Teams of different health service providers have been variously dubbed Accountable Care Organizations (ACO), Sustainability and Transformation Partnerships (STP), Integrated Health Systems (IHS), and Integrated Care Systems (ICS); some would claim their origin in Health Maintenance Organizations (HMO). Ontario Health Teams (OHT) is their most recent sobriquet. What’s an OHT?
There’s no easy answer. It is said of Accountable Care Organizations, the most numerous of the species, ‘if you have seen one ACO you have seen one’. They vary widely in terms of size, not only of their membership and structure but also the in the nature of the populations they serve, their geographic distribution, their mandates, the spectrum of services provided, source(s) of their funding, and other factors too. But they all exhibit the following core characteristics:
- Each is (1) a collection of health service providers, (2) operating within a single, defined budget (3) serving collectively a defined population with (4) a defined range of health/healthcare services for which (5) it is held accountable both to its funder(s) and the population served.
Although no Ontario Health Team has yet been created, it seems clear that each will be expected to meet somewhat greater specificity with respect to at least some of these characteristics. With regard to membership (1) it appears certain from the outset that those who join the team will do so of their own volition – the phrase used is “a coalition of willing partners”. It is also clear that only those individuals, organizations, or institutions that are publicly funded will be partners. As discussed below, that restriction may prove to be a serious problem when considering the range of services (4) a defined population (3) needs to safeguard its health and well-being.
No detail has yet been forthcoming about how OHTs will be funded (2) other than that it will be in the form of “a single envelope”, expenditures from which will be restricted to the purposes for which funds were appropriated by the Ontario Legislature (the so-called ‘votes’). The degree to which an OHT can subsequently reallocate funds from its envelope to achieve for its population optimum outcomes and its members’ most cost-effective productivity is a question yet to be answered. Accountability for better outcomes and cost effectiveness (5) will be discharged formally in ways yet to be specified through defined, measurable contractual obligations to the government and to the people served through their representation in the OHT itself; each OHT must be genuinely “people-centered”, as opposed to provider- or government-centered.
An OHT is conceived of as a team of teams of health and healthcare service providers (HSPs). Think of a hospital, the biggest, most complex of Ontario’s health service providers. Each is, in fact, a team of doctors, nurses, aids, cleaners, maintenance and administrative staff, et cetera, in which the work of each member is both essential to what the organization accomplishes and is necessarily smoothly coordinated with the work of all other members. The same principle should extend to and among every other organization, large and small, that contributes to the range of services needed by a given population to maintain its good health and to restore it to individuals ill, injured, or disabled (4). Conceptually, an OHT would be composed of one or more acute and/or long-term care hospitals partnered with physicians and nurse practitioners providing primary care, whether individually or in teams with nurses, aids, pharmacists, physiotherapists, and other providers. Other partners would be the public health units providing services to the same population, home, paramedical, and palliative care, and agencies offering addiction and mental health support, street health, and other community-based services, including some concerned with the provision of housing and other services recognized to be among the social determinants of health. Few specifics are as yet known beyond that each OHT will be expected to offer “full service”, i.e. the capacity to provide the complete range of health and healthcare services needed by the people served, a population expected to be within a defined geographic area, to an upper limit of approximately 500,000 people. The great promise of an OHT is that each community, district, or region can organize its team of willing members so as to provide one-stop shopping for the full spectrum of health and healthcare services its population needs. In principle, each OHT can develop, structure, govern, and manage its internal system of health services to achieve the best outcomes for the people served at the lowest cost.
Doing that will be easier said than done. All of the willing, and those unwilling to be partners, will be fearful of domination by their potential partner hospitals, of subordination of the entire cascade of health service providers to a hospital’s mission, and management of the OHT’s funding envelope to support its priorities, fears well founded in an unhappy past and present history. But on the up-side for the creation of effective OHTs, most hospitals are well aware of their reputations as predators of other players and that they have to live down that reputation going forward by ensuring that leadership of the OHT of which they are member is truly shared, not only with its other HSP members but with those who represent the people, including patients, of the population they serve. That awareness of the need to avoid dominance is reinforced by the fact that to progress toward the Premier’s Council’s goal of “eliminating hallway medicine” Ontario’s hospitals need more than ever the strong support of their primary, long-term, home, and community care partners. Providing them generous funding and other assistance will be in the hospitals’ best interest, not to mention those of the patients and their families provided care in surroundings more supportive to their health than a hallway’s hard gurney.
As for the administrative ‘back office’ services each OHT will require, the straightforward goal of achieving maximum cost efficiency makes clear the sense of loading that on the already well-tested, relatively sophisticated personnel and processes most hospitals have in place.
How does the mandate of OHTs differ from the planning and resource allocation decisions that Local Health Integration Networks (LHINs) were theoretically set up to make? The goal of integrating the whole spectrum of HSPs in given, communities, districts, and regions remains the same. The only difference is that the integration into genuine systems is to be done directly by representatives of the people served and of their health service providers, the OHT, instead of as directed by a LHIN’s and/or central Ministerial bureaucracy. The promise of this distributed approach is that the between 30 to 50 OHTs that are forecast to be in place on Ontario when they are fully rolled out will be able to coordinate the work of their service providers in ways that fit best the particular characteristics, cultural, ethnic, geographic, density, or whatever, of the population each serves. The failure of one-size-fits-all planning demonstrates conclusively how substantially these characteristics differ among Ontario’s 14.3 million people. OHTs, with sufficient freedom to implement solutions that differ among communities, districts, and regions, offer the opportunity to succeed in system-building where the LHINs failed.
The major proviso, of course, is OHTs have to have the freedom to allocate their resources in accordance with what they find to be the most efficient and effective ways of achieving smooth integration and good communication among the HSPs that serve their populations. Theoretically the LHINs were to have had that freedom but never did. Whose decision will prevail if an OHT’s decision relating to what would work locally conflicts with one following on from government’s central bargaining with the OMA, ONA, or other public-sector unions? To what extent will central government’s political interests constrain what OHTs consider both desirable and achievable in their individual communities, districts, or regions? Such questions will have to be answered before any OHT takes on its intended responsibilities.
Finally, public funding does not extend to many of the services required by people to promote and preserve their health and to restore it when lost. The high cost of prescription drugs is currently much discussed but so also could be home care services, dental care, rehabilitation, addictions and mental health, and many others now more readily available to those able to pay for them out-of-pocket or by private health insurance than to those with fewer financial means. If our society’s goal is to optimize the health of the population, as surely it is, how will OHTs interface with private sector health service providers in their communities, districts, or regions? Could they too be “willing partners”? Could they be contractors to OHTs? And what about those, publicly or privately funded, who are unwilling to become OHT members? Their services will remain essential to the people’s well-being and can’t continue to remain as outside, uncoordinated components of the systems OHTs are to be mandated to create.
Answers to these and other questions must be forthcoming in short order out of discussions with Ontario Health and the Government as proposals to develop Ontario Health Teams are developed in communities, districts, and regions and are submitted. Nobody wants an OHT to be set up to fail.