Collaborative care model a bad financial bet

A future Nova Scotia government, Tory or NDP, will point back at Stephen Mcneil’s Liberals as the rascals who put the province in a financial wringer.

That’s politics as usual here, but next time it will come with a new twist. Nova Scotians will also discover they still don’t have enough family doctors and can’t afford to hire more.

In recent times, with each change in government Nova Scotians have been told that the fiscal prudence of the preceding regime was smoke and mirrors, and the province teeters at the brink of ruin. The current government said it of the NDP, just as the NDP said it of the Tories before them.

Nova Scotia’s Liberal government got the books to balance largely by freezing pay increases across the public sector. Legislation being tested in court now helped the province kick costs down the road to 2020, when pent-up pressure for higher pay will be ready to blow.

A more immediate problem for the province comes due a year earlier, in 2019, when the current agreement expires with Nova Scotia’s doctors.

Fee-for-service docs, the overwhelming majority of Nova Scotia’s 1,300 family practitioners, felt left out in the cold when the few general practitioners who work exclusively in hospitals got a big pay hike recently.

The same week Premier McNeil told family docs they’d have to wait for the next contract for a raise, he also said he intends to run for a third term as premier. Unhappy doctors could make that a tough win.

But the province can get a new deal with doctors and not break the bank.

A bigger financial problem is hidden in the Nova Scotia Health Authority’s scheme for the future of primary care. Primary care is pretty much what family docs do, but the NSHA intends to replace that model with collaborative care, where a team of health professionals will meet patients’ needs.

In theory, this model frees up doctors’ time by off-loading a certain percentage of the patients to nurse practitioners or other professionals. The business case is that these other professionals are less expensive than doctors, so everybody’s happy.

It’s the business case the province needs to challenge, rather than taking the word of NSHA executives.

Working in a collaborative model, doctors are likely to opt for contracts over fee-for-service. In fact, new physicians will generally choose salary over fee-for-service now, if they can, and why not? It’s a better deal.

Fee-for-service docs have no paid vacation or benefits and most pay their own overhead. Salaried GPS are paid about $250,000 annually and work a 37.5-hour week, 46 weeks per year with no overhead.

The bottom line is that salaried family doctors are, and will be, paid much more per patient than fee-for-service doctors are now.

The leap of faith the Mcneil government has taken — hook, line and sinker — is that in a collaborative model Nova Scotia won’t need as many family doctors.

Indeed, the NSHA has operated on that theory for most of its three-year existence and the result is clear for all to see. There’s a shortage of family docs almost everywhere in Nova Scotia, the problem promises to get worse, and it was exacerbated when the NSHA denied family doctors permission to practise in many areas of the province that it deemed over-served.

Given the fatally flawed modelling the NSHA used to create a family doctor crisis, one wonders why the Mcneil government isn’t more skeptical about the NSHA’S collaborative business model.

Right now, the Mcneil government and the NSHA have a lot riding on a dubious bet.

They wouldn’t phrase it this way, but they are betting that fewer doctors seeing fewer patients will somehow solve the problem of not enough doctors. This magic is performed thanks to those other professionals mentioned above, but the best-case scenario in collaborative practices is 30 per cent of patients diverted to nurse practitioners and, even then, the doc needs to step in at least half the time.

The expected decreased demand on physicians in collaborative practice isn’t, even in the best case, enough to balance the increased patient demand created simply by the shift from highly productive fee-for-service practices to salaried docs.

So if the government is willing to bet it all on the collaborative model, it should put up the money. There’d be lots of gamblers willing to take that action, provided the province can pay off when it loses.