Community health centres are better for patients and doctors

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By Dr. Ryan Herriot, Dr. Steven Persaud, Dr. Rannie Tao, and Dr. Stephanie Stacey

As family physicians in the first stage of our careers, we look forward to practising 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. 

It is therefore with great joy that we greet the news 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). The centres, several of which are facing funding cuts under a plan put forward by Vancouver Coastal Health (VCH), are vital to the future of frontline health care in this province. VCH feels adamantly 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 is 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. Unlike in some other provinces, they are currently the only interdisciplinary team model we have. This team approach includes dieticians, nurses, counsellors, pharmacists, and many others who 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 one can only assume that the ministry has not, in fact, chosen to 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 at 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 percent 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 practise 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 leaves good coordination by the wayside.

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 paper just 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 it supports the needs of the modern family doctor. This is truly where the health system can and should be going.

Comments (5) Add New Comment
sevamatters
Thank you - for a well-written article, for the argument and for the passion for a health care system that cares for our 'health' and doesn't just focus on our illness or sickness. Multi-disciplinary care delivered through community health centres ensures that individuals and families receive the care they require to be healthy.
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kootenaygirl
This week I experienced one of those seven minute appointments. One topic with no time for an in-depth explanation or discussion. No follow-up on a previous infection which put me on antibiotics. No taking of routine blood pressure which my previous GP always handled. Instead one got the feeling that it was time to leave particularly since the doctor turned her back on me and left the room as I was speaking. Manners, anyone?
This emphasis on one topic per visit is not only unsatisfactory it is disrespectful of patients. Congratulations to these young doctors for speaking out. Let's hope their ideas spread like the wildfires.
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Vicdoc
As a GP for 21 years, I book 15 min visits for most things, and 30 min for counseling and complete exams. I often take more time than this. I'm usually satisfied and so are most of my patients. I make less money this way, but I'm ok with this. Docs who book 7 min appointments and limit their patients to one problem are income focused, not patient focused.
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Carmen Eadie
I'm still trying to figure out how a higher cost alternative will be funded without more money. All medicare money must "pass through the hands" of a doctor to be paid out to the other members of the team. Question, will the Doctor be guaranteed holidays, malpractice insurance, disability insurance, medical and dental insurance and a pension, like the other members of the team. Will they work 36.5 hours a week on the salary and then be paid "overtime" for on call, evening and weekend work. Will there be a shift differential when working evenings or weekends compared to regular days? Currently, the "siloed" doc is responsible for all overhead costs, heat, light, rent, office equipment, IT, staff, etc. The sessional fee is only about 5$500.00 for a 4 hour morning or afternoon, and doesn't include any of these other costs. The doctor will still have to see a large number of patients to ensure that there is enough "shadow" billing to MSP to cover all the costs, including the salaries and benefits of the other members of the "team". This is why these types of "teams" haven't taken off in BC. After 3-5 years of Seed funding, that is stopped and the costs of the clinic MUST be generated by the physician seeing patients.
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Urbandoc
The newly trained family docs would like to work in a multidisciplinary clinic where they could spend more time with individual patient but as a result see less patients as others would provide part of the health care delivery as well. In order to fund this model, would the new docs accept a significantly lower pay schedule to help fund this more highly staffed office setting? What is the taxpayer supposed to expect when they are no longer linked to one GP (but to a group of family docs) in a longitudinal relationship? Will they be happy to see their GP only once a year for their physicals and see nurses and dieticians and social workers for most of the other routine visits? And would these new docs be willing to take a further pay cut if their new health care model costs the system more that our current flawed system?
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