Financial disincentives, stigma and discrimination create barriers for people who use opioids to access family doctors, study suggests
Dr. Tara Gomes
By Jennifer Stranges
People who are treated for opioid use disorder in Ontario are 45 per cent less likely to secure a primary care provider after previously losing access to care compared to people with no recent prescription opioid exposure, according to a new study led by Unity Health Toronto researchers.
The study, published on June 1 in PLOS Medicine, found that the likelihood of people who use opioids securing a family doctor changed when the type of primary care attachment was factored in. The findings suggest that the gaps in access to primary care for people with opioid use disorder and chronic pain – who may have a high resource requirements – may be influenced by financial disincentives within the healthcare system. Primary care is an integral component of the health care system, and is associated with reduced mortality, increased life expectancy and reduced health care costs.
Using data provided by ICES, researchers analyzed 154,970 Ontarians whose enrolment with a primary care physician was ended between January 2016 and December 2017. The majority of people in each of the patient groups had their enrolment terminated by their physician. The individuals were separated into three groups: individuals who were prescribed opioids for long-term pain therapy (defined as 90 days or more), individuals receiving opioid agonist therapy to treat an opioid use disorder, and individuals with no recent prescription opioid exposure.
Recipients of opioid agonist therapy were 45 per cent less likely to find a primary care provider in the year after terminating enrolment, compared to people with no recent prescription opioid exposure. The study also found that people who were prescribed opioids for long-term pain had a similar likelihood of securing another primary care physician as people with no recent prescription opioid exposure, however they were significantly less likely to access collaborative primary care models that can provide high quality continuity of care, such as family health teams. The long-term pain group also had elevated rates of emergency department visits during their period of provider loss.
“There are considerable barriers to accessing primary care among people who use opioids, and this is most apparent among people who are being treated for an opioid use disorder,” said Dr. Tara Gomes, a Scientist at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital and ICES, and a Principal Investigator of the Ontario Drug Policy Research Network (ODPRN). “This highlights how financial disincentives within the healthcare system, and stigma and discrimination against people who use drugs introduce barriers to high quality care.”
In Ontario, primary care is predominantly provided through primary care enrolment models that pay physicians through capitation (calculated based on the age and sex of each enrolled patient, not by health status or complexity) and enhanced fee-for-service billings. In this model, physicians provide comprehensive primary care to enrolled patients, and are prohibited from refusing enrolment due to patient health status or high service need.
Alternatively, primary care can be delivered through community health centres, which are comprised of multidisciplinary teams that aim to serve populations who may experience issues accessing health services, or through traditional fee-for-service arrangements.
“It was discouraging to see the degree to which we are seeing barriers to access primary care occurring systematically across Ontario. While there are many incredible primary care physicians who provide excellent care in safe environments for all people, it is clear that this isn’t the case for many people in Ontario,” said Dr. Gomes.
The researchers are calling for changes in primary care funding structures that promote physicians integrating all patients into their practices, efforts to integrate treatment for opioid use disorders directly into primary care, and education for physicians about how to use destigmatizing language and remove structural barriers to accessing care within their practices.
About St. Michael’s
St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in more than 27 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the Hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael’s Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.
About Unity Health Toronto
Unity Health Toronto, comprised of Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital, works to advance the health of everyone in our urban communities and beyond. Our health network serves patients, residents and clients across the full spectrum of care, spanning primary care, secondary community care, tertiary and quaternary care services to post-acute through rehabilitation, palliative care and long-term care, while investing in world-class research and education. For more information, visit www.unityhealth.to.
ICESis an independent, non-profit research institute that uses population-based health information to produce knowledge on a broad range of health care issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting health care needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy. In October 2018, the institute formerly known as the Institute for Clinical Evaluative Sciences formally adopted the initialism ICES as its official name. For the latest ICES news, follow us on Twitter: @ICESOntario
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