Systemic Failures in Healthcare: Lessons from the Auditor General's Reports on Emergency Care

Access to timely and comprehensive primary care is a cornerstone of effective healthcare systems. Yet, recent reports from the Auditor General of Ontario reveal a troubling pattern: patients face increasing barriers to primary care, which leads to more severe health issues presenting in emergency departments. These systemic failures are not just administrative problems; they have real consequences for patient health and safety. This post explores the findings from the 2023 and 2025 Auditor General reports, highlighting how billing policies and care practices contribute to poor outcomes in emergency care.

Primary Care Strains and Emergency Department Overload

The Auditor General’s reports draw a clear connection between the strain on primary care services and the rising challenges in emergency departments. Ontario’s healthcare system often uses volume-based billing policies that limit the number of issues a physician can address per visit. This "one issue per visit" rule means patients with multiple health concerns must schedule several appointments, which is not always feasible.

As a result, many patients delay care or receive fragmented treatment. When their conditions worsen, they turn to emergency departments, which are not designed for ongoing primary care. This shift increases wait times and overcrowding in emergency rooms, creating a cycle where patients with advanced illnesses require urgent attention that could have been prevented.

Impact on Patient Outcomes

The reports highlight that patients arriving at emergency departments often have more advanced disease stages due to delayed or inadequate primary care. This delay leads to:

• Increased hospital admissions

• Longer stays in emergency departments

• Higher risk of complications and adverse events

  
  

These outcomes place additional pressure on emergency staff and resources, reducing the overall quality of care.

Missed Diagnoses and Sentinel Events

One of the most alarming findings from the Auditor General is the frequency of missed or delayed diagnoses in emergency departments. In 2022, Ontario hospitals recorded 274 return visits involving sentinel diagnoses. These include critical conditions such as heart attacks and pediatric sepsis that were not identified during the initial emergency visit.

Among these cases, 104 were linked to specific quality issues or adverse events, including:

• Patient mismanagement

• Missed or delayed diagnosis

• Inadequate reassessment during the visit

  
  

These sentinel events often result in patients returning in significantly worse health, sometimes with life-threatening complications.

How Billing Policies Contribute to Diagnostic Failures

The "one issue per visit" billing rule restricts physicians from fully reassessing patients during emergency visits. Time constraints and billing limitations discourage thorough evaluations, increasing the risk of overlooking serious conditions. The Auditor General points out that this lack of comprehensive reassessment is a leading cause of adverse events.

Moreover, the billing system does not have automated mechanisms to flag unusual or high-risk billing patterns. This gap means audits and investigations rely heavily on external complaints or tips rather than proactive monitoring of patient safety trends.

The Need for Systemic Change

The Auditor General’s findings make it clear that addressing these systemic failures requires changes at multiple levels:

• Revising billing policies to allow more comprehensive care during visits

• Improving access to primary care to reduce emergency department overload

• Implementing better monitoring systems to detect quality issues early

• Encouraging thorough patient reassessment to prevent missed diagnoses

  
  

Examples of Potential Improvements

Some jurisdictions have experimented with alternative billing models that reward quality and comprehensive care rather than volume. For instance:

• Bundled payments for managing chronic conditions

• Incentives for longer or follow-up visits addressing multiple issues

• Use of electronic health records to flag high-risk patients automatically

  
  

These approaches can help reduce the pressure on emergency departments and improve patient outcomes.

Conclusion