The waiting room at Dr. Maya Chen’s family practice in Toronto’s west end is unusually quiet this afternoon. Not for lack of patients – her schedule is packed as always – but because of the weight of uncertainty hanging in the air. Dr. Chen, who has run this practice for eleven years, spends her rare free moments reviewing spreadsheets rather than medical journals.
“I’m essentially trying to figure out if I’ll still be able to keep my doors open next year,” she tells me, gesturing to calculations on her laptop screen. “Most of my patients don’t realize we’re running on a system designed decades ago that barely covers our overhead costs anymore.”
Dr. Chen isn’t alone. Across Ontario, family physicians are cautiously examining details of a proposed new compensation model that could fundamentally change how they’re paid – and potentially address a crisis that has left nearly 2.2 million Ontarians without access to primary care.
The Ontario government and the Ontario Medical Association (OMA) recently announced plans to overhaul the compensation system for family doctors, moving away from the traditional fee-for-service model toward a system that pays physicians based partly on the complexity of their patients’ needs rather than simply the volume of visits.
“Right now, I get paid roughly the same whether I see a healthy 30-year-old for a quick prescription renewal or spend 45 minutes with an elderly patient managing multiple chronic conditions,” explains Dr. Chen. “The economics push doctors toward quicker visits, which isn’t always what patients need.”
Under the current system, most family physicians work within what’s called a Family Health Organization (FHO) or Family Health Group (FHG), models that blend capitation (a set amount per patient enrolled) with fee-for-service billings. But rising clinic costs, administrative burdens, and the increasing complexity of patient needs have stretched this system to its breaking point.
The new proposed framework would introduce what the Ministry of Health calls a “complexity modifier” – essentially providing additional compensation for physicians caring for patients with more complicated health needs that require more time and resources.
When I visited Northern Horizons Family Health Team in Thunder Bay last month, Dr. James Wilkinson showed me how this might work in practice. His rural practice serves a diverse population including many Indigenous patients who often face multiple barriers to care.
“About 40% of my patients have three or more chronic conditions requiring ongoing management,” Dr. Wilkinson explained as we walked between examination rooms. “Under the current system, I’m financially incentivized to take on healthier patients who need less time. The new model might finally recognize the reality of modern family medicine.”
According to data from the Canadian Institute for Health Information, the percentage of Canadians with multiple chronic conditions has increased by nearly 14% over the past decade. For family doctors, this means increasingly complex patient visits that don’t fit neatly into the current billing structures.
The Ontario Medical Association, which represents the province’s 43,000 physicians, has been negotiating these changes with the provincial government for months. Dr. Samantha Hill, past president of the OMA, told me by phone that the reforms are “potentially the most significant change to primary care compensation in a generation.”
But not everyone is convinced the proposed changes go far enough. Dr. Nili Kaplan-Myrth, a vocal advocate for family medicine reform in Ottawa, worries the new model might still fail to address fundamental issues driving doctors away from family practice.
“Many recent medical graduates look at family medicine and see a broken system with overwhelming administrative burdens and insufficient resources,” Dr. Kaplan-Myrth explained. “They’re choosing specialties instead, which is why we’re facing such a severe shortage of family doctors.”
Indeed, according to the College of Family Physicians of Canada, the percentage of medical graduates choosing family medicine has declined from 38% in 2015 to around 30% today. Meanwhile, Statistics Canada data shows Ontario’s population grew by nearly 2 million people between 2016 and 2023, further straining the system.
For patients like Mississauga resident Eleanor Zhang, these statistics represent a daily reality. After her family doctor retired three years ago, Zhang joined the growing ranks of Ontarians without primary care.
“I’ve been on waiting lists for years,” Zhang told me when we met at a community health center where she occasionally receives care. “I manage my diabetes through walk-in clinics and the emergency room when things get bad. It’s exhausting and frightening.”
The proposed compensation changes are expected to be implemented gradually starting in 2024, though exact timelines remain uncertain. The Ministry of Health indicates the reforms will be accompanied by efforts to reduce administrative burdens that many physicians cite as a major source of burnout.
Back in Dr. Chen’s office, as afternoon appointments begin, she remains cautiously optimistic. “If this new model actually recognizes the real work we do and covers our increasing overhead costs, it could make a difference,” she says. “But the devil will be in the details.”
As she calls in her next patient – an elderly man with heart disease, kidney problems, and early dementia – the complexity of modern family medicine is on full display. The visit will take at least 30 minutes, likely more.
“This is the reality of family medicine today,” Dr. Chen says quietly. “The question is whether our compensation system will finally catch up to it.”
