[A version of this piece was posted on the Tyee]
Health care is the biggest, most expensive and most important thing that government does. Hospital care swallows up a large proportion of the health care budget, but primary care in the community takes care of most patient needs and keeps people out of hospital. Patients who are connected to a family physician over time suffer less and live longer. But there hasn’t been much of a conversation about primary care reform in this province, and it’s time to start one. The auditor general agrees, and so do the Divisions of Family Practice in BC, whose slick GP For Me campaign was launched this week.
In BC, doctors are paid well, but they are paid by an antiquated compensation model called Fee For Service (FFS), which basically reduces medical visits to a series of billable scenarios. In family practice this is not cost-effective and often leads to “turnstile medicine”, because we can only bill the government for one ailment at a time, and the more patient visits we have, the more money we make. With high Vancouver rents that come out of our wages, the pressure mounts. But there are better options and a substantial group of family doctors in BC who want to open a different type of family practice in BC.
In a BC research study published in the Canadian Family Physician in 2012, we heard from 133 recently graduated family doctors in BC, and 93 of them (71%) preferred progressive models of payment as opposed to the one-problem-per-visit style of practice that we buy in Fee for Service (FFS). As one doctor described:
“I wish that the province would throw out the traditional Fee-For-Service (FFS) model and introduce a whole new system of innovative funding models that will give us like-minded new family physicians much more choice and freedom in choosing our place for clinical practice. Should the province do this, one would certainly see a lot more new graduates move into setting up a practice, rather than remaining in the locum pool. As it stands now in the FFS climate, setting up a practice and being tied to the clock is an onerous and very unattractive option for most of us new family physicians. I never wish to put up a sign on my clinic door saying “one complaint per visit, please.” Fee-for-service must go.”
We began this study with the simple intention of measuring preferences for practice and payment type among recently graduated family physicians in BC, with the hypothesis that younger GPs…
“…have been taught in the new culture of improved patient-centered [care]… and I thus require an innovative way of receiving remuneration for my work. Family medicine in modern times requires alternative models of funding.”
Although we began with a simple 10-item survey to take the temperature on this issue, 82 doctors poured their hearts out when given the option to “explain your choice” of answer.
These physicians issued a compelling call for choice to set up practices that would allow them to practice more complex and comprehensive care, take more time with patients in need, and minimize frustration associated with billing while facilitating better quality of patient care. 86% of respondents identified payment model as “important” in their choice of future practice, 69% wanted to work in a collaborative team practice with other physicians, and 53% wanted to work in an interdisciplinary clinic with other health providers and supports for patients. But what stands out is the numerator: 93 young family physicians who responded to our survey want to open practices in BC, but not in the FFS model. These results echo other research telling the same story.
But unlike other provinces and countries moving towards “medical homes”, this concept of collaborative, interdisciplinary, alternately funded primary care is not what we’re buying in BC, where FFS remuneration encourages a walk-in style of practice:
“Right now it pays to see as many people as possible regardless of the quality of care given. It literally pays to practice poor medicine.”
“I have worked as a locum in a variety of family practice and walk-in settings and, now, as a permanent family doctor in a rural full-service family practice. I was always amazed to find that doctors who saw less complicated patients, spent less time with patients, and who discouraged consistent follow-up actually made the most money (i.e. easy patients = more patients/day = more $$). On the other hand, physicians who had complex patient loads emphasizing comprehensive care and continuity often billed far less, as they simply didn’t have the time to see the same volume of patients. The usual FFS model encouraged high volume, low accountability practice (i.e. bad medicine).”
And it’s not just doctors shedding light on the downside of FFS. In a focus group conducted by UBC family practice residents in 2012, patients spoke up:
“Sometimes they’ll just shove me in the room… My doctor is the 1 problem [per visit], that’s it, that’s all, like 10 minutes. So if I’ve got an earache and want to follow up on tests, I’ve got to make another appointment.”
Similarly, “Definitely they don’t have time to deal with more than 1 or 2 things. If you have a large variety of problems – and I’m on disability, both mental and physical – you are toast. It’s almost like you’re too difficult a patient, too demanding. If a doctor becomes frustrated or is showing annoyance, as a patient it impacts on you and it’s breaking the bond of trust, and understanding, and empathy… The burden of managing the relationship between you and the doctor shouldn’t be on the patient.”
Yet there is enormous reticence to talking about funding models. This avoidance is perpetuated by a similar reticence to talking about inequities in doctors’ wages, and how much doctors should get paid. The Vancouver Division of Family Practice cancelled the remuneration task force called for by its membership, citing that alternate funding options were too big of an issue to tackle. All of our eggs are in the basket of the BCMA’s FFS Attachment Initiative, detracting from movement towards alternate funding options, especially those capable of serving patients with multiple barriers who are high users of the system. Research from Ontario has shown us that salaried providers working in Community Health Centres provide the best care for these patients. In Michael Rachlis’ 2004 book, A Prescription for Excellence, innovation goes hand-in-hand with alternate fee models. Specifically, on pages 351-352, he outlines a graded salary structure based on physician experience. This model was supported by physicians, would save the system money, reduce inequities between specialties, and facilitate the kind of carrot-free funding that fosters motivation and public innovation.
But doctors want to preserve their autonomy, avoid bureaucracy, and don’t mind the carrot incentives:
“In locums thus far, I have billed an average of $1100/day FFS as opposed to receiving $800/day in sessional fees. Thus, as a new graduate with significant debt, there is a strong incentive to practice FFS, even though this leaves me feeling frantic, and with 4–6 hours of leftover charting and paperwork to do by the end of a typical 35–40 patient day.”
However, doctors who are driven by money, high overhead, or frustrated by the lack of innovative practice opportunities are increasingly turning to for-profit clinics like Copeman and a multitude of others, where they can be free to innovate, make their own rules, and restrict their practice to the wealthiest and healthiest patients. The creeping normalization of for-profit clinics is pulling doctors out of the public system, and tax dollars away from health care and towards legal challenges.
In the last ten years, Ontario has moved towards alternate funding in one of the largest known primary care transformations. Although imperfect, it had positive effects of significantly increasing medical student enrolment in family practice residencies and reducing the province’s family doctor shortage. Research has shown how this primary care transformation could have been more cost-effective and equitable, but we have the ability to learn from this example to implement more effective reforms in keeping with robust evidence for alternately funded medical homes.
However, fears of increasing costs and lazy doctors are preventing us from doing so. Instead, we are following the juggernaut of FFS remuneration that incentivizes more service, not necessarily better care. We should not remain trapped in FFS because of the illusion of outcome tracking provided by its billing records. Doctors can always provide more services if we pay them to do so; rather, we need to give them space to think and deliver the right service to the right patient, including education and prevention; “…this is the art and beauty of medicine.” Choosing wisely campaigns in the US and Canada support this trend.
In recent years, insufficient growth in the BC budget has been outpaced by population growth and inflation, meaning that we have less money on the table to work with towards innovation that will pay off in the longer term. This lack of forward thinking reinforces the increasingly inadequate status quo. In this context, if we go to the community for advice and put their needs on the table, we have to be able to address them with innovative policy. Not to do so breaks one of the basic rules of ethics in medicine: don’t look for for a problem unless you have the ability to address it. If we do so with openness to reshape our model of practice and put patients at the centre, we can see tremendous success. If we don’t, then patients may be left wondering whether community engagement initiatives mean anything, if they still don’t have a family doctor at the end of it all.
You don’t need to pay us more, but by paying us flexibly and allowing room for innovation, you may see 93 more family doctors ready to open a practice in BC.