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.