An analysis of policies supporting the roles of family physicians in four regions in Canada during the COVID-19 pandemic

Abstract

Policy supports are needed to ensure that Family Physicians (FPs) can carry out pandemic-related roles. We conducted a document analysis in four regions in Canada to identify regulation, expenditure, and public ownership policies during the COVID-19 pandemic to support FP pandemic roles. Policies supported FP roles in five areas: FP leadership, Infection Prevention and Control (IPAC), provision of primary care services, COVID-19 vaccination, and redeployment. Public ownership polices were used to operate assessment, testing and vaccination, and influenza-like illness clinics and facilitate access to personal protective equipment. Expenditure policies were used to remunerate FPs for virtual care and carrying out COVID-19-related tasks. Regulatory policies were region-specific and used to enact and facilitate virtual care, build surge capacity, and enforce IPAC requirements. By matching FP roles to policy supports, the findings highlight different policy approaches for FPs in carrying out pandemic roles and will help to inform future pandemic preparedness.

Introduction

Pandemic response requires coordinated actions by governments, healthcare and professional organizations, and healthcare providers. Family Physicians (FPs) are well positioned to carry out a number of critical roles and activities during the various stages of a pandemic while continuing to provide essential primary care services. ¹ While pandemic response plans published prior to the COVID-19 pandemic outline FP roles, few describe the policy supports needed to enable FPs to carry out these roles.^2,3

The purpose of this study was to identify the regulation, expenditure, and public ownership policies that were implemented to support FPs in carrying out pandemic roles during COVID-19. Pandemic roles refer to the specific tasks and/or responsibilities that FPs are expected to fulfill during the pandemic, but which are expected to stop once the pandemic is over and “normal” operations resume. By policies, we mean the range of instruments that governments can use to achieve its goals.^4,5 Deber ⁶ outlines five types of policy instruments used in health policy contexts: do nothing, exhortation, regulation, expenditure, and public ownership. “Do nothing” refers to policy-makers’ belief that an issue will resolve without explicit government action. Exhortation policies include information, education-based initiatives, and symbolic gestures. Regulation policies introduce or amend formal rules to influence behaviours, such as changing licensing rules to make it easier for retired health professionals to return to the workforce. Expenditure policies include taxation and funding for new programs or services. Public ownership refers to government assuming responsibility for the operation of programs or services. In this study, we focus on regulation, expenditure, and public ownership policies because they require a coordinated approach from government and health system organizations. Unlike do nothing and exhortation policies, FPs have little choice but to comply with regulation, expenditure, and public ownership policies. The study aims to support the development of future pandemic plans for primary care. Moreover, it informs the evaluation of the COVID-19 pandemic responses by highlighting the policy approaches used in different jurisdictions to support FPs’ roles.

Methods

As described in a published protocol, ⁷ we conducted a multiple case study of four regions in Canada: the Vancouver Coastal health region in British Columbia (BC), the Eastern Health region in Newfoundland and Labrador (NL), the province of Nova Scotia (NS)—which only has one health region, and Ontario (ON) Health West. The four regions cover a range of health services and had different rates of COVID-19 cases, hospitalizations, and deaths; region-specific organization of primary care services; and utilized FPs in different ways as part of their pandemic response.

As part of the case study, we conducted a document analysis. ⁸ From March 2020 and April 2022, we identified publicly available policy documents impacting FP roles during the pandemic. To identify relevant documents, we used a combination of targeted and general search strategies. As part of a targeted search, we reviewed the web sites of government (federal, provincial, and municipal), public health organizations (e.g. Public Health Agency of Canada and regional public health units), professional organizations (provincial Colleges of Physicians and Surgeons, College of Family Physicians of Canada, provincial colleges of FPs, provincial medical associations, Canadian Medical Association, and local/regional primary care networks), hospitals, health institutions, and medical schools in the four regions. These targeted web sites facilitated snowball searches of linked and/or referenced web sites, documents, and resources. In addition, we searched local and national media reports. As part of a general search, we conducted an on-line search using the Google search engine using the following terms and logic: province or region name or abbreviation (e.g. “BC” or “British Columbia” or “VCH” or “Vancouver Coastal Health”); and “COVID” or “COVID-19” or “coronavirus”; and “primary care” or “family physician” or “family doctor.”

To be included in the analysis, a policy had to influence (directly or indirectly) the roles of FPs or primary care practices during any stage of the COVID-19 pandemic. ¹ Policies could be new or modifications of existing policies, but had to be introduced or re-introduced between January 2020 and April 2022. The policy could relate to any sites where FPs routinely worked but must relate specifically to FPs or practice staff (as opposed to all Emergency Room [ER] or Long-Term Care [LTC] staff) and to activities at all locations in the region (as opposed to a single ER or LTC facility). For each policy, research assistants recorded the following information into a Qualtrics data entry form: jurisdiction (region affected by policy), date when policy was issued, summary of policy, organization issuing policy, type of policy instrument, and source.

We examined regulation, expenditure, and public ownership policies that were introduced to support FPs in performing pandemic roles. We summarized the various roles supported by these policies and described regional variation in the types of policies implemented. We presented an initial list of policies to our broader study team as well as to family physicians, public health officials, healthcare administrators, and policy-makers to confirm the description of these policies and identify any that may be missing.

Results

Regulation, expenditure, and public ownership policies supported FP roles in five areas: FP leadership, Infection Prevention and Control (IPAC), provision of primary care services, COVID-19 vaccination, and redeployment. Table 1 summarizes the types of policies that supported FP roles while Table 2 highlights the variation by region of specific regulation, expenditure, and public ownership policies.

Table 1.

Regulation, expenditure, and public ownership policies introduced to support family physicians in carrying out pandemic roles in four regions in Canada.

Regulation	Expenditure	Public ownership	Family physicians pandemic roles and activities
	✓		Provide leadership at clinic, institutional, or regional levels
	✓	✓	Implement infection prevention and control
			Screen patients (active and passive screen)
		✓	Test patients or refer patients for testing
		✓	Use special procedures to access supplies (swabs and personal protective equipment)
			Educate patients about COVID-19, and infection control
	✓		Use virtual and telephone visits
			• Triage patients requiring in-person care
			• Advise patients on isolation/quarantine
			• Direct patients to assessment centres/telephone triage lines
			• Modulate referrals to elective, specialist, surgical care, imaging, and/or lab testing
			• Support travellers requiring screening/testing/isolation
			• Update care plans/goals for long-term care residents
	✓		• Monitor COVID-19 patients recovering at home
✓	✓		• Identify and support vulnerable patients (e.g. frailty and addictions)
	✓		Staff assessment centres
	✓		Identify and support patients prioritized for vaccination
	✓		Address vaccine hesitancy
✓	✓	✓	Staff vaccination centres and mobile clinics
	✓		Support community-based residential facilities experiencing outbreaks
✓	✓		Staff field hospitals or mobile health clinics
	✓		Assist with capacity in emergency departments and hospitals
			Participate in evaluations of pandemic response

Table 2.

Regional variation in the types of policies introduced to support family physicians in carrying out pandemic roles.

Type of policy	BC	ON	NS	NL
Regulation
Virtual care billing [35,40]	✓
Scope of practice during redeployment [24,57]	✓		✓
Implementation of safety plans [12]	✓
Virtual care delivery of medical assistance in dying [37,38], opiate agonist treatment [39]	✓		✓
Licensing of retired physicians and international medical graduates [55,56]	✓		✓
Prescribing of controlled substances [36]	✓	✓	✓	✓
Expenditure
Billing code for planning meetings [10]	✓
Billing codes for virtual care [30,31,32,33] including specific services [34]	✓	✓	✓	✓
Reimbursement of infection prevention and control expenses [13]	✓
COVID-19 vaccination sessional fees [52,53] and billing codes [54]	✓	✓	✓
COVID-19 vaccination counselling billing fee [49,50,51]	✓	✓		✓
Assessment centre session fee [31,45]		✓
Income stabilization programs [42,43,44]		✓	✓	✓
Public ownership
Centralized PPE distribution [22,23,24,25,26]	✓	✓	✓	✓
Assessment centres [14,15,16,17]	✓	✓	✓	✓
Advice lines [18,19,20]	✓		✓	✓
Influenza-like illness centres [16,17]			✓	✓
Mass vaccination centres [45,46,47,48]	✓	✓	✓	✓

FP leadership

FPs carried out leadership roles in implementing the pandemic response. The leadership roles of FPs included conveying knowledge to decision makers, FP colleagues, patients, and communities; adapting public health measures to primary care settings; and advocating for vulnerable patients. ⁹ As an example, BC introduced a fee to reimburse FPs for up to 35 hours of active participation in pandemic response planning meetings during the early months of the pandemic. ¹⁰

Infection prevention and control

In Canada, practice and system-wide interventions were implemented to limit the risk of COVID-19 exposure in primary care settings, by screening patients and diverting potentially infected patients from presenting in-person at practices. ¹¹ At their practices, FPs were responsible for implementing IPAC, screening patients (using active and passive methods), advising patients on isolation/quarantine, using special procedures to access supplies (swabs and Personal Protective Equipment [PPE]), educating patients about COVID-19, and infection control. To divert potentially infected patients from presenting in-person at family practices, FPs were also responsible for referring patients for testing, directing patients to assessment centres/telephone triage lines, triaging patients requiring in-person care, and providing virtual care.

FPs enacted IPAC protocols in their practices to limit the potential spread of COVID-19 to patients, staff, and themselves. While all regions relied on exhortation policies (and existing public health regulations) to encourage FPs to implement IPAC measures, BC required FPs to submit safety plans ¹² and offered remuneration to offset the costs of developing and implementing the plans, including one-time costs to install Plexiglass barriers and/or retrofit or renovate office space as outlined in the plan. ¹³ In all four regions, governments enacted public ownership policies and centralized assessment and testing centres to divert high-risk patients from presenting in-person to primary care practices.^14-17 BC, NS, and NL also implemented telephone advice^18-20 and screening lines,^20,21 and operated influenza-like illness centres for limited periods during the pandemic^16,17 (ON also operated influenza-like illness clinics but not in the region used in our study). In all four of the regions in our study, provincial governments (working in collaboration with regional health authorities and/or medical professional organizations) introduced centralized PPE distribution sites and assumed responsibility for sourcing, storing, and distributing PPE.^22-26 For a limited period of time, PPE was available for free to FPs (including community-based FP practices operating as private businesses and not affiliated with health authorities).

Provision of primary care services

Many FPs were involved in roles related to the provision of ongoing primary care as well as education and care specific to COVID-19. Due to IPAC requirements limiting in-person services, many primary care appointments were delivered virtually.^27,28 In addition, laboratory and diagnostic testing and specialist services, including elective surgeries, were often delayed or suspended, resulting in modifications to the provision of primary care services. ²⁹ All four regions implemented fee codes to support delivery of virtual care,^30-33 including fee codes in specific regions (Table 2) for patients requiring individualized services such as opioid agonist treatment, counselling, chronic disease management, paediatric assessments, and COVID-19 treatment and monitoring. ³⁴ BC introduced changes in the Medicare Protection Act to facilitate virtual care ³⁵ medical services. Other regulatory policies supporting virtual care included changes to the prescribing of controlled substances (implemented by the federal government but applicable to all study regions), ³⁶ as well as clarification of professional standards related to virtual assessments for medical assistance in dying^37,38 and patients who use substances, ³⁹ as well as the storage of personal health information. ⁴⁰

The sudden decrease in the number of in-person visits, especially during the early weeks of the pandemic when PPE was in limited supply and practices were transitioning to virtual care, raised concerns in fee-for-service practices about cash flow and paying for fixed overhead costs. ⁴¹ In response, three regions introduced remuneration policies to stabilize funding for practices that were financially struggling. ON’s COVID-19 Advance Payment Program provided physicians with cash advances (up to 80% of previous years’ billings) that physicians would pay back in future instalments. ⁴² In NS and NL, practice funding stabilization programs were tied to continuation of normal practice activities as well as potential redeployment for COVID-19-related activities, such as working in vaccination or assessment centres.^21,32

COVID-19 vaccination

All four regions introduced mass vaccination sites to deliver COVID-19 vaccines.^45-48 FPs played important vaccination-related roles, including prioritizing high-risk patients for vaccination, counselling individuals (especially vaccine hesitant patients), vaccinating long-term care residents, and staffing mass vaccinations centres and mobile clinics for hard-to-reach populations. ¹ New fee codes were implemented for the purposes of identifying priority patients and providing patients with counselling, and vaccination or sessional fees were provided to FPs for working in vaccination clinics.^49-54 In addition, BC and NS introduced polices to allow recently retired FPs to help with vaccination campaigns.^55,56 BC also allowed unlicensed international medical graduates (who met specific qualifications) to work at vaccination clinics in order to increase the number of providers who work at vaccination centres. ⁵⁵

Redeployment

FPs were called upon to take on additional responsibilities such as staffing assessment centres, vaccination clinics, and influenza-like illness clinics. ¹ They were also expected to assist with outbreaks in LTC homes and provide surge capacity in emergency departments and hospitals. Regulatory policies to support these redeployments included assurance that physicians required to work outside routine scope of practice while providing COVID-19-related care would not be violating professional standards.^24,57 As noted above, NS and BC introduced policies to increase provider capacity in COVID-19 vaccination programs.^55,56

In addition, all four regions introduced expenditure policies to remunerate FPs for taking on these new roles. In ON, FPs could charge a sessional fee for work in assessment centres, vaccination clinics, or assisting in LTC facilities or other sites that were not covered by pre-existing contracts. ⁴⁵ BC introduced sessional and fee-for-service rates for vaccination. While NS included practice-based COVID-19 vaccination fees (once vaccines became more widely available), NS and NL used the practice funding stabilization programs to cover additional COVID-19-related duties at other settings (e.g. assessment centres and influenza-like illness centres).^43,44

Discussion

The four regions in our study used unique combinations of regulation, expenditure, and public ownership policies to support FPs in carrying out pandemic-related roles. Public ownership policies were used to operate mass assessment, vaccination, and influenza-like illness clinics, and to facilitate access to PPE. Public ownership policies were integral to safeguarding primary care practices by diverting high-risk patients to dedicated assessment settings, facilitating access to PPE, and providing access to COVID-19-related services. Expenditure policies were used to remunerate FPs for virtual care and new COVID-related roles, and reimburse costs associated with the implementation of IPAC procedures. Regulatory policies were used to facilitate virtual care, build surge capacity, and enforce IPAC requirements. While all four regions used public ownership and expenditure policies to achieve fairly consistent goals, there was more variation in the use of regulatory policies, reflecting the unique differences in existing legislation in each province (e.g. definition of virtual care in BC’s Medicare Protection Act) and alternate approaches to addressing COVID-19-related needs (e.g. use of telephone advice and assessment lines and increasing workforce capacity). While our analysis focused on regulation, expenditure, and public ownership, exhortation policies were also widely used and integral to supporting FP roles. Through various organizations, FPs were provided information on the epidemiology of the virus, symptoms and management of COVID-19, access to testing and vaccination, safe management of primary care practices, and access to diagnostic and specialist services. ⁵⁸

The regulation, expenditure, and public ownership policies were introduced in the first two years of the pandemic (between 2020 and 2022). While our analysis focused on the four specific regions, these policies applied to the province as a whole. Public ownership policies were generally abandoned by mid-2022, and over time, governments adopted more “do nothing” policies (that is, no explicit government action), including limiting exhortation policies such as reporting of cases and encouraging of masking, physical distancing, and other public health measures. In contrast, the expenditure and regulatory policies, especially those relating to the provision of virtual care, remain in place as of spring 2023. It is widely expected that virtual care will remain an integral mode of primary care delivery overall; however, remuneration policies are currently changing in some jurisdictions to reflect the importance of longitudinal relationships between physicians as patients in virtual care provision. ²⁷

Three regions (ON, NS, and NL) implemented income stabilization programs to address the reduction in visit volumes and resultant incomes for FPs working in fee-for-service models who were experiencing a decrease in fee-for-service billings. In addition to sharp decreases in patient volumes during the early stages of the pandemic, FPs have also highlighted the negative impact of isolation requirements and sick leave on the ability of fee-for-service practices to maintain sufficient cash flow. ⁴¹ In NS and NL, income stabilization was linked to performing COVID-19-related duties, while sessional fees were primarily used to remunerate physicians for carrying out these roles in ON. Further research is needed to assess the uptake of these programs, their impact on the operations of family practices during the pandemic, and the effectiveness of these different approaches to remunerating FP roles.

Limitations

Our analysis included publicly available policies. As a result, we would not have data on extensions of private arrangements (for example, remuneration for leadership roles through pre-existing contracts in ON). Although we took a number of steps to ensure the completeness of the policies, including generalized and targeted searches and confirming findings with frontline and health system managers, we may nonetheless have missed policies, especially if they did not appear to relate directly to FP pandemic roles. We focused exclusively on policies related to FPs. Policies related to other health professions that may indirectly affect FPs (e.g. expanding the scopes of practice of pharmacists to include COVID-19-related testing, vaccination, and prescribing; redeployment of nurses to public health settings) were not included in the analysis, but are being examined in other ongoing studies. We examined four regions in Canada; findings may not be reflective of experiences in other jurisdictions.

Conclusion

Regulation, expenditure, and public ownership policies were used to support FP leadership, the implementation of IPAC in family practices, the provision of primary care services including virtual care, COVID-19 vaccination, and redeployment of FPs. Public ownership and expenditure policies were employed to achieve similar goals across the four regions. Public ownership polices were used to operate mass assessment, vaccination, and influenza-like illness clinics and facilitate access to PPE, while expenditure policies were used to remunerate FPs. Regulatory policies were region-specific and used to facilitate virtual care, build surge capacity, and enforce IPAC requirements. With the exception of policies supporting virtual care, governments relied less on these policies over time, especially as the care of COVID-19 became increasingly integrated into the routine operations of family practices. By matching FP roles to policy supports, the findings from this study highlight different policy approaches to FPs in carrying out pandemic roles and will help to inform future pandemic preparedness.

ORCID iDs

Dana Ryan https://orcid.org/0000-0001-7949-8849

Emily G. Marshall https://orcid.org/0000-0001-8327-0329

Lauren Moritz https://orcid.org/0000-0002-0802-0140