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.

http://www.vancouversun.com/touch/story.html?id=9636915

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?

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 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).

References
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

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.

References:
Auditor General of British Columbia. (2014). Oversight of physician overview. Retrieved from
http://www.bcauditor.com/pubs/2014/report11/oversight-physician-services
BC Chamber of Commerce (2011) The voice of business in BC Provincial Issue: Health. Health
Crisis- Canada needs thousands of doctors now. Retrieved from
http://www.bcchamber.org/advocacy/policy/provincial_gov/health/canada_needs_
thousands_of_doctors_now.html
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
Jones, R. (Feb 21, 2014). The early edition with Rick Cluff. Retrieved online from
podcast.cbc.ca/mp3/podcasts/bcearlyedition_20140221_12089.mp3
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
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/
Utilization_of_Nurse_Practitioners_and_Physician_Assistants.pdf.

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.

References

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.

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). 

References

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 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.

References

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.