I had a patient recently go to the Emergency Department (ED) for a pregnancy test! It was a very expensive pregnancy test…not for her, but for our health care system. The cost of this test came out of my pocket and yours. I reflected about how and why our patients use the ED and the unfortunate state of our health care system.
The ED has replaced general primary health care for some. It’s a costly shift. Amidst the array of reasons for this is because the general public does not have access to the primary health care providers they desperately need and want. One of the root causes is the fee-for-service remuneration of family physicians. The BC Auditor General has finally revealed the reality of this backwards system and concluded what we already know - it’s not value for service.
Every day I hear complaints from patients who go to walk-in clinics for their regular care. They have no other choice. They express frustration at not being listened to, being rushed and not getting the services they need. I see these patients going from clinic to clinic trying to find someone who will listen to them for more than five minutes. This leads to duplication of services with every visit and repeated lab work, imaging and consultations - a cost to our health care system but money in the pockets of these physicians. Where’s the motivation to change?
Patients are consistently surprised to learn that walk-in clinics are actually businesses. I explain to them that these physicians are forced to prioritize business (aka making money) over quality health care. It’s why the patient is rushed in and out. More patients = more money. The fee-for-service model does not motivate physicians to take the time to listen and educate and provide high quality care. These aren’t bad doctors, they are trying their best within an inadequate system. The general public doesn’t realize that in order for the doctor to spend the time to provide the quality care that patients need and deserve, the physician personally loses money. Patients aren’t informed of the personal costs to an individual physician that are associated with running a clinic. The care is “free” for the patient so they accept mediocre service and continue to visit the ED because their needs aren’t met. This is the reality of supporting a fee-for-service primary health care system.
We build bigger and fancier EDs and put in “fast track” areas to manage patients who are more appropriate candidates for primary care. We pay big bucks for care for these patients…dollars that could be allocated to more appropriate services. Ever wonder why nurses are no longer present in physician’s offices? It’s because the fee-for-service model does not support the more appropriate interdisciplinary care. There is no direct funding for registered nurses to see patients in primary care offices. Every patient the nurse sees would be money out of the physician’s pocket. It forces health care to be physician-centric not patient-centred.
It is with hope that I read the Auditor General’s report. Will the public and government finally realize the ridiculousness of the current model? It’s high time the public finds out what “fee-for-service” actually means and how it affects the care they get. It’s also time we stopped forcing our physicians to be business people and allow them to get back to providing good quality care within a coordinated and comprehensive multi-disciplinary health service system.
It just makes good sense!
Click here to view the BC Auditor General’s Report Oversight of Physician Services
ABOUT HANNAH VARTO, MN, NP(F)
Hannah Varto is a family nurse practitioner and an ARNBC Network Lead. She enjoys working as a part of interdisciplinary teams of health care providers. Her career focus has been primarily in the field of sexual and reproductive health, specific to women and adolescent populations. She has worked in a variety of settings including public health, youth clinics, walk-in clinics, telehealth, education, travel medicine, communicable disease and as a sexual assault nurse examiner. Hannah is on the board of directors for the McCreary Centre Society, a leading non-profit organization focusing on adolescent health research. Currently Hannah is leading the implementation of ARNBC's first community of practice - the BC Contraceptive Management Community of Practice.
Having been part of the advisory group setting the legislative, regulatory and educational framework for Nurse Practitioners in BC (2002-2006), I know that this “sticky issue” of reimbursement mechanisms has plagued the implementation process from the outset. When the NP movement began in BC, with the enthusiastic involvement of the BC Government as part of its primary care reform initiative, there were widespread high hopes that primary care was on a path to being effectively aligned with other health services within the province’s health authority structure, and that fee-for-service GP practice would soon be a thing of the past. Little did we know how complex that particular puzzle would be to resolve, or how much intense resistance would be exerted to try to defend the status quo.
While it may seem bad form for nursing to comment on physician income, I’d like to make it perfectly clear that I am strongly in favour of paying them plenty. They play an immensely important role in the health service spectrum and deserve an excellent quality of life. What I strenuously object to is the mechanism by which that most of that reimbursement occurs. It forces them to set up a business model of care, responding to specific acts that are “incentivized” (which means you can bill for them) rather than the more holistic approach that primary care often demands. Because your income is directly tied to how many billable things you can fit into a workday, it creates a competitive model that inevitably leads to limits in time and access, rather than focusing your priorities on clinical need. Any of us would behave differently if only parts of what we believed were the right thing to do were tied to our income, and other parts (such as spending more time with the frail elderly who have multiple questions) were detracting from it. And I know that hundreds of fine family physicians in BC also want to get out of the business of administering their fee-for-service practices and go back into the world of doing what they came into medicine to do – putting their minds to finding creative solutions to the interesting clinical problems that come their way and serving their patients within a coordinated and functioning health care system.
There are many many GPs out there who have tried very hard to challenge and resist the current reimbursement model as detrimental to their practice and to their patients. We in the academic sector have certainly have seen how detrimental it is to clinical education (where’s the incentive to slow down your practice and mentor the next generation of practitioners?). And we know that it becomes a demoralizing way to work when you find yourself focusing on the reimbursable parts of the whole people who seek out your wisdom. No wonder so many have given up trying to offer continuity of care and have settled instead for the patchwork service delivery through the walk-in clinics. We can’t blame them when the option is so unpalatable.
It is important that, in speaking up now, nurses are not challenging our physician colleagues’ right to a good salary, or questioning the quality of the contribution they can make. We know first hand how valuable they are, even as we see them struggling to make a dysfunctional system work. We also know that those (relatively few) family physicians who have been able to bypass the mainstream fee-for-service delivery approach and find their way into integrated interdisciplinary practices LOVE that model. So we are not inflicting our distinctive nursing approach to care delivery onto theirs. There is plenty of evidence out there to demonstrate that fee-for-service models ARE the problem.
I think the time for politely waiting for change is over, and it is reasonable to speak out with a loud and collective voice. The physician bargaining unit (Doctors of BC, formerly known as BCMA, and specifically its GP Services Committee) has been far too closely integrated into government policy planning processes. This was made patently evident in the clear signals it sent out over social media and on its website in recent months leading up to this provincial budget that it was well aware of what the Ministry of Health Service Plan would contain (including, for example, its unfortunate position on nurse practitioners). This embeddedness of the bargaining unit with the policy process (which of course is entirely linked with the reimbursement model), combined with the dismantling of options for nurses and other health care professions to be welcomed into Ministry discussions, is the heart of the issue around which we need to galvanize discussion right now.
I deeply appreciate Hannah’s contribution to helping nurses understand why they really do need to care about how physicians get paid. It is a key policy barrier that we must confront – arm in arm with our professional partners in medicine and health care – and overcome.
Sally I agree with your comments whole-heartedly. I too think that physicians deserve to be well paid for the challenging and difficult work they often do. I'm saddened that they are prevented from utilizing their broad scope and advanced training by being part of the FFS system. Again, we need to look for the right professional, at the right time, for the right patients, at the right price.
Thank you Hannah for this thoughtful and provocative discussion. One of the foundational principles of all organizational changes is the rule that “structures drive behaviour”. It is in my personal view that the Province of BC is the orchestrator of these behaviours. As a Director of Home Health Services and who sees first hand multiple initiatives to decrease the use of our Emergency Departments (ED), such as the Integrated Health Networks (IHN), working with the General Practitioner Divisions, the spotlight continues to identify the lack of funding for Primary Care (PC), and Home Care, even though this is one of the “Key Result Areas” or KRA’s the province holds the Health Authorities (HA) to deliver on. This strategy has not been successful as acute care continues to gobble up the lion’s share of Health Authority (HA) dollars and in many cases is increasing. I wholeheartedly believe the fee for service methodology is fundamentally working against primary care and driving behaviours as you suggest to force clients into ED departments and non PC centers for basic health care. I believe Physicians, like nurses come to work everyday to provide excellent client care, however, they also need to feed their families. I believe we need Provincial leadership not only to review this ineffective fee-for-service methodology but to force the hand of HA’s to fund primary care based on a percentage of the provincial health dollars. This would take Leadership and vision.
Carl your points are well taken. Recently VCH congratulated it's ER staff for seeing increasing numbers of patients than ever before. I absolutely applaud the staff for their dedication and commitment but it got me thinking that perhaps we're looking at the issue backwards. Are there really that many more true emergencies? Should we be patting ourselves on the backs for seeing an increase in visits? As with you Carl, my career has been primarily in the community setting, and I see the dollars pouring into acute care for conditions that could have (should have) been prevented and treated in the community.
The issue of funding by health authorities is a trickier one. HAs are primarily set up to run acute care facilities, home care and public health services. The fact that HAs are taking on primary care services at all speaks to the greater issues of access - especially for the most vulnerable populations. The HA primary care clinics are specifically designated for vulnerable populations because they acknowledge that these people cannot navigate the 5 minute walk-in clinic FFS system and they were showing up at the ER instead. So, rather than reviewing how the current primary care system was failing the patients most in need of care, HAs set up their own clinics to keep them out of the ER. I believe the HA primary care clinics are an excellent example of how interdisciplinary care can provide for these patients and demonstrate excellent outcomes. Don't we all deserve this type of value for dollar care?
Incentive systems are no more than interconnected mechanisms to shape behaviours for the attainment of a particular goal(s) and they need to evolve because the value of the rewards and the goals change over time. For example, once people make a certain amount of money they are more motivated by intrinsic desires and FFS was invented during a time when prevention and promotion wasn't emphasized by the healthcare system. Therefore, rather than asking myself what is it about physician pay that isn't working, I prefer to ask what needs to be different to deliver us good health?
Thanks for your comments Ken. I appreciate you pointing out that we also need to look at solutions rather than just what is not working.
There are a number of models of remuneration that could be used, all with their own pros and cons. There are remuneration models throughout all job sectors including hourly, salary, capitation, commission-based etc. By examining the different models of funding and their individual pros and cons I believe we can come up with a system that meets the needs of the patients and also provides fair compensation. I believe, however, that we've come into a roadblock situation with the Ministry of Health because the physicians are the only ones sitting at the funding table. As Julie Fraser points out in her blog post, this is cause for even greater concern.
In my opinion, we need to look at solutions that meet the following three criteria:
1) The most appropriate health care provider for the patient.
This might mean that physicians, nurses, NPs, nutritionists, pharmacists etc work together. Allowing health care providers to work to their full scope of practice would also allow the physician to be utilized to their greatest scope potential and provide the best care possible for the patient. Instead of patients being allocated to only one provider, why not allocate them to a team of providers? They see the most appropriate person for their specific needs. Let's call the physicians who work as part of these teams "Primary Care Specialists" and pay them as such.
2) Pay based on utilization of training and scope of practice. If you are the highest trained/educated professional and managing the most complex patients then you should be paid higher than those who are less trained and seeing the less complex patients. One professional should not be paid more than another for doing the exact same task (ie. what is the difference between a physician providing a vaccination versus an NP versus an RN versus a pharmacist...why is there a cost difference at all?)
3) Quality patient outcomes. This is by far the most difficult to measure. However, it could be very simplistic to start: the more your team keeps the patient out of the ER for non-emergencies, the more your clinic makes (notice I said "clinic" and not the professional - a marker of team based care).
I welcome others to chime in with their thoughts and solutions.
Thank you, Hannah, for this timely blogpost and for stimulating the fascinating responses from colleagues as we reflect on the Auditor General’s Report.
During the past week many nurses have voiced their opinions about the B.C. Budget delivered on February 18 and, in particular, the Ministry of Health Service Plan for the next fiscal year. The comments in response to Julie Fraser’s recent blogpost and on ARNBC social media platforms tell us that nurses are paying close attention to these policy issues and have constructive ideas to bring to the ongoing conversations. Your comments are providing thoughtful analysis, examples from your practice settings and practical ideas for change. ARNBC will refer to your collective wisdom and important themes when communicating with the Ministry of Health.
Thinking about the urgent need for change in physician funding models in British Columbia reminds me of the unrealized potential to expand the community health centre (CHC) approach in our province. Sadly, we have lagged behind most other provinces and territories in implementing CHCs as a cornerstone of our health system. One of the key elements of the CHC approach is a core value of team-based care with all providers on salary or other similar remuneration mechanisms rather than on fee-for-service arrangements. The Ministry of Health along with leaders in our health authorities and health professions could be doing so much more to ensure full implementation of this model throughout the province. A good national resource on this topic is the Canadian Association of Community Health Centres: http://www.cachc.ca/
I encourage everyone to keep reading, listening to one another’s views and adding your voice to the conversation.
Thanks for your comments Nora.
The community health centre, family health team and NP-led clinics (such as in Ontario) all model excellent examples of how primary care can be delivered differently and from a team-based approach. I know a number of physicians who would be happy to work in a salaried position that includes benefits, mat/pat leave, vacation pay, sick leave and pensions...something the FFS model also does not offer the physician.
I'm intrigued as to the shift that has occurred, however, in the responsibility that HAs have taken in trying to fill the primary health care gaps by creating their own primary health care clinics (or community health centres). I think they are excellent examples of care, but does this not speak to the bigger issue that the most vulnerable patients in need of care are not getting it from the regular system - and why not? And why is it the responsibility of the HAs to fill this gap? Should we not be putting the responsibility for caring for ALL of the population back on the Ministry of Health and their system of primary health care and asking why these patients are not being cared for? If HAs are going to take over primary health care services, then the Ministry of Health also needs to acknowledge this shift in delivery of services and start to examine the model they currently have and the value-for-money it supports (or doesn't support).
Great post Hannah!
I agree wholeheartedly - just before I moved to BC (2005) many "Family Health Teams" were being set up, and I've heard the initiative has been expanded.
I'm intrigued by this idea and have long wondered why our CHC's, primary care clinics, and family practitioners weren't adopting something similar.
I've known so many people who have had to present to ED for something they knew wasn't appropriate for ED, but since they had no family physician or they were closed - they had no choice. And as you mentioned the HAs and MOH are throwing resources and initiatives at the ED's - rather than appropriately setting up alternate care settings.
I think this strengthens the need for a cohesive nursing voice that can help ensure that safe client care is kept in mind when setting up and hopefully revising our systems!
What a great discussion. Sally you have really summarized a very complex issue well. I work in a FFS practice as a salaried NP, paid by the HA. Our collaborative relationship has evolved and often been challenged by issues that arise from the FFS environment.
The FFS system drives everything in the office, when really patient care should be the driver. The Doc of BC in collaboration with the ministry have created many more monetary incentives to increase the pay for GP, such as complex care and chronic care fees. However these very costly fees may not be doing anything to improve outcomes for patients.
In fact it is likely costing the system much more with no accountability build it.
I welcome the AG report and hope it will shine the light on the HUGE amount of money being spent without any one asking what am I I getting for my 350.00 complex care visit?
Hannah thank you for sharing your view.
The public also needs to see their responsibility in the scheme of things. Pregnancy tests are neither urgent, nor a responsibility of a clinic or walk in centre. Anyone can conduct their own test, at home, with a home pregnancy test. For decades we have removed the patient from the costs ands ownership of health care and its costs. When you ask most people they say "its free"! I am all for providing a cumulative statement of expenditures made on behalf of patients in ever fiscal year. It gives many people something to think about, in terms of what the health care systems costs (its certainly not free), and it also is an audit of sorts to ensure that people are only being billed for treatments they actually had. Its not punitive, it is transparent.
Further to this I think patients would be interested to know what MSP is billed for when the patient leaves after their ten minute office visit. Ultimately it is the tax payer who pays. They should know what they are paying for.
J and Lori - I agree with both of you. Wouldn't it be interesting if we could all see a "bill" for how much we each spent in health care dollars each year? Would this change patient behaviours or simply provide education about the "free" services they receive?
So, how do we create public awareness of the costs of their health care? In my opinion, this is the only way that change will occur...when the public becomes informed and starts to demand value for service.
Nurses and NPs can continue to speak out as much as we like but we will continue to be seen as "self-serving" and in competition with our physician colleagues. Heck, we're not even invited to the Ministry of Health table to discuss it. It's becoming obvious that our cries are falling on deaf ears in BC.
It is the public who will need to demand change in order for change to truly occur.
Perhaps it's time to look at a public awareness campaign.
Healthcare has evolved since the day it began – indeed, in the early 1900s nurses administered anaesthetics in the U.S. until the anaesthetist profession was established in the 1930s, as a response to advancements in anaesthetic medicine (Cockerham, 2014). Healthcare should evolve to meet the changing needs of medicine, patient population, and health issues. So why does the government insist on pandering to just one group, namely Doctors of BC, when it comes to long-term planning for the health of all British Columbians? “Doctors of BC… has indicated that it supports nurse practitioner [NP] practice only when it is under the delegated authority of medicine” (Burton, 2014, para 4). The government plans to consult with the College of Physicians and Surgeons of BC regarding issues of NP scope of practice rather than NPs’ own regulatory body (Burton, 2014). Additionally, the government has discussed the introduction of Physician Assistants (PAs) to BC, which raises the question of why the government would move to implement a new healthcare provider when the current NP profession has not been fully and effectively established (Burton, 2014). Could the reason be that Doctors of BC has been pushing for PAs over NPs because PAs increase billings for GPs? After all, PAs (unlike NPs) work under GPs and we must assume their time will therefore also be billed using the fee-for-service (FFS) system. Is our healthcare system being determined by what does and does not benefit the GP’s FFS system?
Healthcare expenditure is continuously increasing. This increased rate of spending has not been met with improvements in outcomes (Fierlbeck, 2011). Fierlbeck (2011) notes that while Canada’s tax-based system for healthcare funding gives a centralized structure, the healthcare system itself is largely decentralized. Therefore, many factions of the healthcare system are not accountable for the outcomes they produce. Case in point, the physician FFS system finances medical care without stipulating any outcome-related performance expectations (Fierlbeck, 2011).
BC has the fastest growing population of seniors in Canada. That population is expected to double in the next 25 years (Ministry of Health, 2014). Additionally, there are increased rates of chronic health issues and mental illness (Ministry of Health, 2014). This should signify a need to shift away from acute care and towards multi-disciplinary primary care. I would like to assert that I do not believe any one healthcare profession is superior to others. I believe GPs, NPs, and PAs all have their unique strengths and weaknesses that, if used in collaboration with one another, would provide the best health outcomes for patients. Our healthcare system cannot sustain a GP dominated system. This is particularly true in regards to the FFS model, which essentially places more importance on number of patients seen and services provided, than it does to improved health outcomes.
The government needs to accept that times are changing. In order to both support and advance British Columbia’s healthcare system, we need to focus on improving the integration of multi-disciplinary health teams. Amendments to the pay structure of healthcare providers, in particular, the FFS system, are a key strategy to support this goal.
Burton, A. (2014, February 19). News release: Budget puts B.C. nurse practitioners in jeopardy. BC Nurse Practitioner Association. Retrieved from http://bcnpa.org/wp-content/uploads/2014/02/NewsBudgetFINALupdated1.pdf
Cockerham, A. Z. (2014). A brief history of advanced practice nursing in the United States. In A. B. Hamric et al. (Eds.) Advanced practice nursing: An integrative approach (5th ed.) (pp. 1-26). St. Louis, MI: Elsevier Saunders.
Fierlbeck, K. (2011). Health care in Canada. Toronto: University of Toronto Press.
Ministry of Health. (2014, February). 2014/15 – 2016/17 service plan. Retrieved from http://bcbudget.gov.bc.ca/2014/sp/pdf/ministry/hlth.pdf
Joanna - you make excellent points and I appreciate your references. A multi-disciplinary team in which each profession is both respected, utilized to their full scope and fairly compensated seems to make common sense. I'm continually baffled by the Ministry of Health's hippocritical stance on NPs (and integrating nurses back into primary care in general).
We need the right profession for the right patient at the right time in the right location for the right cost.
So how do we do this?
The recent report by the Auditor General of British Columbia on the Oversight of Physician Services brought to light some significant issues to the delivery and sustainability of health care services in British Columbia. The primary issue with physician services is that government is unable to demonstrate if the current physician remuneration system is cost effective, delivering good value for monies spent and that the services rendered are high quality (Auditor General of British Columbia [AGBC], 2014).
Physicians deserve to be paid fairly, many have given up years of potential earning capacity and significant financial investment to enter their chosen profession. However, as taxpayers and users of the health care system we need to know that the process of financial remuneration for physicians is cost effective, delivers good value and is equitable for all physicians involved (Lewis, 2008). In British Columbia the most common current remuneration models are the fee-for-service (FFS) and Alternative Payment Program (APP) (AGBC, 2014).
The FFS model has done a disservice to the medical profession, it rewards those that work with their hands and under rewards those who use their brain, for example the ophthalmologist who earns $1.5 million per year versus the GP who earns $320,000.00 per year (Lewis, 2008; MSC, 2012/13). Government bowing to medical organizations such as the Doctors of BC leads to perpetuation of financial agreements, incentives and policies that continue to promote the FFS model (Lewis, 2008). An example of this organizational control is seen when physicians in rural areas are not able to work on call 24/7, 365 days per year. Rather than utilizing nurse practitioners (NPs) or looking to group practice models, more money is given to continue working in the same manner because physician leaders claim the other solutions will not work (Lewis, 2008). Eventually this leads to physician burnout and the issues we see with retention of physicians in rural areas.
However, change is afoot as newly practicing family physicians whose education has included improved patient-centered communication will require longer interactions with patients requiring an alternative model of funding (Brcic, McGregor, Kaczorowski, Dharamsi, & Verma, 2012). These same graduates do not wish to be tied to the clock in providing quality patient care or limiting patients to one problem per visit, recognize that FFS needs to be replaced with models of funding that encourage primary care reform (Brcic et al., 2012). In addition new family physician graduates have also indicated their preference to work in interdisciplinary group practices (Brcic et al., 2012).
Collaborative practice models such as those that incorporate NPs do poorly under FFS as there is no compensation to the physician for the patients seen by the NP (Robinson, 2001; Donald et al., 2010). Frayne (2012) suggests the use of a fixed model of funding that is based on the illness burden of patients and their clinical outcomes. The model encourages illness prevention and motivation to keep patients well, as fewer office visits and hospital admissions means a greater profit to the practice. This links practice to quality of care which FFS does not (Frayne, 2012). This population-based blended funding model encourages the use of non-physician practitioners such as NPs. Practice benefits include increased capacity, decreased hospital admission rates, high patient acceptance, physician satisfaction and higher patient attachment rates (Frayne, 2012).
However, this population-based blended funding model, like the FFS model has no detailed cost benefit analysis. We return to the initial problem illustrated by the Auditor General report that we have no “hard” evidence-based data as to the value per dollar spent for healthcare. The Ministry of Health must begin to consider to practice outcomes data if we are to move forward in providing sustainable primary health care in this province.
Auditor General of British Columbia. (2014). Oversight of physician services. Retrieved from http://www.bcauditor.com/pubs/2014/report11/oversight-physician-services
Brcic, V., McGregor, M. J., Kaczorowski, J., Dharamsi, S., & Verma, S. (2012). Practice and payment preferences of newly practising family physicians in British Columbia. Canadian Family Physician 58(5), 275-281. Retrieved from http://www.cfp.ca/content/58/5/e275
British Columbia Ministry of Health. (2013). Medical Services Commission: Financial statement for the fiscal year ending March 13, 2013. Retrieved from http://www.health.gov.bc.ca/msp/legislation/pdf/bluebook2013.pdf
Donald, F., Martin-Misener, R., Bryant-Lukosius, D., Kilpatrick, K., Kaasalainen, S., Carter, N., . . . Bourgeault, I. (2010). The primary healthcare nurse practitioner role in Canada. Canadian Journal of Nursing Leadership 23(special issue), 88-113. Retrieved from http://www.longwoods.com/publications/nursing-leadership/22240
Frayne, A. F. (2012). Population-based funding: A better primary care option? British Columbia Medical Journal 54(5), 250-251. Retrieved from http://www.bcmj.org
Lewis, S. (2008). Spare the policy, spoil the profession. Longwoods Essays December 2008, 1-2. Retrieved from http://www.longwoods.com/content/20360
Robinson, J. C. (2001). Theory and practice in the design of physician payment incentives. The Milbank Quarterly 79(2), 149-177. Retrieved from http://www.milbank.org/publications/the-milbank-quarterly
Karen - you make some excellent points. One of the things I mentioned earlier in response to the comments was about how physicians are done a disservice under the fee-for-service model. This is something you touched on. Physicians in rural areas are set up for burn out - you're absolutely correct! Can you imagine being the only doctor in a rural town and never really having "time off". How would you balance family and work? Every person in the community is your patient. You run into them in the grocery store, in the local pub, at the park...everyone knows where you live and your business. You're never not the doctor. On top of this, the fee-for-service model does not provide for vacation pay, maternity/parental leave, pensions or benefits. I believe that many of the new graduate physicians value these things as well as a family-work-life balance and will struggle to find this in the current FFS model. So, it brings me to question, will it be the new physicians who create the change? Or, will these physicians simply seek alternate employment that better suits their personal life - such as sessional, alternative funding, private clinics or salaried work?
The fee-for-service (FFS) remuneration scheme is the most common method of payment for physicians in Canada (Blomqvist & Busby, 2012). This payment model is employed by approximately 40% of working physicians and makes up more than 90% of their total income (Blomqvist & Busby, 2012). Thiry-three percent of doctors are compensated through ‘blended’ systems, that is, a combination of two or more payment schemes (Blomqvist & Busby, 2012). Of these physicians, 45% also use the FFS model. (Blomqvist & Busby, 2012). About a quarter of Canada’s physicians are paid almost exclusively by a fixed salary, and only 1% receive most of their income by capitations (Blomqvist & Busby, 2012).
The manner in which physicians are paid is extremely important. It can influence their practice decisions by creating incentives for different approaches to patient care (Blomqvist & Busby, 2012). Under the fixed salary model, for example, physicians are paid a pre-determined amount, regardless of the quality of patient care (Robinson, 2001). Therefore, this system fails to encourage efficiency and productivity on the part of the physician. In contrast, a FFS scheme does provide incentives for productivity, however it often results in unnecessary referrals and repeat visits (Robinson, 2001). Additionally, since this payment method directly rewards the efforts of the individual, it can be a barrier to cooperation and team building (Robinson, 2001) This can then become challenging when integrating other primary health care providers, such as nurse practitioners into the health care system (Donald et al., 2010). Finally, the capitation remuneration model rewards the provision of inappropriate services as well as the continual referral of patients deemed too complex for general practice (Robinson, 2001). Care provided by specialists for patients that can be managed by a primary health care provider drives up healthcare costs and results in an inefficient system (Robinson, 2001).
What is the solution then, if none of these schemes encourages really effective patient care? Health care is complex, and to suggest a simple payment system would not reflect the multi-faceted nature of the discipline (Robinson, 2001). A blended method that can combine the advantages of individual payment schemes may be a viable plan (Donald et al., 2010; Robinson, 2001). For example, providing a base salary to physicians with added bonuses for increased complexity or illness severity would facilitate appropriate and yet effective care (Robinson, 2001). Another suggestion is fixed case rates for certain procedures, which would include both pre and post procedure care (Robinson, 2001). It is important to note that as nurse practitioners (NPs) continue to be integrated into the Canadian healthcare system, the problems with the aforementioned payment schemes will also be relevent to their practice. Therefore, suggestions for a combination of different compensation methods will likely be applied to NPs at some point, since they are also primary care providers. Donald et al. (2010) found that facilities using a blended model experienced a decrease in unnecessary admissions, as well as increased productivity and physician satisfaction. Regardless, the FFS remuneration model needs to be readdressed and a scheme blending two or more models may be the answer.
Blomqvist, A., & Busby, C. (2012). How to pay family doctors: Why “pay per patient” is better than fee for service (Commentary No. 365) Retrieved from website: http://www.cdhowe.org/pdf/Commentary_365.pdf.
Donald, F., Martin-Misener, R., Bryant-Lukosius, D., Kilpatrick, K., Kaasalainen S., Cater, N., Harbman, P., Bourgeault, I. & DiCenso, A. (2010). The primary healthcare nurse practitioner role in Canada. Canadian Journal of Nursing Leadership 23, 88-113. Retrieved from http://www.longwoods.com/content/22271
Robinson, J. C. (2001). Theory and practice in the design of physician payment incentives. The Milbank Quarterly, 79(2), 149-177. Retrieved from http://www.econ.canterbury.ac.nz/personal_pages/john_fountain/econ337/reading/RobinsonMQonIncentives.pdf.
The British Columbia Ministry of Health (MoH) 2014/15 -2016/17 Service Plan (2014) sends conflicting messages not only to the British Columbian public but also to its health care professionals. The Ministry of Health in 2012 revealed the Nurse Practitioner (NP) 4BC initiative and over the three years 2012- 2015 will fund 135 new NP positions in British Columbia (BC). In light of the NP4BC initiative, the NP role according to the BC MoH Service Plan (2014) needs to be expanded but under the guidance of the College of Physicians and Surgeons of BC (CPSBC). NPs are autonomous health care providers and are regulated by the College of Registered Nurses of BC (CRNBC) (British Columbia Nurse Practitioner Association, 2014). According to BC Minister of Health Terry Lake, NPs are part of the solution for residents of BC to have increased access to primary care and to be part of the interdisciplinary team that would include physicians and NPs working together (Canadian Broadcasting Corporation [CBC], 2014a). This statement is rather contradictory given that the aforementioned policy change in the Service Plan does not promote a healthy relationship between physicians and NPs. The CPSBC will now determine the scope of practice of NPs rather than the regulatory body of NPs, the CRNBC.
Interestingly enough a similar argument can be made about the BC Auditor General Russ Jones' comment that the BC government along with the Doctors of BC need to look at other funding models and not just the fee-for-service (FFS) model currently used in BC (CBC, 2014b). Why not include NPs in this conversation about funding models and for that matter other health care professionals too? Yes, physicians are an important part of the health care system but that does not and should not exclude other health care professionals from the conversation. I agree with BC Auditor General Russ Jones that in order to have cost effective and quality health care with a link to patient outcomes, the current funding model of FFS needs to be addressed (CBC, 2014b).
British Columbia Ministry of Health. (2014, February). 2014/15 – 2016/17 service plan. Retrieved from http://bcbudget.gov.bc.ca/2014/sp/pdf/ministry/hlth.pdf
British Columbia Nurse Pracitioner Association. (2014, February). News release: Budget puts BC Nurse Practitioners in jeopardy. BC Nurse Practitioner Association. Retrieved from http://bcnpa .org/wpcontent/uploads/2014 /02/NewsBudgetFINALupdated1.pdf
Cluff, R. (Canadian Broadcasting Corporation). (2014b, February 21). BC Auditor General report [Audio podcast]. Retrieved from http://podcast.cbc.ca/mp3/podcasts/bcearlyedition_20140221_12089.mp3
Cluff, R. (Canadian Broadcasting Corporation). (2014a, February 25). BC Minister of Health Terry Lake [Audio podcast]. Retrieved from http://podcast.cbc.ca/mp3/podcasts/bcearlyedition_20140225_32116.mp3
The thought that physicians have the ability to run their clinics as a business is disconcerting. When the system of health care delivery emphasizes monetary gain over the quality of care delivered, there is a problem. In the perspective of a health care professional, patient care should be the top priority. The fee-for-service (FFS) payment system used to reimburse the majority of BC physicians provides no incentive to base their practice on patient centered care. I agree with the thoughts in previous posts, I do not believe that physicians are lacking in wanting to provide the best care for their patients, the current system puts them at odds. As Hannah Varto has explained, when doctors are run as a business the emphasis is on making money and the current FFS system supports a “physician-centric not patient centered” (para. 4) approach to health care.
The FFS system rewards physicians for increasing the volume of patients seen in the least amount of time. The Auditor General of British Columbia (AGBC) (2014) acknowledges the fact that FFS system can decrease wait times but at the expense of the patient being limited to one issue per visit. This results in the need for more office visits. The more treatments and procedures the physician provides the higher the financial reward. The FFS system provides an incentive to accept relatively healthy patients who can be dealt with quickly and a dis-incentive to accept complex patients who would take up valuable time (Robinson, 2001). These factors highlight the need for a change to the FFS system to bring patient centered care into focus (AGBC, 2014).
The current FFS system does not allow for the application of interdisciplinary health care teams. When physicians hire other health care professionals to work in their office, the wage comes out of the physician’s profits. The current FFS model only allows for physicians to charge for services they carry out themselves, which inhibits their ability to work with a health care team (AGBC, 2014). Even though the inclusion of additional health care professionals would benefit the patients’ care and experience, it is not done because it would cost the business more money. “Not being able to bill for collaborating with PHCNPs (primary health care nurse practitioners) was reported to be a disincentive for physicians to work with them” (Donald, Martin-Misener, Bryant-Lukosius, Kilpatrick, Kaasalainen, Carter, Harbman, & Bourgeault, 2010, p. 102). I can appreciate why physicians, under the current fee for service system, are disinclined to work with nurse practitioners. They stand to lose money in such a system.
According to Donald et al. (2010) “a government interview participant commented that remuneration mechanisms need refinement to ensure fair compensation of primary health care teams and suggested a team-base approach to remuneration negotiations” (p. 102). There is a need for the refinement of physician payment schemes that promote more patient centered care, allow for being part of a multidisciplinary care team, and focus on positive patient outcomes as the driving factor for remuneration. Frayne (2012) discusses a possible solution to this dilemma in the way of a population-based funding model, “…namely involvement in a type of practice that is funded largely based on the illness burden of the patients and not on the reimbursement of individual services rendered to those patients” (p. 250). In this system, funding is allocated according to adjusted clinical groupings and the expenditures associated with these depending on provincial averages (Frayne, 2012). This system also allows for the implementation of non-physician health care team members because they would be considered employees of the funded practice (Frayne, 2012). In this type of system, practices are promoted and remunerated to “optimize care, prevent unnecessary visits, streamline referrals, and minimize admission to hospitals” (Frayne, 2012, p. 250). In this system the optimization of patient health would not only benefit the patient but also the health care team and patients with complex health care needs would be welcomed.
British Columbia Medical Association (2013, October). Policy Statement. Nurse Practitioners. Retrieved form http://www.bcma.org.
Donald, F., Martin-Misener, R., Bryant-Lukosius, D., Kilpatrick, K., Kaasalainen, S., Carter, N., Harbman, P., & Bourgeault, I., (2010). The primary healthcare nurse practitioner role in Canada. Advanced Nursing Practice, 23(special issue), 88-113.
Frayne, A.F., (2012). Population-based funding: A better primary care option? the experience of practices using a capitated funding model suggests there are many benefits. BC Medical Journal, 54(5), 250-251.
Hannah Varto (2014, February 22). Doctors should not be a business [Web log post]. Retrieved from https://www.nnpbc.com/blog/doctors-should-not-be-a-business-by- hannah-varto-mn-npf/
Office of the Auditor General of British Columbia (2014). Oversight of Physician Services.Retrieved from http://www.bcauditor.com.
Robinson, J.C., (2001). Theory and practice in the design of physician payment incentives. The Millbank Quarterly, 79(2), 149-177.
The Auditor General of British Columbia (AGBC), Russ Jones, states that the BC government lacks oversight on the value for money paid to physicians. The Auditor General found that there was “no clear, consistent and continuous mechanism for managing physician performance” or any definition of what defined value for money (AGBC, 2014). The AGBC identifies the fee-for-service FFS payment model as problematic and suggests that if physicians want to continue to use the FFS model, it needs to be reworked and linked to patient outcomes. The FFS model remunerates physicians based on how many patients they see and services they provide. Robinson (2001) explains that the FFS model encourages over provision of care and discourages the use of non-physician primary care providers.
Taxpayers deserve a health care system modeled to maximize efficiencies without sacrificing quality. The AGBCs question of what constitutes good value and how we measure it is a good one and admittedly not easy to answer. A fair measure of value would include how well the principles of the Canada Health Act are being met. The principle of access is not being met when “An estimated 4 to 5 million Canadians have no family physician or are ‘orphan patients’” (BC Chamber of Commerce, 2011, para 2). Nurse practitioners could fill that unmet need for primary health care providers. Wong and Farrally (2013) state,
Numerous individual studies and systematic reviews published in both Canada and the US since the mid-1970s have substantiated that NPs are capable of substituting for 80% to 90% of the primary health care (PHC) routinely provided by physicians, with commensurate levels of quality and safety and often with higher levels of patient satisfaction (p.48).
Wong and Farrally (2013) report that since 2006 “…BC invested heavily in developing a new NP workforce by establishing Master’s-level NP education programs at three BC universities” (p. 50). NPs are autonomous health care professionals who can “diagnose, order and interpret diagnostic tests, prescribe pharmaceuticals, and perform specific procedures within their legislated scope of practice” (Wong and Farrally, 2013 p. 22). There has already been a large investment in developing the NP role, yet little real progress in implementing it. The FFS model presents a financial disincentive for physicians to work with NPs, which poses a barrier for their implementation. The AGBC has found that the FFS model does not lend itself to any measure of value for money. Perhaps it is time for change in how health care is funded in BC.
Auditor General of British Columbia. (2014). Oversight of physician overview. Retrieved from
BC Chamber of Commerce (2011) The voice of business in BC Provincial Issue: Health. Health
Crisis- Canada needs thousands of doctors now. Retrieved from
British Columbia Ministry of Health. (2013). Medical Services Commission: Financial statement
for the fiscal year ending March 13, 2013. Retrieved from
Jones, R. (Feb 21, 2014). The early edition with Rick Cluff. Retrieved online from
Robinson, J.C. (2001). Theory and practice in the design of physician payment incentives. The
Milbank Quarterly, 79(2), 149-177. Retrieved from http://www.econ.canterbury.ac.nz/
Wong, S.T. & Farrally, V. (2013). The utilization of nurse practitioners and physician assistants: a
research synthesis. Michael Smith Foundation for Health Research, Nursing Research
Advisory Council. Retrieved from http://www.msfhr.org/sites/default/files/
The British Columbia (BC) Ministry of Health 2014/15- 2016/17 Service Plan released recently has addressed a number of challenges which exist within the realm of our health care system followed by subsequent solutions to these challenges. With a strategy to address cost containment, emphasis is being placed on measures to address service demand and improve quality (British Columbia Ministry of Health, 2014). As an aspiring nurse practitioner (NP)--and an experienced registered nurse-- I find I am disillusioned with the Ministry’s minimal emphasis on NPs as an integral resource in health care quality improvement.
Professional autonomy is “having the authority to make decisions and the freedom to act in accordance with one’s professional knowledge base” (Skar, 2010, p. 2226). BC NPs are designated to be autonomous in practice (College of Registered Nurses of British Columbia (CRNBC), 2012a). Scope of practice is determined by regulation reflected within the Health Professions Act which corresponds with CRNBC standards, limits, and conditions, as endorsed by the Nurse Practitioner Standards Committee (NPSC) (CRNBC, 2012). Two of the twelve members of the NPSC are physicians. The remaining members are comprised mainly of nurse practitioners in addition to one appointed board member, one Ministry of Health nominee, one nurse educator, and one College of Pharmacists nominee (CRNBC, 2014b). Although physician involvement is present within the NPSC, NPs “do not work under the authority of physicians” (British Columbia Nurse Practitioner Association (BCNPA), 2014, para. 7). The BCNPA (2014) has addressed concern over a key action included in the Service Plan which has potential to threaten the practice autonomy of NPs in BC. Specifically, the BCNPA (2014) has voiced concern over “the government [giving] responsibility for increasing NP practice to” (para. 9) the College of Physicians and Surgeons of BC, rather than CRNBC. The BCNPA (2014) has made reference to the Doctors of BC “support[ing] NP practice only when it is under the delegated authority of medicine” (para. 7). The Ministry selecting physicians to decide NP scope of practice further solidifies a reinforcing belief that organized medicine has state support to do so. The Practice Consultation Initial Report by Calnan and Fahey-Walsh (2005) prepared for the Canadian Nurse Practitioner Initiative, indicates physician perception of NP scope of practice represents an intrusion into the practice of medicine and NP’s ability to diagnose and prescribe have been perceived by some physicians as contributing barriers to NP role implementation. However, reduced autonomy would erode the ability of NPs to maximize utilization of their skills in practice and potentially reduce NP’s influence on health care policy development (Bahadori & Fitzpatrick, 2009).
Bahadori, A., & Fitzpatrick, J. J. (2009). Level of autonomy of primary care nurse practitioners. Journal of the American Academy of Nurse Practitioners, 21(9), 513-519. doi:10.1111/j.1745-7599.2009.00437.x
British Columbia Ministry of Health. (2014, February). 2014/15- 2016/17 Service Plan. Victoria, BC: Ministry of Health. Retrieved from http://bcbudget.gov.bc.ca/2014/sp/pdf/ministry/hlth.pdf
British Columbia Nurse Practitioner Association. (2014). Nurse practitioners: Nurse practitioners are threatened in BC. Retrieved from http://bcnpa.org/wp-content/uploads/2014/02/BCNPA-Fact-Sheet1.pdf
Calnan, R., & Fahey-Walsh, J. (2005). Appendix A: Practice consultation initial report: Prepared for the Canadian nurse practitioner initiative. Retrieved from http://www.npnow.ca/docs/tech-report/section3/02_Practice_AppendixA.pdf
College of Registered Nurses of British Columbia. (2012a, July). Scope of practice for nurse practitioners: Standards, limits, and conditions. Retrieved from https://crnbc.ca/Standards/Lists /StandardResources/688ScopeforNPs.pdf
College of Registered Nurses of British Columbia. (2014b). About CRNBC: Nurse Practitioner Standards Committee. Retrieved from https://www.crnbc.ca/crnbc/Board/committees /Pages/NPStandardsCommittee.aspx
Skar, R. (2010). The meaning of autonomy in nursing practice. Journal of Clinical Nursing, 19(15-16), 2226-2234. doi: 10.1111/j.1365-2702.2009.02804.x
There are NPs working in the Fraser Valley in private MD offices under FFS situations that will be similar to the way PAs will be utilized when they arrive. These offices have been well audited and everything is legit. Hard-working NPs could be better compensated under this method than the health authority NPs who essentially have lost wages over the past 5 years (reduction in benefits,etc).
The GP society of BC has attempted to engage the BCNPA unsuccessfully, primarily because the FFS ideal will not be discussed. This also limits NPs from pursuing additional income which potentially could face a legal challenge in the future.
Check out this opinion piece from the Vancouver Sun. This physician seems to get it.
I'm amazed, I must say. Rarely do I encounter a blog that's equally
educative and engaging, and let me tell you, you've hhit the nail on the head.
The issue is something that too few men and women are speaking intelligently about.
I'm very happy I came across this durng my hunt for something concerning this.