Family medicine reform comes in many ways

The crisis in family medicine cannot be resolved with piecemeal solutions like those we’ve seen so far.

Urgent-care clinics? Perhaps, but where are the physicians to staff them?

Training more doctors and nurses? Yes, but this takes years and we have a problem right now.

Attracting more foreign trained physicians? Again yes, but a large percentage of these physicians either fail entry exams, or require significant retraining.

Viewed against the huge structural problems confronting family medicine, we need a more fundamental rethink.

The main obstacle to family practice reform is an outdated fee system.

On the current model, known as fee for service (FFS), physicians bill the Medical Services Plan for each patient they treat. FFS was intended to reward efficiency; the more patients you saw, the more you could bill.

This might have been fine when the population was young and treatments were simpler. But times have changed. Patients are older with more chronic diseases that need team-based care.

FFS also assumes physicians are running small businesses and will pay for their overhead from the fees they earn. With rising real estate prices, labour shortages and complex administrative demands, this is increasingly impractical.

The picture of a family doctor working alone in a downtown office no longer seems viable. So what are the alternatives?

First, recognize the complexity of modern patient care and try to move family doctors out of solo practice and into team-based care.

Health authorities are offering family physicians contract-based employment, with a financial incentive to spend more time with older or sicker patients.

These contracts also offer an opportunity to work with allied professionals like nurse practitioners, social workers, psychologists and physiotherapists. The main requirement is that physicians who join this fee model must work in groups of at least three.

Second, for those physicians who don’t want a contract, develop more incentives to remain in practice.

Part of this revolves around the miserly fee increases granted family practitioners over the years.

Two examples: The fee for a standard office visit was $30.64 five years ago. Today it is $31.62, an increase of just 3%.

In 2006, under pressure to offer incentives for chronic disease management, the government introduced a new fee. But the amount set remains largely unchanged today.

There is also the issue of pay equity. An ophthalmologist can bill $1 million a year. Most family doctors are held to about a quarter of that.

One option here would be to bring the earnings of family physicians more in line with other clinical fields.

Then use the information we already have to identify the most pressing primary care needs and set up clinics to address them.

B.C. already has cystic fibrosis clinics. Why not contraceptive clinics or migraine clinics for patients who do not have a family physician?

Give pharmacists authority to renew routine prescriptions like contraceptive pills or asthma inhalers, or prescribe selected medications.

And remove the requirement that physicians may only write prescriptions lasting three months at a time.

It would help if the Ministry of Health laid out a comprehensive plan.

And lastly, we need the legislature to bend its collective mind to enacting these reforms.

If real improvements are to be made, everyone involved must be willing to give up long-cherished routines and face the need for real change.