The B.C. government announced last month it's 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 a number of experts for this story to shed light on the current fee-for service model and what's being developed.
What can be expected from the new model?
Dr. Ramneek Dosanjh, president of Doctors of BC, says the new model will address the rising business costs of running a family practice.
“We're hoping that this new payment model would help mitigate [rising costs], to meet operating costs, but also to ensure that [physicians] are recognized for the extra time spent on complex-care patients and for the time they spend on administrative work right now that they're doing, without pay, often into the evenings,” she said.
The new model is slated to be revealed between October 2022 and January 2023.
In addition to announcing a new compensation model on Aug. 24, the Ministry of Health and Doctors of BC said there will be a $118-million investment to cover the costs of overhead. That adds up to $25,000 per physician.
The new model hopes to compensate physicians better for time spent with patients, Dosanjh says.
According to Dr. Rita McCracken, a family physician and assistant professor at UBC, prioritizing time spent with patients within B.C.'s fee-for-service system has been attempted with "time modifiers" — a term used when a physician is billing for a more complex-care patient that may take up more of the physician's time.
She tells Glacier Media time modifiers are also used in Alberta's health-care system; however, McCracken says "we are still seeing more family doctors leaving Alberta and coming to British Columbia."
"By a significant factor,” she said, referring to data from the College of Family Physicians of Canada.
According to McCracken, in 2000, B.C.'s General Practice Services Committee introduced bonus codes that physicians could bill under for people who have specific chronic diseases. These bonus codes would account for the extra time needed to review and apply care.
“There was no change to the outcomes for patients, so there was no reduction in the number of times those patients went to hospital, there was no change in their mortality. We also saw that physicians got paid more and that physicians saw fewer patients,” she said.
She adds there is a “mountain of evidence” showing that bonus codes in a fee-for-service system does not improve patient access.
A 2016 analysis also shows that when incentive payments were used to compensate doctors for complex patient care, there was no improvement on primary access or continuity.
"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 model for physician payment in B.C.
Despite its wide use, many physicians have qualms about how the model is structured and its emphasis on the physician to run the business of a family practice.
“The underlying issue is that all primary-care infrastructure is funded via physician payments,” she said. “That is equivalent to saying... if we were to graduate teachers and say, ‘Hey, here, we're gonna give you a chunk of money, per lesson, per student, go out and start a school.’ That is fee for service.”
Fee for service encourages physicians to see as many patients as possible while also keeping up with other aspects of running a business such as administrative work.
Under fee for service, physicians are viewed as self-employed professionals who are responsible for 100 per cent of the costs to run the practice. These overhead costs account for roughly 30 to 40 per cent of a physician's pay, according to McCracken.
Dr. Anthony Fong, an emergency physician and locum family doctor for rural areas, says that billing under the fee-for-service system is “stressful.”
Locum physicians 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 has come across: fee for service and the alternative payment plan (APP), though fee for service is the most common.
APP includes service contracts, sessional contracts, salary agreements, and in some cases, population-based funding and pay-for-performance arrangements, according to a Doctors of BC backgrounder on payment models.
“For my 15 years of practice in family medicine and emergency medicine, my overwhelming opinion is that fee for service is not desirable,” he said. “It's a system where I'm worried about seeing enough patients to pay the bills.”
For physicians in rural areas, fee for service can cause stress when a family physician requires time off. They are then required to find someone who will 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 keep on paying their overhead while taking time off,” Fong said.
What do physicians want in a model?
McCracken says that a new model needs to have evidence and informed focus groups that will ensure the application of the model has productive outcomes.
“We need to be providing something that is going to work for the system and that's going to work for the citizens of British Columbia, not for small interest groups of physicians,” she said.
In addition, she hopes to see a metric that will analyze how the model is affecting patient access to care.
“How preposterous is it that in this completely crumbling system, that we don't have a metric that we can use to say things are getting better or things are getting worse,” she said.
Up until 2019, a federally funded health-care survey collected data on how many Canadians had access to primary care or a family physician. Now, the data used to understand how many physicians there are is complicated, says McCracken.
For Fong, a new model needs to prioritize the rising costs of living and running a family practice.
“The elephant in the room is that if the government does choose to preserve the fee-for-service system, it's got to be said that the billing codes for family doctors have only increased 3.2 per cent over the last five years,” he said.
The billing codes themselves are not accounting for inflation or the rising cost of rent, he says.
“There's tons of people still choosing family practice. They're graduating, saying, 'I want to provide longitudinal community-based care.' And then we don't provide them a job that allows them to live as a human being,” McCracken said.