Dr. Ryan Herriot, Dr. Steven Persaud, Dr. Rannie Tao, and Dr. Stephanie Stacey are Resident Physicians in Family Medicine at St. Paul’s Hospital, UBC Faculty of Medicine
As family physicians in the first stage of our careers, we look forward to practicing medicine in a world that would be unrecognizable to our predecessors: a world where all patients have access to dedicated “primary care homes,” where multidisciplinary care is the norm, and where siloed, fee-for-service practice no longer predominates.
Therefore, we are very happy that Vancouver’s City Council has voted unanimously to support the continued and expanded provision of multidisciplinary primary care at Vancouver’s Community Health Centres (CHCs), which are vital to the future of frontline health care in this province. However, several of these Centres are facing funding cuts under a plan put forward by Vancouver Coastal Health (VCH). VHC is adamant that their plan is a rational one that will shift resources away from low-needs patients towards high-needs ones. We feel, however, that this a classic example of “robbing Peter to pay Paul.” Many patients will be forced into inferior care models and many “high needs” patients will be forced to travel great distances to a single “super clinic” being created at one CHC, Raven Song. We are not alone in this view, as many patients and doctors have mobilized to oppose this misguided reorganization.
British Columbia’s CHCs have been around in some form or another since at least 1969. They are currently the only interdisciplinary team model we have. Dieticians, nurses, counselors, pharmacists, and many others work together to provide the comprehensive care that a solitary doctor simply cannot provide alone. Physicians who work at the clinics have typically been paid either a salary or a sessional rate – in contrast to the traditional fee-for-service payments that dominate physician compensation in the province. These alternative payment models help to emphasize quality of care over quantity.
The B.C. Ministry of Health, in its February 2014 Service Plan, highlights “a provincial system of primary and community care built around inter-professional teams” as a priority objective. VCH gets its funding (and priorities) from the Ministry, therefore the Ministry has clearly chosen to not put its money where its mouth is on this issue.
Primary care researchers in the province have noted that many jurisdictions including British Columbia are facing a family physician shortage, and that many young physicians are choosing to work in walk-in clinics for extended periods of time, rather than taking over the practices of retiring doctors. When surveyed, however, new doctors in British Columbia express a strong preference to join a full-service practice if they could do so under a non-fee-for-service regime. In fact, 71% of new grads expressed this preference in a comprehensive 2012 survey. This is because they feel that non-fee-for-service forms of physician compensation allow them to deliver higher quality patient care.
In our opinion, many patients and doctors are not truly satisfied with the traditional “meat grinder” of one problem per visit, at an average of seven minutes per appointment. This model serves no one well. It does not allow us to practice to the best of our abilities and it does not allow patients to have a meaningful role in their own health care or to access the services they need in a timely manner. It shifts too much of the burden of care onto more expensive specialists and neglects good coordination of care.
Critics will argue that CHCs cost more than traditional fee-for-service care, but this is a short-sighted assertion that ignores the evidence. While CHCs definitely do involve more up-front costs per patient, access to flexible appointments and to the right professional at the right time actually reduces emergency department visits, a far more expensive form of care. Research from Ontario also shows that patients attached to a fee-for-service practice are twice as likely to visit a walk-in clinic as those enrolled in other models. While the kind of definitive economic analysis that many would like to see has not yet been completed, we strongly suspect that the CHC model, as described, actually results in a net reduction of costs to the health system.
Moreover, the notion – put forward in internal VCH documents – that ”moderate needs” patients will be “stabilized” and then transferred to a fee-for-service practice is contrary to the underlying philosophy of family medicine. We know that when a good relationship is developed over time with one primary care provider, all health outcomes improve. Why sever this relationship by forcing many patients to travel further to a new doctor at the Raven Song “super clinic”? Why punish success by forcing patients who are now “healthy” to switch to a fee-for-service practice? Why punish doctors by forcing them out of a comprehensive care model that they love?
Other provinces have forged ahead into the realm of interdisciplinary care. For example, a large fraction of primary care in Ontario is now delivered by one of four different forms of team-based clinic. Alberta, for its part, is expanding the development of its “Family Care Clinics.” B.C. is now a laggard in this area.
Up to this point, our provincial government and the Doctors of B.C. (formerly the BCMA), acting through the Divisions of Family Practice, have been laudably attempting to find a medical home for a greater number of B.C. patients via something called the “Attachment Initiative“. It relies on a series of additional fees designed to entice Family Physicians to take on additional and more complex patients. While noble in intention, this initiative simply does not have the policy tools at its disposal to move our primary care into the 21st century. It retains many of the flaws of traditional fee-for-service by continuing to itemize care into “saleable units” and focusing resources on the isolated family doctor. It does nothing to encourage flexible, interdisciplinary care and it completely ignores the preferences of new family physicians. In addition, research suggests it’s not working. A very recent paper published in the journal Healthcare Policy suggests that these reforms, initiated in 2002, do not appear to be meeting their stated aims, with an overall decrease in measures such as access, continuity and coordination of care.
Further, the auditor general of B.C. recently released a damning report, castigating the B.C. government for contributing $1 billion of new money into this fee-for-service system, without actually tracking the quality of the output in terms of patient care.
It’s time for a new approach.
As future family physicians of B.C., we urge the Ministry of Health to follow the lead of City Council by adopting wholehearted support for the CHC model and providing funding to preserve and promote this type of care. It is better for patients, it is cost-effective in the long run, and supports the needs of the modern family doctor. This is truly where the health system can and should be going.
Thank you for your important questions, Carmen. It is important to note that the Community Health Centres we describe are not hypothetical, they are extant sites of primary care delivery in B.C.
For more general info, I suggest you check out the B.C. Federation of Community Health Centres: http://www.bcfchc.ca/
They may be able to answer specific questions as well.
Up to this point, CHCs have been funded with block grants from our local health authority, Vancouver Coastal Health. Many doctors, however, will no longer be paid this way but will instead be forced into the Fee for Service system. To the best of my knowledge, most CHCs in Vancouver have a “sessional” system, not unlike a shift work schedule, that is filled by both regular and locum Family Doctors. There is no call requirement (just as there is no call requirement for most Family Doctors who do not practice obstetrics). I don’t believe there is any benefit package associated with the positions. Generally, the docs who work there see their own patients, although from what I’ve witnessed they often informally assist other professionals with “hallway consults” as required. Often there are quick “team meetings” where it might be discussed that patient x would be best served by accessing service y, which might be delivered by a Family Doctor or might not.
I still don’t know how these clinics will be funded. How much ‘on call’ the FP’s associated with these teams/clinics will have to provide. Will the FP’s get the same benefit packages as the support staff and other team members? Will FP’s have to take on a consultant role for the other team members (pharmacists and Nurse Practitioners in particular) .
Having been a psychiatrist for 40 years and having practised in both models I would certainly advocate for an option of a community based multidisciplinary model for more timely and effective health care. I believe that our negotiation team at BC Dooctors needs to re-evaluate their priorities to get better long term outcomes for our patients and from our health dollars total expenditure.