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Human Resources for Health
Published in: Human Resources for Health 1/2018

Open Access 01-12-2018 | Research

Funding models and medical dominance in interdisciplinary primary care teams: qualitative evidence from three Canadian provinces

Authors: Wiesława Dominika Wranik, Susan Marie Haydt

Published in: Human Resources for Health | Issue 1/2018

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Abstract

Background

Primary care in Canada is the first point of entry for patients needing specialized services, the fundamental source of care for those living with chronic illness, and the main supplier of preventive services. Increased pressures on the system lead to changes such as an increased reliance on interdisciplinary teams, which are advocated to have numerous advantages. The functioning of teams largely depends on inter-professional relationships that can be supported or strained by the financial arrangements within teams. We assess which types of financial environments perpetuate and which reduce the challenge of medical dominance.

Methods

Using qualitative interview data from 19 interdisciplinary teams/networks in three Canadian provinces, as well as related policy documents, we develop a typology of financial environments along two dimensions, financial hierarchy and multiplicity of funding sources. A financial hierarchy is created when the incomes of some providers are a function of the incomes of other providers. A multiplicity of funding sources is created when team funding is provided by several funders and a team faces multiple lines of accountability.

Results

We argue that medical dominance is perpetuated with higher degrees of financial hierarchy and higher degrees of multiplicity. We show that the financial environments created in the three provinces have not supported a reduction in medical dominance. The longstanding Community Health Centre model, however, displays the least financial hierarchy and the least multiplicity—an environment least fertile for medical dominance.

Conclusions

The functioning of interdisciplinary primary care teams can be negatively affected by the unique positioning of the medical profession. The financial environment created for teams is an important consideration in policy development, as it plays an important role in establishing inter-professional relationships. Policies that reduce financial hierarchies and funding multiplicities are optimal in this regard.
Appendix
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Literature
1.
Beckhard R. Organizational issues in the team delivery of comprehensive health care. The Milbank Memorial Fund Quarterly. 1972;50(3):287–316.CrossRefPubMed
2.
Bower P, Campbell S, Bojke C, Sibbald B. Team structure, team climate, and the quality of care in primary care: an observational study. Quality and Safety in Health Care. 2003;12:273–9.CrossRefPubMedPubMedCentral
3.
4.
Hogg W, Lemelin J, Dahrouge S, Liddy C, Armstrong CD, Legault F, Dalziel B, Zhang W. Randomized controlled trial of anticipatory and preventive multidisciplinary team care. Can Fam Physician. 2009;12:e78–85.
5.
6.
Lowe F. O'Hara S. 2000. Multi-disciplinary team working in practice: managing the transition. Journal of Interprofessional Care 14(3):269–279.CrossRef
7.
Pearson A, Porritt KA, Doran D, Vincent L, Craig D, Tucker D, Long L, Henstidge V. A comprehensive systematic review of evidence on the structure, process and characteristics and composition of nursing teams that foster a healthy work environment. International Journal of Evidence Based Healthcare. 2006;4:118–59.PubMed
8.
Proudfoot JG, Bubner T, Amoroso C, Swan E, Holton C, Winstanley J, Beilby J, Harris MF. Chronic care team profile: a brief tool to measure the structure and function of chronic care teams in general practice. J Eval Clin Pract. 2009;15:692–89.CrossRefPubMed
9.
Rodriguez HP, Rogers WH, Marshall RE, Safran DG. Multidisciplinary primary care teams: effects on the quality of the clinician-patient interactions and organizational features of care. Med Care. 2007;45(1):19–27.CrossRefPubMed
10.
Russell G, Dahrouge S, Hogg W, Geneau R, Muldoon L, Tuna M. Managing chronic disease in Ontario primary care: the impact of organizational factors. Ann Fam Med. 2009;7(4):309–18.CrossRefPubMedPubMedCentral
11.
Schuetz B, Mann E, Everett W. Educating health professionals collaboratively for team-based primary care. Health Aff. 2010;29(8):1476–80.CrossRef
12.
Shaw A, de Lusignan S, Rowlands G. Do primary care professionals work as a team: a qualitative study. Journal of Interprofessional Care. 2005;19(4):396–405.CrossRefPubMed
13.
Willens D, Cripps R, Wilson A, Wolff K, Rothman R. Interdisciplinary team care for diabetic patients: primary care physicians, advanced practice nurses, and clinical pharmacists. Clinical Diabetes. 2011;29(2):60–7.CrossRef
14.
15.
Farris KB, Cote I, Feeny D, Johnson JA, Tsuyuki RT, Brilliant S, Dieleman S. Enhancing primary care for complex patients: demonstration project using multidisciplinary teams. Can Fam Physician. 2004;50:998–1003.PubMedPubMedCentral
16.
Drew P, Jones B, Norton D. Team effectiveness in primary care networks in Alberta. Health Quarterly. 2010;13(3):33–8.CrossRef
17.
Solheim K, McElmurry BJ, Kim MJ. Multidisciplinary teamwork in US primary health care. Soc Sci Med. 2007;65:622–34.CrossRefPubMed
18.
Deber, Hollander, Jacobs. Models of funding and reimbursement in health care: a conceptual framework. Canadian Public Administration. 2008;51(3):381–405.CrossRef
19.
Milliken O, Devlin RA, Barham V, Hogg W, Dahrouge S, Russell G. Comparative efficiency assessment of primary care service delivery models using data envelopment analysis. Canadian Public Policy. 2011;37(1):85–109.CrossRefPubMed
20.
Muldoon L, Dahrouge S, Hogg W, Geneau R, Russell G, Shortt M. Community orientation in primary care practices: results from the comparison of models of primary health care in Ontario study. Can Fam Physician. 2010;56(7):676–83.PubMedPubMedCentral
21.
Cohen S, Bailey D. What makes teams work: group effectiveness research from the shop floor to the executive suite. J Manag. 1997;23(3):239–90.
22.
Griffiths J, Austin L, Luker K. Interdisciplinary teamwork in the community rehabilitation of older adults: an example of flexible working in primary care. Primary Health Care Research and Development. 2004;5:228–39.CrossRef
23.
Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA. 2004;291(10):1246–51.CrossRefPubMed
24.
Hurst K, Ford J, Gleeson C. Evaluating self-managed integrated community teams. Journal of Management in Medicine. 2002;16(6):463–83.CrossRefPubMed
25.
Rubin I, Beckhard R. Factors influencing effectiveness of health teams. The. Milbank Memorial Fund Quarterly. 1972;50(3):317–35.CrossRefPubMed
26.
Xyrichis A, Lowton K. What fosters or prevents interprofessional teamworking in primary and community care? A literature review. Int J Nurs Stud. 2008;45(1):140–53.CrossRefPubMed
27.
West MA, Borrill CS, Dawson JF, Brodbeck F, Shapiro DA, Haward B. Leadership clarity and team innovation in health care. Leadersh Q. 2003;14:393–410.CrossRef
28.
Chesluk BJ, Holmboe ES. How teams work-or-don’t-in primary care: a field study on internal medicine practices. Health Affaris. 2010;29(5):874–9.CrossRef
29.
Jansen L. Collaborative and interdisciplinary health care teams: ready or not? J Prof Nurs. 2008;24(4):218–27.CrossRefPubMed
30.
Liau CY, Lin CC, Lin YK, Blossom YJL. Partnership disengagement from primary community care networks (PCCNs): a qualitative study for a national demonstration project. BMC Health Serv Res. 2010;10(87):2–8.
31.
Long S. Primary health care team workshop: team members’ perspectives. J Adv Nurs. 1996;23(5):935–41.CrossRefPubMed
32.
Murray S, Silver I, Patel D, Dupuis M, Hayes SM, Davis D. Community group practices in Canada: are they ready to perform their practice? J Contin Educ Health Prof. 2008;28(2):73–8.CrossRefPubMed
33.
Ross F, Rink E, Furne A. Integration or pragmatic coalition? An evaluation of nursing teams in primary care. Journal of Interprofessional Care. 2000;14(3):259–67.CrossRef
34.
Dobson RT, Taylor JG, Henry CJ, Lachaine J, Zello GA, Keegan DL, Forbes DA. Taking the lead: community pharmacists’ perception of their role potential within the primary care team. Res Soc Adm Pharm. 2009;5:327–36.CrossRef
35.
McDonald J, Powell Davies G, Jayasuriya R, Fort Harris M. Collaboration across private and public sector primary health care services: benefits, costs and policy implications. Journal of Interprofessional Care. 2011;25(4):258–64.CrossRefPubMed
36.
Pringle D, Horsburgh ME. Interdisciplinary collaboration and primary health care reform. Canadian Journal of Public Health. 2000;91(2):85–6.PubMedPubMedCentral
37.
Goroll AH, Berenson RA, Schoenbaum SC, Gardner LB. Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care. J Gen Intern Med. 2007;22(3):410–5.CrossRefPubMedPubMedCentral
38.
Kiran T, Kopp A, Moineddin R, Glazier RH. Longitudinal evaluation of physician payment reform and team-based care for chronic disease management and prevention. Can Med Assoc J. 2015;187(17):E494–502.CrossRef
39.
Kiran T, Victor JC, Kopp A, Shah BR, Glazier RH. The relationship between primary care models and processes of diabetes care in Ontario. Can J Diabetes. 2012;38(3):172–8.CrossRef
40.
Petersen LA, Simpson K, Pietz K, Urech TH, Hysong SJ, Profit J, Conrad DA, Dudley RA, Woodard LD. Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized trial. JAMA. 2013;310(10):1042–50.CrossRefPubMedPubMedCentral
41.
Lin Y, Yin S, Huang JDL. Impact of pay for performance on behaviour of primary care physicians and patient outcomes. Journal of Evidence-Based Medicine. 2016;9(1):8–23.CrossRefPubMed
42.
43.
Gillam SJ, Niroshan Siriwardena A, Steel N. Pay-for-performance in the United Kingdom: impact of the quality and outcomes framework—a systematic review. Ann Fam Med. 2012;10(5):461–8.CrossRefPubMedPubMedCentral
44.
Scott A, Sivey P, Ait Ouakrim D, Willenberg L, Naccarella L, Furler J, Young D. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database of Systematic Reviews. 2011;9:CD008451.
45.
Beales J, Walji R, Papoushek C, Austin Z. Exploring professional culture in the context of family health team interprofessional collaboration. Health and Interprofessional Practice. 2011;1(1):eP1004.CrossRef
46.
Freund T, Everett C, Griffiths P, Hudon C, Naccarella L, Laurant M. Skill mix, roles and remuneration in the primary care workforce: whoa are the healthcare professionals in the primary care teams across the world? Int J Nurs Stud. 2015;52(3):727–43.CrossRefPubMed
47.
Heale R. Overcoming barriers to practice: a nurse practitioner-led model. J Am Acad Nurse Pract. 2012;00:1–6.
48.
49.
50.
51.
52.
Marchildon GP, Hutchison B. Primary care in Ontario, Canada: new proposals after 15 years of reform. Health Policy. 2016;120:732–8.CrossRefPubMed
53.
Levesuqe JF, Haggerty JL, Hogg W, Burge F, Wong ST, Katz A. Barriers and facilitators for primary care reform in Canada: results from a deliberative synthesis across five provinces. Healthcare Policy. 2015;11(2):45–57.
54.
Wranik D, Durier-Copp M. Physician remuneration methods for primary physicians in Canada: expected outcomes and lessons learned. Health Care Anal. 2010;18(1):35–59.CrossRefPubMed
55.
Bourgeault IL, Mulvale G. Collaborative health care teams in Canada and the USA: confronting the structural embeddedness of medical dominance. Health Sociol Rev. 2006;15(5):481–95.CrossRef
56.
McNeill KA, Mitchell RJ, Parker V. Interprofessional practice and professional identity threat. Health Sociol Rev. 2013;22(3):291–307.CrossRef
57.
Bury M, Taylor D. Towards a theory of care transition: from medical dominance to managed consumerism. Social Theory and Health. 2008;6:201–19.CrossRef
58.
Angus J, Bourgeault IL. Medical dominance, gender and the state: the nurse practitioner initiative in Ontario. Health & Canadian Society. 1998;5(1):55–81.
59.
Blishen B. Doctors in Canada: the changing world of medical practice. Toronto: University of Toronto Press, in association with Statistics Canada; 1991.CrossRef
60.
Coburn D, Rappolt S, Bourgeault I. Decline vs. retention of medical power through restratification: an examination of the Ontario case. Sociology of Health & Illness. 1997;19(1):1–22.CrossRef
61.
Freidson E. Profession of medicine: a study of the sociology of applied knowledge. New York: Dodd, Mead; 1970.
62.
Willis E. Medical dominance: the division of labour in Australian health care (Revised Ed). Boston: Allen & Unwin; 1989.
63.
Coburn D. Phases of capitalism, welfare states, medical dominance, and health care in Ontario. Int J Health Serv. 1999;29(4):833–51.CrossRefPubMed
64.
Toth F. Sovereigns under siege. How the medical profession in changing in Italy. Soc Sci Med. 2015;136-137:128–34.CrossRefPubMed
65.
Sena B. Professionalization without autonomy: the Italian case of building the nursing profession. Professions and Professionalism. 2017;7(3):e1900.CrossRef
66.
Auta A, Strickland-Hodge N, Maz J. Challenges to clinical pharmacy practice in Nigerian hospitals: a qualitative exploration of stakeholders’ views. J Eval Clin Pract. 2016;22(5):699–706.CrossRefPubMed
67.
Alubo O, Handuh V. Medical dominance and resistance in Nigeria’s health care system. Int J Health Serv. 2017;47(4):778–94.CrossRefPubMed
68.
Wranik WD, Haydt SM, Katz A, Levy AR, Korchagina M, Edwards JM, Bower I. Funding and remuneration of interdisciplinary primary care teams in Canada: a conceptual framework and application. BMC Health Serv Res. 2017;17(1):351.CrossRefPubMedPubMedCentral
69.
Wranik D, Korchagina M, Edwards J, Bower I, Levy A, Katz A. 2015. How best to pay interdisciplinary primary care teams? Canadian Institutes of Health Research, Health Care Renewal Policy Analysis Reports http://​cihr-irsc.​gc.​ca/​e/​49737.​html. Accessed 17 July 2018.
70.
Collier D, LaPorte J, Seawright J. Putting typologies to work: concept formation, measurement, and analytic rigor. Political Research Quarterly. 2012;65(1):217–32.CrossRef
71.
72.
Wranik WD, Hayden JA, Price S, Parker RMN, Haydt S, Edwards JM, Suter E, Katz A, Gambold LL, Levy AR. How best to structure interdisciplinary primary care teams: the study protocol for a systematic review with narrative framework synthesis. Systematic Reviews. 2016;5:170.CrossRefPubMedPubMedCentral
Metadata
Title
Funding models and medical dominance in interdisciplinary primary care teams: qualitative evidence from three Canadian provinces
Authors
Wiesława Dominika Wranik
Susan Marie Haydt
Publication date
01-12-2018
Publisher
BioMed Central
Published in
Human Resources for Health / Issue 1/2018
Electronic ISSN: 1478-4491
DOI
https://doi.org/10.1186/s12960-018-0299-3

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