words of one PCN leader,
The accountability part is a question we’ve been asking since our very first business plan in 2004 – about how do we know we’ve made a difference. (P2)
The challenge, from the clinical and PCN perspective, being that performance measurement in primary care is confounded by the chronic, longitudinal nature of the work. The same participant noted:
We envy the acute care people because they can say “Oh, here’s a fracture. We fixed the fracture.” And six weeks later, the person is walking just fine. It’s a very obvious result. Primary care, particularly with chronic disease is [more a case of] “If we do this [one intervention] well, [the patient] will be in better shape 30 years from now.” [That sort of approach] doesn’t have very much political cachet. And so, a lot of [our performance measurement] is activity-based [showing] we’ve supported a lot of patients. (P2)
Another participant described the choice as one between following indicators of process or indicators of outcome.
You know, do we continue with process measures, or do we really just focus on outcomes and [the PCNs] figure out a way to get to those outcomes. (P10)
In this fraught, uncertain, and politicized measurement context, the AG’s 2012 report urged the MoH to, among other actions, establish clear expectations and targets for the PCNs, and to design systems for evaluating and monitoring their performance. Responding, the MoH worked with the AMA to create the PCN Evaluation Framework which would eventually lead to a set of performance indicators known as Schedule B.
As a policy-maker described it, the process of creating the Schedule B indicators was one of trying to make the highly localized operations of the PCNs not just amenable to measurement, but fungible across the system.
In order to get performance data out, you have to sort of do a lot of work around standardizing the [various] numerators and denominators so [the PCNs] can set those up in their systems. [To support] Schedule B – which is part of [the PCNs’] grant agreement – we have [measurement] toolkits. [Without the kits] what they report on isn’t apples to apples. [Developing those standards is] a whole process that needs to be ongoing. You can't do it all at once. (P9)
Schedule B’s measures of PCN performance focus on operationalizing 7 distinct policy goals through 9 indicators:
Table 3 here
Developed out of the policy direction provided in the province’s 2014 Primary Health Care Strategy, Schedule B in this form was part of all the grant agreements between the MoH and the PCNs in 2019.
If Schedule B was, and is, a paper presence, the on-the-ground variations in PCN form, size, and service delivery mean there are gaps between the rule of measurement and its practical implementation. From the PCN’s perspective the developed standards remain open to significant local interpretation.
it’s a very subjective report in many respects. It doesn’t [tell a story like]“We made a million dollars and distributed the dividend to our shareholders.” I mean, it’s just not that precise. (P2)
With neither the work of primary care delivery, nor the indicators of Schedule B seen as amenable to the precision of corporate-style annual reports, AH also finds itself in a gray area when it comes to enforcing accountability. As a policy-maker noted, because there has been
variability in the decision-making from the funder, [the PCNs] have a lack of clarity in exactly what some of those performance accountabilities and outcomes currently are…
If [a PCN] struggled and was unable to meet [performance targets] there was variability in the approach from [AH] as to how lenient or strict to be. So there’s some policy gaps there. (P7)
In sum, accountability has been, and remains, a key point of contention and effort for both the PCNs and the MoH. Gaining momentum with the 2012 AG’s report, AH’s efforts to gain a view of, and exert more control over, the PCNs, have been ongoing. Although driven by policy, the choice of indicators has proved a challenge to implement and enforce in the primary care environment. Nonetheless, the work of developing standards and then establishing reasonable tolerances for acceptable performance within those standards has emerged as a common project that the PCNs too have embraced.
The Arrival of Governance and Integration
The move towards oversight through accountability was accompanied by a novel governance structure (see Figure 2) that had, at least in part, its origins in what might be mistaken for Frontier Era policy generation. A physician leader described generating a rough draft of what would become the governance structure.
on a paper napkin for the deputy minister [of AH] in a cafeteria [and then turning it] into something concrete and then, socializing [it] and getting it ratified and voted on and accepted. (P6)
Sold as being a combination of integrative co-planning and a representative voice locally and provincially, the governance structure that was once merely a paper napkin attained more than 80% support from the 3800 family physician members of the PCNs in 2017. It created a structure in which AHS and the PCNs would co-plan their service delivery. The new governance structure includes a Provincial level PCN Committee - providing governance, leadership and strategic priorities - and five Zone level PCN Committees. The MoH, AHS, PCN physician leads, and a non-voting AMA representative are members of the Provincial PCN Committee. The sub committees are positioned at the AHS zone level, and so representatives from PCNs within each of the 5 AHS zones are now regularly drawn together with AHS personnel and community members to plan.
FIGURE 2 HERE
For their part, the cross-cultural meetings of Zone PCN Service Planning committees that bring together primary care and health system personnel, are, in their infancy. As one participant noted:
They’re just in the initial phases right now of starting to look at [co-planning]. And [the zonal committees are] looking at it from the perspective of some very specific populations. A lot of them are focusing on addictions and mental health: no surprise [there]. But another group is [focused on] the complex, elderly. Those kinds of things. (P4)
As this implies, while the policy direction for the zonal committees splits their focus across five populations – Well and At Risk; Maternal; Chronic Co-Morbid; Addiction and Mental Health; and Frail Seniors – the on-the-ground reality is one of locally chosen emphasis within these broad categories of policy and public health concern. In this way we see the search for local solutions to universal problems adapting to include consideration, and prioritization, of issues that have recently come to be seen, in Alberta, as major social and healthcare challenges.
As fledgling efforts at co-planning specifically, and trust and integration more generally, these zonal committees remain objects of concern for both sides. On the AHS side, one participant noted:
I’m not convinced that [the planning committees are] the great leveller. But I think there’s lots of opportunity for growth on both sides. Growth and learning. (P4)
From the other side, a PCN leader noted,
AHS feels an ownership of everything. They have a big ego, and it’s misapplied. Oftentimes I think of them as the kid at the candy store with their nose pressed up against the glass…It’s a candy store in primary care, and AHS wants to be part of it. (P2)
Another PCN leader used the same metaphor, describing how,
As the governance structure started to change, [our PCN’s] physician leader said to me, “You know, it’s like AHS is standing outside the candy shop scratching on the window, trying to figure out a way to get in.” (P11)
In describing what they see as AHS’s imperial ambitions, both participants are expressing the same anxieties that were present as the PCNs were originally created. Beyond reformulating a fear that the bigger organization might consume them, the PCN personnel are highlighting the size of the task that has been given to the local committees and the provincial-level body that oversees them.
In addition to creating lines of communication and accountability, the hope is that, through their work, the committees will mitigate the mutual mistrust of the two joint venture partners by bridging their cultural differences. These cultural differences are not just a theoretical challenge, but also a source of significant tension in the applied work of co-planning. As one participant noted, the PCNs find themselves caught up in their members’ cultural expectations and operational norms:
Primary care doctors are used to getting the information [from a patient] and making decisions and getting out of the [exam] room in 12 minutes. And they bring that same attitude towards their PCNs and their PCN operations. Now obviously, PCNs can’t make changes that fast. And so, [the doctors] already find PCNs slow. Then, [in the case of] PCNs working with AHS, AHS seems to move, from a primary care doctor’s [perspective at] a glacial speed. (P3)
Beyond frustration at the speed with which the larger bureaucracy of AHS moves, the PCNs and their members continue to assert their core cultural value: independence. What AHS or the MoH may see as policy directives to be implemented, the family care physicians see more as options on a menu. As a PCN leader noted,
the physicians on the front lines are kind of ‘a la carte accepting’ [of the various measures and priorities]. We are seeing good traction on the front lines for [some of] those. [But] it’s always a work in progress. It could always be better.” (P3)
Aware of the ‘a la carte acceptance’ engendered by the FFS remuneration structure and independence narratives of the family physicians, another participant highlighted the limits of AH’s capacity to push policy priorities downward. She posed the following questions:
How much accountability does the network membership – so the physicians and the clinics and teams – have to the actual PCN itself? The big challenge [has been] how do you get the adoption of these core priorities. How do you get the primary care docs to buy in and align their own practice priorities and plans [with the policy goals] so that you get a cascading upward effect? (P10)
While these questions have yet to be answered, the acknowledgement that alignment with PHC policy comes mostly from the bottom up rather than entirely from the top down, has been central to whatever success the zonal co-planning committees have enjoyed. A policy maker described how some of the committees have managed to avoid duplication, and so presumably save costs, while determining priorities from the bottom up:
A brand new program may come into place that AHS is creating, owns, and operates. And it could potentially be duplication of… some existing program that had been in a PCN business plan or [was already a] service plan priority. (P7)
The policy maker went on to note that it is “mostly AHS” that needs to amend and adapt its programming to avoid duplicating the work of the PCNs. This observation suggests both the relative nimbleness and responsiveness of the smaller organizations as well as their intimate knowledge of the populations they are serving as they make a la carte choices from policy priorities.
In sum, a governance structure at once desired by AH and popular with the PCNs’ family physician members arrived as part of the Era of Accountability. At the provincial level this structure provides the doctors with a voice upward, while acting as a downward conduit for AH priorities and thinking. At the AHS zonal level it is becoming a site for more or less fraught collaborations between the PCNs and AHS. In this co-planning space the cultural values and operational differences of the two joint venture partners are very much on display. Indeed, jealousies and perceived incompatibilities are just as likely as trust and consensus to characterize these early exchanges as relationships are being built. Given how new this cultural contact through substantive activity is, this is perhaps unsurprising. In any case, the zonal committees are facilitating conversations that would likely not have occurred in the Frontier era, or if they had, would have occurred in the isolation of individual PCNs with little chance of spread, scale or the emergence of standards at zonal or even provincial levels. Occurring in the Era of Accountability, these co-planning focused conversations are substantively focused on fostering greater mutual knowledge of one another’s activities with a corresponding reduction in duplicative programming. There is at least some perception that these gains are asymmetrical – with AHS seen as learning more about the wide variety of PCN programming that is already in the field, than the PCNs are learning about what they see as their AHS colleagues’ top-down policy and public health driven work. Beyond these perceptions and the substantive mission of the committees lies the hard and slow cultural work of developing good will towards one another.
The Arrival of Quality
If the province’s 2014 Primary Care Strategy supplied the policy criteria for the arrival of accountability and Schedule B, two years later AH defined four new objectives for PCNs that have become, as the various players interpret and operationalize them, a focus on quality. The Auditor General report (2017) suggested that these 4 new objectives were aligned and consistent with the original 5 federal objectives that had launched the Frontier Era. In this way,
- Accountable and Effective Governance;
- the Health Needs of Community and Population;
- the Patient Medical Home (PMH); and
- Strong Partnerships and Transitions of Care
became the new menu from which PCNs and their member physicians began, and are now, making their ‘a la carte’ choices.
While policy makers and AHS personnel tend to see the governance, population health, and integration priorities on this list as equally important, their counterparts in the clinical and PCN world tend to emphasize the PMH. Indeed, the core mission of the PCNs in the view of rank and file as well as leader members, has in many ways, come to be seen as offering support for operationalizing the PMH. As one participant described it, the PCNs have,
a central, co-ordinating… administrative and support function [for the PMH] that is operationalized [in ways that are] somewhat up to the [PCNs] themselves, based on the needs of their members. (P10)
Another participant further underscored the PCNs’ presumptive role in supporting the changes required to enact the PMH. She noted that a large body of evidence
demonstrates that the majority of [family medicine] practices cannot [transform towards the PMH] on their own. A few early adopters can. But the majority of practices cannot. They require extensive coaching to learn:
How to be a team-based practice;
How to take best advantage of the resources that PCNs can bring;
How to manage their panel – now that they have panels, mostly;
How to do pro-active chronic disease management;
How to enact the medical home model. (P5)
In enumerating a number of the key features of the PMH – at least as they are stated in a recent iteration that can be traced from the original ‘patient centered medical home’ concept in the US, through versions espoused by the Canadian College of Family Physicians, to the AMA’s Towards Optimized Practice program – the participant provides a theoretical and technical understanding that is not necessarily front-of-mind for those on the clinical front lines. Another participant described how the ‘majority of practices’ in the PCNs experienced the arrival of the PMH as a single priority rather than a differentiated list of key features. He described how, as the PMH became part of the policy conversation, family physicians quickly cut to the chase asking:
“You want us to do quality improvement? Fantastic! So who’s gonna do that? Am I gonna do it, or do I need a person to do that? [A person] to help me to run my panels and my disease registries, and my screening lists, et cetera. (P6)
For the participant, as with many of the province’s operationally focused independent contractor family physicians, the PMH becomes synonymous with QI not so much as an aspirational mindset, but rather a set of tasks that will need to be carried out and paid for.
Whether theoretically well developed or operationally focused, in the minds of PCN member physicians, not only is the PMH an option on a broader policy menu, it is the preeminent option and in most cases a synonym for QI. As such, the PCNs are expected and envisioned primarily as vehicles for achieving QI. This might, at the low end of the spectrum, involve members seeking support in achieving the pre-requisite switch from paper to an electronic medical record (EMR). Further along the spectrum, it might involve support for understanding and deploying an EMR to work with now-empaneled patients to conduct population health interventions and improve integration with specialists and services in the community.
As one participant described it:
On the physician side, I think that there is a spectrum where there are a lot of physicians on the front lines who don’t know much about the PMH. But [others] in leadership positions have really embraced it, and are really helping to drive towards that direction. (P3)
Another participant described how, for him, Albertan
primary care is in its infancy in quality improvement. The new graduates coming out [of medical school] have some quality understanding and [are able to] apply it. But the vast majority of practitioners are really on the tip of what they need to be doing, or need to understand, from a quality perspective… Once you get quality improvement thinking, it changes the language, it changes the understanding [and it] opens the door to applied research evaluation. (P4)
As the participant elides the specificities of the PMH into a general capacity for QI, he highlights the idea that, setting the leaders and early adopters aside, the majority of family medicine practices need material assistance in understanding and applying the new principles of what they see as the preeminent policy option on the government’s menu. Material assistance here is not limited to finding ‘a person to do that,’ although this is clearly a necessary pre-requisite. In addition to providing incentives and supports, there is a need for improved front line understandings of the PMH/QI so that the measurement and evaluation expected by government are meaningful rather than tick-box exercises.
Where the physicians’ see the PMH as a menu of technical QI options within a menu of policy options, those in policy circles interacting with broader healthcare constituencies, see the ‘medical home’ as limiting and politically inappropriate. As a policy maker described it to an interviewer who had asked about the PMH,
You used the words “Medical Home.” If you said that to a room full of nurses, you might not survive. Cause there’s also the concept of a “Health Home.” And [non physicians] get very twitchy when you talk about medical home, because medical means “Doctor” in Alberta. And that means that you’ve already decided the primary caregiver is always going to be a physician. (P1)
This decision to have the primary caregiver be a physician was one that has been challenged as recently as 2012, the year that the AG’s report ushered in the Era of Accountability. As a physician leader described it, there was
at the time, a huge move from alternate providers, specifically Nurse Practitioners. They found favour with the premier [of the province]. And they were seen as somehow the new knights in shining armor that could somehow rescue primary care. And so, unfortunately, it became a turf war in the background between family docs and nurse practitioners (P6)
The move the participant describes was supported by the newly installed government of the day and sought to create Family Care Clinics (FCCs) run by Nurse Practitioners. The FCCs were, in the eyes of another physician leader, a politicized and ill-conceived attempt to resuscitate a concept that had proved unworkable in the US years before. He noted
Anybody who had a lick of sense could see…that the FCCs were unworkable. But [the government] were, nonetheless, pushing ahead with it. The PCNs were – and the medical profession were – screaming “Foul!” And the AMA was quite opposed to the FCCs as well. During that era three FCCs actually got launched. A few others were planned. I think one or two of the planned ones eventually happened as well. The whole Wave Two was abandoned. Wave Three was written off completely. As soon as [the government of the day was] replaced …the FCCs were just abandoned. (P5)
Having survived this bid from alternate providers and a hostile government it is perhaps unsurprising that PCN members are focused on the specifics of the PMH interpreted as QI.
Beyond being a casualty of a turf war, the health home concept does not, as a physician policy-maker noted, lend itself to winning the minds of that majority of independent family physicians who want to base their practice on evidence. He described the problem as one of credibility and authority,
The label – which is in the [academic] literature – is ‘Patient’s Medical Home.’ And it is really hard for us to change the label, and still be evidence-based.
I think we’d have gotten much further with the MoH if we’d used their preferred label, which is health home. [But], we can’t say to physicians, “You should move towards the health home,” and then point off at medical home literature without them going, “Well, wait a minute. Which one is it? We’re following the literature, not just [some] kind of random idea.” (P3)
The PMH, then, is both the intellectual grounding for a broader, a la carte, move towards QI thinking and activity, as well as an ongoing source of authority in a presently cold turf war with the allied health professions.
In sum, quality arrived in the PCNs alongside 3 other policy priorities and was generally interpreted by doctors as a cipher, or synecdoche, for the PMH. Both the MoH and AHS took the other 3 priorities to be equally important but, typically, the province’s physicians took an a la carte approach to adoption and focused on quality as a synonym for and the ultimate goal of the PMH. As both physician leaders and regular PCN members have come to see their organizations as delivery mechanisms for the PMH/QI – and not the Health Home preferred by policy makers – they are making politically saavy choices. The PMH carries with it a robust and authoritative literature, and, in its very name, it asserts a territorial claim in an presently cold turf war with allied health providers who have, and may again, try to advance in the province’s PHC space. As the politics and economics of healthcare in the province shift, and the PCNs continue to evolve, the fate of the Health Home and the elided PMH/QI formulation is certainly not set in stone.