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Are band-aids the right Rx to save family medicine?
Public
The $118 million announced consisting of $75 million new money plus redistribution of existing funds as a "stabilization fund" is an interim measure, a one-time handout over 4 months October 2022 to Jan. 31st, 2023, to help family physicians (FP) in the community, both longitudinal practices and walk-in clinics with overhead costs to keep their doors open until January 2023. This first step is intended to buy more time for the government and DoBC to develop a "new payment model" that will be introduced and implemented. According to DoBC President's letter, the new model will be based on compensation determined by a number of factors including time, patient encounters, and attachments/complexity.
Band-aid solution
Is a temporary band-aid the right intervention to stop the massive hemorrhage of burned out FPs providing comprehensive longitudinal care, when the root causes of the systemic disease have still not been addressed?
This announcement was made through a News Conference in partnership between Health Minister Adrian Dix and DoBC President Dr Rumneek Dosanjh.
While BC doctors as members were asked to provide their input through engagement sessions in July, they were not consulted about the agreement that was struck between the BC Government and DoBC. Not all DoBC members received the President's letter in an email after the announcement that they learned about through the media.
Of concern is the negotiations process of DoBC working in a collaborative relationship with the BC Government that is making funding and policy decisions without the knowledge or consent of BC doctors as DoBC members. The Physicians Master Agreement had expired in May 2022, and these negotiations are now being conducted outside of the PMA process that would normally require ratification through referendum vote by the DoBC membership.
Ignoring the disease: Politics trump Medicine
What are the implications of this approach of announcing new funding that may placate doctors and the public while helping the government to score political points?
Is this buying more time for the government to implement their agenda of replacing independent family physicians working under FFS with employed workers in a "team-based model" under the control of MOH and health authorities? This is not a conspiracy theory, but the writing on the wall based on the BC Ministry of Health primary care strategies, "Primary and Community Care in BC: a Strategic Policy Framework (2015)" and "Implementation of the Integrated System of Primary and Community Care" (Dec 2017).
This strategy of dealing with the serious FP crisis in BC through a parallel process outside the stalled PMA enabled the BC government to push FP Contracts by directly approaching the "New to Practice" (NTP) family physician graduates to sign 2 yr contracts with Health Authorities. These contracts are in direct competition with the community family physicians who are already struggling due to the low fees to recruit new FP graduates to join their practices or to provide locum coverage to relieve family doctors for vacation, illness, maternity leave, etc.
Health Minister Adrian Dix has said to the media that he wants to significantly reduce "fee-for-service" (FFS) to alternate payment models. The majority of self-employed family physicians as independent contractors work under FFS fees that have not increased substantially for two decades and have not kept up with inflation and rising overhead.
The good ol' family doc now becoming extinct is dying of strangulation, but can be easily saved by the government simply loosening the noose under the current system - pay reasonable fees that compensate the FP for the time that's necessary to care for our aging population with complex, multiple problems under the public system. Instead of fixed office fees of about $32-45 that pay for 5-10 minutes, MSP can pay for eg. 20-30 minutes that the patient needs rather than requiring the doctor to absorb the rising costs.
The independent FFS family doctors office closures are caused by low MSP fees imposed by successive governments for decades, which does not keep up with inflation and rising overhead. And now both new and experienced family doctors are quitting or retiring en masse because they "cannot take it anymore."
But it doesn't have to be this way.
The Cure
The right prescription for the family physician crisis is to fix what's broken, don't fix what's not broken.
Addressing the root causes of burnout and office closures - chronic devaluation of family physicians that are driving good doctors out of business - will also alleviate the symptoms of MD burnout and increase retention and recruitment of family physicians to practice high quality, full scope medicine as the cure to deliver primary care for the whole population.
Instead of paying family doctors as the foundation of the health care system, the BC government strategy has been to pour funding to build Urgent and Primary Care Centres (UPCCs) across BC (now 59 to 100 next year) that does NOT provide longitudinal care. As part of Primary Care Reform, the government is investing in a new model of primary care with teams of allied health professionals and Nurse Practitioners (NPs) to replace family doctors.
In sum, the generation of family doctors that have propped up Canada's health care system with their personal sacrifices for decades have reached retirement age, while new graduates are fleeing family medicine to choose other careers with higher pay and better lifestyle.
The question is what are the right systemic interventions to save family medicine now approaching the moribund stage as the foundation of a collapsing health care system after 3 decades of neglect?
Many physicians who have experienced inadequate representation by provincial and national medical associations have lost hope and are leaving BC or exiting medicine to save themselves. Will doctors trust the government and DoBC to keep working as indentured slaves and continue to be told how they should practice and should be compensated without choice under the public system? Who can be trusted? Are doctors finally saying enough is enough, and will they use their power to stand up for themselves and for patients?
Not forgetting that doctors are human, and we are all patients.
Caroline Wang
Groups:
Do we know what needs to be fixed?Public
The problem for a few years in BC medical is that FPs have been exercising control by walking away. Good. The government only pays attention when the pressure from the public gets really high. Now is a time for advocating & negotiating for a better deal. The trouble is do we know what needs fixed. Not everyone will initially want to be involved in that, it takes all types.
Money alone will not cut it. I think we are going to need a separate overhead calculation. Blend of salary or per diem + FFS. Tame the electronic info barrage. Preservation of time-off. Locum roster?
Hopefully this is the startPublic
Hopefully this is the start of a much longer discussion: and one that involves those involved with the CMA and BCMA.
Not a day goes by now without comment in the media to the effect that the Health Care system in Canada is in crisis.There was a long article in the Saturday National Post by Conrad Black for instance. For once he actually made some sense.
The worst thing that could happen would be some further tinkering at the edges - or band aids. The concept of universal health care needs a fundamental re-appraisal from the bottom up. I would suggest that a road map might look something like this:
1. We ask ourselves (as a society, as a nation), what public health care should look like in very general terms. Not just what we are lookig for, but what are we trying to avoid. The general question should be very broad: for instance, what do we need to do for the frail and elderly? What do they deserve? What should be the personal responsibilities of the citizens in their usage of a 'precious' resource? Should some behaviours be rewarded (e.g. maintaining a healthy body weight and engaging in an exercise program?) Should other behaviours be penalised (smoking, alcohol, reckless self endangerment in sport?)
2. Next we might look at levels of access. Should citizens be required to contribute towards the cost of 'non-essential' services? (Yes, yes, I know that defining non-essential is a potential minefield, but that's no reason to avoid it!)
3. Do we need to take a closer look at the type of people who enter both the medical and nursing professions? Is technical competence in study and execution a sufficient criterion? Should we focus on attracting individuals whose patterns of thinking tend to be innovative as well as disciplined? (The profession needs to progress within certain desirable parameters such as 'evidence' based practises?)
If we went back to the drawing board to create a public health care system, where would we start?
Chris,
Family Practice renewal - Rx for quality and sustainabilityPublic
This is a conceptual model that I developed with other physician colleagues as ideas for innovative payment reform to revitalize family medicine as the foundation of a high quality health care system, and strategy to achieve the quadruple aim.
“Proposal for Renewal of Family Practice: Blueprint for Quality and Sustainability” was written as input for the DoBC Negotiations in January 2021, and presented again more recently to Dr Rumneek Dosanjh, DoBC President in a zoom meeting.
Innovative ideas are needed to solve the crisis in family medicine and to save our health care system from collapse, starting with a robust and ongoing dialogue on potential solutions for transformation of our health care system.
I hope to hear your thoughts.
Caroline Wang
A couple of days ago one ofPublic
A couple of days ago one of our dogs developed a severe limp, and even went off her food - highly unusual for her. So yesterday I took her to the vet - was able to get an appointment the same day - and watched as he did a thorough and methodical examination. Just as the rule is for humans he carefully examined the joints above and below the suspected site of injury (the knee) and the foot pad; and of course compared with the opposite limb; and finally took her temperature. He guided my hand to the slight puffiness around the knee capsule and tried to demonstrated a draw sign (negative). She had a minor cruciate injury. No imaging needed: just good clinical skills.
He prescribed the usual anti-inflammatory (Metacam).
I was more than happy to pay his bill of $160 for a less than 20 minute consultation. In fact it was a bargain.
Now why aren't MDs paid at least that for an equivocal consultation?
Chris.
PS - today my doggie had a nice walkies almost without any sign of antalgic gait.
AddendumPublic
I should just clarify: the payment mentioned was for consultation fee and prescription combined. By itself the consultation fee with the vet was a mere $85.00. The amount currently paid to family doctors for exactly the same consultation is $31.72 ...
Does the rest of the BC population know this?
Chris.
PS: I imagine the vet also makes a mark-up for selling the medication, which BC doctors are not allowed to do (nor would they want to.).
More of the samePublic
We tend to forget that every system is perfectly designed to get the results that it obtains. A system that rewards volume and not results gets the problems we now face. Perhaps we need to develop better problems.
Doing the same thing harder isn't going to make things better. I'm speaking both as a physician and as someone who has had more than a passing aquaintance wth service received.
In my view, fee for service should be taken behind the barn and given a lead injection. Band-aids aren't going to work. Bigger fees aren't going to work. And our cottage industry medical system isn't going to work either. As a patient, the only thing I care about is results. And I have to tell you that the results aren't that great.
So, let's talk about how to get better patient centred results. We sure as hell aren't getting them now with a system that encourages one problem, one visit. Do we imagine that patients have nothing better to do than see us?
I'm going to suggest ending payments to individual doctors, and instead paying health networks. Just for a starting point, let's say that we'll pay the network (GPs and Specialists) 80% of previous FFS earnings. Each network will need to sort out how much each individual is paid. But the thing here is that we don't care if service is delivered by a MD. The network could hire dieticians, social workers, psychologists, physios, plumbers - anyone who could help improve health outcomes.
So what about the remaining 20%? It would be paid in bonuses to networks that achieved improvements in the health of the population served. In this model, there would be more potential for improvement to the health of the downtown east side than West Vancouver, so we might actually see resources flowing to areas of need.
But this is just the view of someone who has personal experience in what it's like to be a patient. Ignore me if you want, but I vote.