For years, the United States (US) and Canada have aimed to improve value in health care. Yet, health care consumes an increasing share of national expenditures,1 while expected gains in patient experience and population health outcomes have not been realized.
High-performing primary care is considered critical to achieving the triple aim of health reform: better health, improved patient experience, and more affordable costs.2 Improving primary care and making it responsive to the needs and preferences of patients and families are high priorities for both countries,3 as systems that emphasize primary care achieve better health outcomes and health equity at lower costs.4 The past decade has seen numerous initiatives to advance primary care, ranging from local efforts to regional or national experiments.
However, efforts to share knowledge and compare strategies and outcomes are often directed within rather than between countries. This is not surprising because between-country differences in financing and delivery are often considered so substantial as to obviate the relevance of findings in one country for another country. In the US, Americans obtain insurance and care through a complex mix of public and private providers, and a sizable number remain uninsured or underinsured. In contrast, Canadian health insurance is primarily provincial government–based with citizens receiving first-dollar coverage for hospital and physician care. While the American system permits consumers to select competing plans with varying coverage, Canadian benefits are accessible, transferable among provinces, and largely consistent. While these differences often lead to dismissals of transnational comparisons, there are more similarities than differences in the gaps and challenges advanced primary care systems face in meeting patient needs and expectations, as well as optimizing their health.
Our populations share the enviable position of having relatively high overall health status.5 However, there are large health inequities across the socioeconomic spectrum, such that the socioeconomic health gradient is more pronounced within than between our countries.5 Moreover, we share similarities regarding key social determinants that contribute to health inequities,6 including poverty rates,7 education gaps,8 unemployment,9 geographic isolation and distribution,10 and indicators of racial and ethnic disparities.11
The populations in both countries have changing primary care needs that demand more capable, coordinated, and longitudinal systems. Chronic disease is increasingly common, with multimorbidity becoming the norm rather than the exception.12 Recent cross-national surveys demonstrated similar gaps in primary care delivery.13 In 2016, 34% to 51% of citizens in both countries reported having difficulties getting same-day or next-day appointments or receiving after-hours care easily, or visiting the emergency department because their primary care providers were not available.13 In both countries, a considerable proportion of patients presenting to emergency departments are not connected to a primary care provider, either owing to issues of access or preference, especially among certain demographic groups.14–16 Many patients also reported coordination-of-care gaps regarding the timely transfer of clinical information among their physicians.13 More than one-third of patients with chronic illness reported not discussing their goals, priorities, or treatment options with their primary care provider in the past year.17
Both countries have recognized that the gaps in primary care delivery need to be addressed and that a coordinated research agenda is required to understand which strategies are successful in the provision of care to various populations. For this reason, collaborators from both countries came together to plan an inaugural cross-border symposium focused on primary care.
This symposium brought together more than 150 leaders in primary care delivery to exchange cross-border stories in primary care transformation, develop a binational research agenda to support primary care transformation, and support cross-border learning and collaboration. Stakeholders included not only clinicians but also policy makers, researchers, payers, system designers, and patients. This symposium was committed to collaborating and finding ways to support primary care transformation at practice, policy, and research levels.
Vision for primary care transformation
Consensus emerged among participants about core features for primary care transformation. Transformation must first be framed around an expanded “quadruple aim” that includes health equity, and around the evidence-based principles of primary care (first contact, continuous, coordinated, comprehensive). Within this framework, there is a need for new models of primary care that are reinvigorated with the “joy of practice,” embrace a broader definition of primary health care that includes a patient-centred approach and behavioural care, and reflect the interdependence of the health care system and primary care’s role within it, as well as linkages to community-based resources and nonmedical health determinants. Furthermore, access to actionable data about both clinical conditions and social determinants of health at the community and individual levels will be needed for success.
To support the vision
Directions for clinical leadership and practice.
The most important challenges facing primary care are the imperatives to meet the needs of people with multiple chronic conditions and to address inequities in health and health care. The former was eloquently highlighted by a patient representative who reminded the group that the current delivery system treats patients as “complex patients” instead of as “people with complex health care needs.”
A moral challenge on both sides of the border is that health care disparities continue to exist because we tolerate them. It was recognized that while primary care could not be expected to solve all broader community issues, such as food insecurity, social integration, and environmental exposures, it cannot improve health without strategies and models of care that address them.
As health and health care are local phenomena, no single delivery model can be expected to succeed everywhere. Professionals and practices need flexibility in order to identify the outcomes they want to achieve, meet the needs of communities, and design and adapt their practices to achieve these. The key priorities and directions for primary care practice transformation are outlined in Table 1.
Priorities and directions for primary care practice transformation
Directions for policy to support effective primary care.
A key theme that emerged for policy makers was the need for a broader perspective on health care. Future investments in primary care systems need to be based on an overarching vision with clear goals, as well as on a policy framework that aligns policies and incentives, including but not limited to payment. While there is no perfect model, there was consensus among members on the key components for effective primary care (Table 2).
Policy directions to support effective primary care
To build a robust foundation for effective primary care, policy makers need to address prices and value by rebalancing payment for primary and specialty care; invest in practices rather than providers; invest in data collection infrastructure and analysts to support continuous quality and outcome improvement; and develop a richer set of performance metrics that monitor the principal requirements of primary care, as well as equity. In turn, primary care needs to strengthen its governance and accountability for population health, and embrace joint responsibilities for continuous improvement and innovation.
Directions and priorities for primary care research and evaluation.
To foster sustainable innovations in primary care, research funders should facilitate partnerships with health system stakeholders in which, for example, the implementation of new models would be funded by the health system, and funders would support their evaluation. Rapid advances could be facilitated by platforms that support health care, research, and practice-based evidence development. Ultimately to have health effect, mechanisms are needed to spread and scale successful innovation.
There are also perceived benefits to cross-agency collaboration among funders to support cross-border research on primary care. To facilitate comparisons of natural experiments within and across health systems, efforts should be directed to a focus on positive variance and attributes associated with better outcomes. Creative ways of comparing primary care innovations included funding implementation incubators, or implementing research laboratories in both countries that mindfully learn from each other. Table 3 outlines the top 10 priorities identified for primary care research.
Top 10 priorities for primary care research
Conclusion
The striking differences between the Canadian and US primary health care systems offer an opportunity for transnational knowledge exchange owing in large part to our confronting similar challenges. Primary care thought leaders who gathered at the symposium recognized the imperative to develop sustainable models of high-quality primary health care delivery. Successful models will provide comprehensive, patient- and family-centred care in the context of community. They will integrate behavioural health care and in turn be embedded and coordinated within the larger health care delivery system. New models will also connect primary care with public health and community-based resources to provide whole-person care that addresses both social and medical determinants of health. Primary care must raise its aims to address health disparities and healthy work environments that restore the joy of practice to those who dedicate themselves to providing primary care.
To achieve these goals, our nations need to align health and health care policies to foster the development and spread of these models. Policy models such as the US Center for Medicare and Medicaid Innovation should be expanded in the US and adopted in Canada to develop, evaluate, and scale up effective primary care delivery models.
To stimulate the development of new models, funding partnerships offer an opportunity to advance rapid-cycle, pragmatic primary care research. By learning from one another, Canada and the US can accelerate research and implementation in primary care delivery and ensure that primary care innovations are shared across borders to the benefit of all people.
Acknowledgments
The findings and conclusions in this article are those of the authors, who are responsible for its content, and do not necessarily represent the views of the Agency for Healthcare Research and Quality. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or of the US Department of Health and Human Services.
Notes
Hypothesis is a quarterly series in Canadian Family Physician (CFP), coordinated by the Section of Researchers of the College of Family Physicians of Canada. The goal is to explore clinically relevant research concepts for all CFP readers. Submissions are invited from researchers and nonresearchers. Ideas or submissions can be submitted online at mc.manuscriptcentral.com/cfp or through the CFP website www.cfp.ca under “Authors and Reviewers.”
Footnotes
Competing interests
None declared
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