Ontario government faces lawsuits over troubled Family Health Teams
NationalPost.com – FullComment – Toronto
Jun 8, 2012. Christie Blatchford
Major flaws are emerging in what is supposed to be the crown jewel in Ontario’s changing health care system.
Family Health Teams or FHTs, a seven-year-old creation of the Dalton McGuinty government, are widely seen as the best model for family doctors and patients both.
Though they take different forms, they share a common vision — to offer better primary care by having groups of physicians, nurses, nurse-practitioners and other medical professionals work as a team either in one physical location or through a single hub.
And for the most part, the early evidence is that FHTs do result in better outcomes for patients, particularly those with complex medical problems such as diabetes.
The move to FHTs also has seen more than 2.1 million Ontarians who didn’t have a family doctor get one.
Rolled out in five waves starting in 2005, Ontario has poured millions into the teams — $244-million in fiscal 2010-11 and $347-million in fiscal 2011-12 alone — and now has 200 FHTs across the province, serving 2.8 million patients.
That money doesn’t include salaries paid to physicians, who — under the complex new “alternate funding arrangements” which go hand-in-hand with FHTs — earn about 25% more than their counterparts who work solo and are paid on the old fee-for-service model.
But serious problems at two different FHTs — one of the oldest, a community-led team in Shelburne, north of Toronto, and one of the newest, a physician-led team in the city’s impoverished Jane-Finch area — suggest there may be widespread gaps with oversight and real potential for abuse and even wrongdoing.
“It’s a better [potential] scandal than Air Ornge or eHealth,” says one insider, referring to the province’s beleaguered air ambulance service and well-documented spending spree with electronic health records, “because it’s a systemic problem.”
With at least a couple of FHTs, for instance, Postmedia News has learned that the province has been paying for years for what could be called “ghost” employees, contract health practitioners the FHTs are funded to hire on a part-time basis but haven’t yet been able to find.
And when the FHTs in question told the ministry that, for instance, they hadn’t yet hired the nurse-practitioner or other “allied professional” they were funded for, “they kept sending us the money,” the bewildered source says.
The ministry disputes the term “ghost” employees but acknowledges some funds aren’t spent by FHTs “for a period of time” and defends the practice as giving the teams “the flexibility to hire” whenever they’re able to do so.
At one FHT, when staff reportedly couldn’t persuade bureaucrats to stop sending payments for ghost employees, the FHT banked the money and allegedly gave their regular physicians an unsolicited — and improper, as defined by the FHT-ministry deal — “bonus” at year’s end.
All three troubled areas — Air Ornge, e-Health and FHTs — fall under the ambit of the same government arm, the Ontario ministry of health and long-term care.
Both the Mel Lloyd FHT in Shelburne and the Humber River FHT in northwest Toronto recently have seen clashes between administrators allegedly trying to bring standard governance procedures to the FHT boards, followed by a round of firings and staff or board member resignations.
The Mel Lloyd FHT, where board directors have twice resigned en masse and where staff turnover reached 51% last year, now faces two wrongful dismissal suits from a former executive-director and a former administrator.
One of the suits, which seeks $800,000 in damages, alleges some of the doctors had been lured to the FHT by promises they could work part-time hours but be paid full-time.
The FHT is vigorously defending one of the suits, which was filed last December: the $800,000 one was just recently filed. None of the allegations in either suit have been proven.
Alerted to the problems by community members, the ministry called in an audit team from the finance department.
The team presented its report — the focus on management and governance problems — to senior officials in Health Minister Deb Matthews’ office just last month.
Though the report doesn’t deal specifically with the allegations in the lawsuits, auditors found that two board members, including one of the FHT physicians, were in a conflict of interest. “Although the two board members may not gain financial benefit, they will likely gain personal benefit from their involvement,” the report concludes.
The auditors urged the government to strengthen the conflict-of-interest section of the agreements it signs with FHTs.
At Humber River, which is located near the high-needs Jane-Finch community, the executive-director recently was fired after, sources say, she learned that some of the doctors allegedly were seeking cheaper leases for themselves than for other medical professionals at a new satellite site under development.
She also questioned the lack of documentation for payments made to a consultant who was pitching the site.
Armed with a legal opinion letter, which confirmed in stark terms that some of the doctors were proceeding with a deal “that advantaged the physicians over the FHT” and that it appeared the full board had not approved it, the executive-director brought the issue to the board on March 27.
She was fired three days later.
At first blush, even these are significant problems.
Almost half the 200 FHTs, for instance, are physician-led, which means they were established by a Family Health Organization (a FHO) or a Family Health Network (FHN).
Both are groups of family physicians who band together and who, instead of being paid for each medical service they provide, are paid an annual fee, called a capitation fee, to provide a set list of services for each patient they “enroll.”
According to the latest report by the provincial auditor-general, Ontario has 17 different kinds of such arrangements for family doctors, each with a different payment structure.
For the doctor-led family health teams, it means that only members of the FHOs (that is, the physicians) are voting members of the FHT board.
That inherently puts the physicians, Angie Heydon of the Association of Family Health Care Teams of Ontario acknowledges, in a difficult spot.
“They are by definition conflict-of-interest boards,” she said in a recent interview.
But because of ministry scrutiny — what Heydon calls “line-by-line accounting” and strict reporting — she believes “the risk of misuse of public money is really, really small.”
Yet despite that supposed scrutiny — as Health Minister Matthews says, each FHT is matched to a ministry official responsible for oversight — the auditors at Mel Lloyd found numerous irregularities.
Among them were that the FHT’s financial statements weren’t up to snuff and were submitted late, payroll reports weren’t reviewed and “there were no receipts” for about $5,600 of $7,500 of purchases put on two FHT corporate credit cards.
These were just the purchases the auditors looked at, or “sampled.”
Matthews takes comfort in the fact the government has commissioned the Conference Board of Canada to do an evaluation of the FHTs — now in the third year of a five-year review.
“When we started talking in the 2002-03 elections [about FHTs], we had great dreams and great expectations, that they would keep people out of emergency rooms, keep people healthier,” she says.
“We need to find out [if the FHTs are working] . . . we have a lot more people with family doctors, but we’re also paying a lot more. Are we getting the [patient] outcomes we expected to get?
“We think it’s really important we do a really good evaluation. I think we have to do the evaluation, see what we learn, and put in place real accountability standards.”
Heydon remains concerned with issues of governance and accountability at the FHTs.
Three years ago, when the third wave of teams was being rolled out, the association surveyed its members about just that subject.
The results of the survey, answered anonymously and without identifiers, were unsettling: Asked about conflict of interest, for example, a significant number of respondents replied the matter hadn’t come up or that the board had no policy, while a handful complained that physicians were hard to manage because they “have a pecuniary interest on some of the decisions.”
Early last year, the association presented the ministry with a project to deliver a governance program to FHT boards.
Minister Matthews says “yes, absolutely” the ministry is looking at how it can do more to improve FHT governance.
Phil Graham, the ministry’s manager of FHTs, told Postmedia in a phone interview his officials are in regular, even daily, contact with all the FHTs. “I think in the majority of cases, they’re doing great things . . . they’ve really improved the quality of care.”
Instances such as those at Shelburne and Humber River, he says, “are either isolated, or not widespread by any stretch.” He points out that 50 teams are less than a year old, another 50 a little older than that, and says that “building capacity is a process.”
Postmedia has learned the ministry is now trying to retroactively account for some of the money spent (or not spent) by the FHTs for the past six years and has even demanded hefty repayment from some of the teams.
Matthews confirmed that the ministry has “recovered” $121-million back from FHTs where money wasn’t spent appropriately or where the teams weren’t able to hire the staff they were funded to get.
But to some who work within the system, that’s akin to trying to shut the gate long after the horses have bolted.
But, as one source involved with FHTs since their inception says, “Six years later and they’re trying to catch up.”
“They had great intentions with the FHTs. But especially in the early days, they (the ministry) said ‘Look, here’s all this money, go fill up a board, hire some staff, some medical people.’
“It was careless, at the very least.
“They should not be turning millions of dollars over to people they’ve not vetted. If you’re an embezzler, this is the place to be.”
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