Physicians’ fee schedule should be revised
I was not at all surprised when I read that higher complex-care fees have not reduced hospital visits or increased patient care (“Study: Complex-care fees haven’t met objectives.” Aug. 16).
The complex-care fees, along with other chronic-disease incentive fees (for diabetes, heart failure, for example) were negotiated to try to recompense full-time, full-service family physicians for the extra time that patients with complex conditions require. The payoff was hoped to be quality improvement in patient care, with fewer visits to the emergency room and smaller numbers of hospital admissions.
I think a key reason an improvement was not observed is that family physicians were already doing an excellent job. In order to claim these fees, it is necessary to complete flow charts and extensively document treatment plans.
The result is that the family physician either works late into the evening or, more likely, goes to the office but does not see patients — tackling the burden of paperwork instead.
How these incentive fees came about is not pretty. The Doctors of B.C. negotiate with the government on behalf of all fee-for-service physicians — that is, specialists, walk-in clinic physicians and full-service family physicians.
When an agreement is reached, the Doctors of B.C. then negotiate internally (to put it politely) how the increase will be divided. The complexcare fees were, in part, a devious way of directing funding toward full-service family physicians, and away from walk-in clinic work and the specialists. Ways of equitably allocating the funding have disastrously failed over many years.
It gets worse. The fees paid to physicians are in part for their professional skills, and a proportion for providing an office and employing staff. The physician who works in a group and employs a nurse, a medical-office assistant and a typist will likely provide excellent and timely service for patients.
However, a colleague who handwrites charts and employs one highschool student at minimum wage will offer an inferior service — but he or she will take home considerably more income.
This is a gross unfairness. It reflects on the fee guide, which should now be declared obsolete.
I have the privilege of meeting physicians throughout the province, and have had the opportunity to observe both types of practice described in the previous paragraphs. Most family physicians are not happy. They want to do an excellent job unfettered by the additional paperwork tied to incentives.
They want time and space to deal with the vital, emotionally demanding and time-consuming opiate and benzodiazepine tsunami. They would like someone to listen to them and offer practical help to deal with the escalating number of patients and the everincreasing complexities they present.
I suggest that the fees be divided into a professional element and a substantial financial component for overhead expenses. Most physicians are not business-savvy and do not make good employers.
Hospital doctors have had free typing transcription for many years — this is easily available through the Internet to any physician with an electronic medical record.
A nurse or a nurse practitioner would increase the productivity of any physician’s office, but is an unrealistic expense to the physician.
A GP for Me, chronic-disease management incentives and complex-care initiatives have all failed. I suggest the newly created Division of Family Practice negotiate directly with the government (notwithstanding the unconscionable legally entrenched monopoly granted to the then-B.C. Medical Association many years ago), and simplify the fee schedule.
Providing a typing service and quality staff would enable family physicians to see and treat more patients, should significantly reduce wait times at walk-in clinics (now an integral part of the health-delivery system) and maybe reduce emergency-room visits.
What is there to lose? It would involve a paradigm mindset change; once that’s achieved, there is a chance that full-service family practice would become attractive again.