The BC government announced last month that it is working on a new physician compensation model, expected to be unveiled later this year. For many British Columbians, this is just another piece of the primary care puzzle. Will the changes have an impact on how patients receive care? Glacier Media interviewed several experts for this story to shed light on the current billing service model and what is developing.
What can we expect from the new model?
Dr. Ramneek Dosanjh, president of Doctors of BC, says the new model will address the increasing business costs of running a family practice. “We hope that this new payment model will contribute to the mitigation [rising costs]to cover operating costs, but also to ensure that [physicians] they are recognized for the extra time they spend on patients with complex care and for the time they spend on administrative work now that they do, without pay, often late into the evening,” he said. The new model is expected to be presented between October 2022 and January 2023. In addition to announcing a new reimbursement model on Aug. 24, the Ministry of Health and Doctors of BC said there will be an investment of $118 million to cover overhead costs. That adds up to $25,000 per doctor. The new model hopes to better compensate doctors for the time they spend with patients, Dosanjh says. According to Dr. Rita McCracken, a family physician and assistant professor at UBC, prioritizing time spent on patients within BC’s fee-for-service system has been attempted with “time modifiers” — a term used when a doctor charges for a more complex — Care for patient who can take up more of the doctor’s time. He says at Glacier Media time modifiers are also used in Alberta’s health care system. However, McCracken says “we’re still seeing more family doctors leaving Alberta and coming to British Columbia.” “By one major factor,” she said, referring to data from the College of Family Physicians of Canada. According to McCracken, in 2000, BC’s General Practice Services Commission introduced bonus codes that doctors could bill for people with certain chronic conditions. These bonus codes would account for the extra time required to review and apply care. “There was no change in patient outcomes, so there was no reduction in the number of times these patients went to hospital, there was no change in their mortality. We also saw that doctors were getting paid more and that doctors were seeing fewer patients,” he said. He adds that there is a “mountain of evidence” showing that bonus codes in a fee-for-service system do not improve patient access. A 2016 analysis also shows that when incentive payments were used to reimburse physicians for complex patient care, there was no improvement in primary access or follow-up. “Policymakers should consider other strategies to improve care for this patient population,” the study said.
An outdated model in a changing system
McCracken says the current fee-for-service model is the most widely used physician payment model in BC. Despite its widespread use, many physicians have misgivings about how the model is structured and its emphasis on the physician running a family practice business. “The underlying issue is that the entire primary care infrastructure is funded through physician payments,” he said. “That’s the equivalent of saying … if we graduated teachers and said, ‘Hey, here, we’ll give you a chunk of money, per subject, per student, go out and start a school.’” That’s fee-for-service. “ Fee-for-service encourages doctors to see as many patients as possible while juggling other aspects of running a business, such as administrative work. Under fee-for-service, physicians are considered self-employed professionals who are responsible for 100 percent of the costs of running the practice. These overheads account for about 30 to 40 percent of a doctor’s fee, according to McCracken. Dr. Anthony Fong, an emergency and family physician for rural areas, says billing under the fee-for-service system is “stressful.” Local doctors act as a substitute for family doctors in areas that are either underserved or require someone to fill in. He says there are two payment models he’s come across: fee-for-service and alternative payment plan (APP), although fee-for-service is the most common. The APP includes service contracts, session contracts, salary agreements and, in some cases, population-based and pay-for-performance funding arrangements, according to one of BC’s Physicians for Payment Models. “In my 15 years of practicing family medicine and emergency medicine, my overwhelming opinion is that fee-for-service is not desirable,” he said. “It’s a system where I worry about seeing enough patients to pay the bills.” For physicians in rural areas, fee-for-service can cause stress when a family physician requires leave. They are then asked to find someone to cover for them in an area that may already be underserved. “These family doctors are usually desperate to have locum coverage because that’s the only way they can continue to pay their overhead while they take time off,” Fong said.
What do doctors want in a model?
McCracken says a new model needs to have evidence and informed focus groups that will ensure the model’s implementation has productive results. “We need to provide something that will work for the system and work for the citizens of British Columbia, not small interest groups of doctors,” he said. In addition, he hopes to see a metric that analyzes how the model affects patient access to care. “How absurd it is that in this system that is completely falling apart, we don’t have a metric that we can use to say things are getting better or things are getting worse,” he said. Until 2019, a federally funded health care survey collected data on how many Canadians had access to primary care or a family doctor. Now, the data used to understand how many doctors there are is complicated, McCracken says. For Fong, a new model must prioritize the rising costs of living and running a family practice. “The elephant in the room is that if the government chooses to keep the fee-for-service system, it has to be said that billing codes for family doctors have only increased 3.2 percent over the past five years,” he said. . The pricing codes themselves don’t account for inflation or the rising cost of rent, he says. “There are many people who still choose daily practice. They graduate saying, “I want to provide community-based chronic care.” And then we don’t provide them with work that allows them to live as people,” McCracken said.
