Ontario Needs a Primary Care Allocation Model to Ensure Universal Coverage

From: Will Falk and Rosalie Wyonch
To: Canadian Healthcare Observers
Date: April 21, 2025
Re: Ontario Needs a Primary Care Allocation Model to Ensure Universal Coverage

Ontario has committed $1.8 billion to expanding family health teams and attaching 2 million more Ontarians to primary care. While this is a meaningful investment, it does not change how patients are assigned to providers. Ontario still relies on passive rostering, where patients must find their own doctor – a system that has already left 2.5 million Ontarians without access.

This is not a new problem. The province has tried and failed to create structured allocation before. In 1995, the Harris government attempted to encourage geographic distribution by varying fee codes based on service levels, aiming to persuade physicians to practice in underserved areas. However, this model was rejected by the Ontario Medical Association, reinforcing the reality that physician autonomy limits the effectiveness of financial incentives alone.

Jane Philpott and her team seem well aware of these challenges, having visited other jurisdictions and explored alternative models. Ontario could attempt to rely on price signals to balance supply and demand, but this approach seems unlikely given past failures and ongoing physician resistance.

Instead, let’s examine the main allocation models under consideration.

Geographic allocation models

Several international and interprovincial models provide examples of active patient allocation. Each comes with advantages and challenges:

• Denmark and Norway’s municipal model: Local governments oversee primary care, directly employing doctors and ensuring universal access. While successful in Scandinavia, this would require a major governance shift in Ontario and may not align with Canada’s existing provincial health structure.
• Quebec’s PREM model: Physicians are regionally assigned based on provincial workforce targets. This model has led to dissatisfaction, physician shortages and unintended consequences, making it a cautionary tale rather than a model to emulate.
• Netherlands’ insurance-based model: Patients must register with an insurer, which then ensures access to primary care and other services. The insurer typically has 4-percent overheads, and there are patient co-pays and contributions. This would require expanding Ontario’s not-for-profit insurance framework. While attractive, it violates the Canada Health Act as currently interpreted. Still, this model deserves serious consideration.

Each of these models could work, but only if supported by the necessary legislative, regulatory and payment reforms. The excellent primary care systems in Denmark and the Netherlands did not happen by chance – they resulted from deliberate policy choices that Ontario has yet to make.

Other allocation possibilities

Beyond geography-based models, Ontario could also consider:

• ServiceOntario-based rostering: Patients are auto-assigned through health card registration. This would ensure universal attachment but could create panel size imbalances, leading to access and quality concerns.
• Fee schedule-based distribution: Modify physician compensation to encourage equitable distribution. Previously attempted and failed but could be revisited through municipal bonuses for new practices in underserved areas.
• Virtual care models: Atlantic provinces have had success guaranteeing virtual-first access and then transitioning patients to geographic practices as needed. Ontario could adapt this model to bridge existing access gaps.
• Hybrid approaches: Expanding family health teams while layering on academic, community health centre, nurse practitioner-led clinics and Indigenous care models. Mixing virtual and physical care models. Notably, an unexplored option is structuring teams so revenue structures (capitation payments and fees-for-services) and compensation structures are distinct. Structuring team or hybrid virtual/physical care to align incentives with improved patient outcomes and a seamless continuum of care while also providing performance incentives for providers would require significant changes. These hybrids are promising but may not be enough without a structured allocation system.

Ontario must choose a model

The province’s investment in family health teams is significant, but money cannot substitute for clarity. Without an allocation system, universal access remains an illusion.

If Ontario does not actively assign patients to primary care, millions will remain unattached and primary care expansion will fail to deliver on its promise.

A structured allocation model is not optional – it is essential. It will also have to align with physician remuneration mechanisms, provide equitable access, respect mobility rights and align with the Canada Health Act.

Will Falk is an Executive-in-Residence at Rotman School of Management and a Senior Fellow at the C.D. Howe Institute, where Rosalie Wyonch is Associate Director of Research.

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The views expressed here are those of the authors. The C.D. Howe Institute does not take corporate positions on policy matters.

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