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OP-ED: Fee-for-service billing a hindrance to quality care

March 20, 2014

The Vancouver Sun

Dr. Vanessa Brcic

No one is comfortable talking about how much doctors should be paid. But after the rising cost of pharmaceuticals, doctor salaries are the second leading cause of increasing health system costs.

According to a recent British Columbia auditor general’s report, we’re not receiving good value for this money, but no one seems to know how to get it. Here are some ideas.

First, we need an open conversation about inequalities in doctor wages between different specialties. In the fee-for-service system, specialists who perform more procedures make more money (for-profit clinics rely on this principle). To bridge the wage gap, we increased fees for the lower-earning specialties. New innovations become billing addons, pouring more money into the billing system and hindering opportunity for new models of funding and service delivery. This is an incentive for more care, not necessarily better care.

Second, patients now suffer from chronic disease more than acute illnesses, and these needs are better met in the community than in a hospital. Patients connected to a primary-care provider suffer less and live longer, so shifting our focus from hospital care to primary care will take pressure off acute-care services and save money in the long term. Let’s join the global movement toward “medical homes,” accessible, one-stop-shops based on the best evidence, for patients to have all their health needs met under one roof.

Third, we must demand large-scale public system reform. Investors in private clinics are happy to have the word innovation equated with for-profit options, but that is a disgrace to myriad public system innovations that already exist, ready to be scaled up (see the B.C. Patient Safety & Quality Council’s Quality Awards and the now-defunct Health Council of Canada’s Innovation Portal for examples).

Fourth, younger family physicians are trained in an era of chronic disease and patient-centered care, and we want to solve problems in delivering complex care creatively and efficiently. We also see the impact of the social determinants of health, and want to bridge the huge inequalities that exist between those who can and can’t easily achieve good health. This will improve health outcomes and save money in the long-term. We are grateful for new billing incentives to care for patients with chronic diseases, but there is still a disconnection between our vision of care and fee-for-service remuneration that pays for one problem per visit. If we want incentives for every element of complex care, we will need to keep adding incentives; society doesn’t have the money for that.

The Divisions of Family Practice is an inspiring example of family doctors working toward community-level change. But their efforts don’t acknowledge the global shift toward medical homes, or that other payment models exist. One option is capitation, in which doctors receive an annual fee per patient that can be adjusted based on how sick the patients are. Another is the salaried, interdisciplinary community health centre model, which performs best for patients with the highest needs.

My research indicates we could have 93 more family physicians opening practices in B.C. if we gave them the choice to open alternately funded practices with interdisciplinary teams. http://www.cfp.ca/content/58/5/e275.full That was the trend in Ontario after the move to alternate models of primary care funding in the last decade.

Detailed billing rules don’t provide incentive for innovation. Alternate funding options can go beyond billing incentives to encourage family doctors to do more than treat patients, supporting them to identify unmet needs in their practice populations and find solutions to address them.

Capitation payment has great promise for this and, in the book Prescription for Excellence, author Dr. Michael Rachlis also outlines a salary framework proposed by the Ontario Medical Association. Introducing modest but desirable alternate payment options could save money and foster flexibility and innovation in primary care clinics. Such models can help us ask critical questions: Whose needs aren’t being met? Are all my diabetes patients, or single moms, or frail elderly receiving the care they need? How can I do better?

Finally, if we want to invest in primary care that is high quality and accountable, public health specialists can help. They are in the business of trying to meet communities’ health needs. They also recognize one of the best ways of doing so is through the lens of primary care, where we can enact change that will benefit patients and entire populations.

It’s time to shift away from fee-for-service billing. Doing so will allow doctors to focus on providing the amount and type of care their patients need, while reducing pressure on our busy hospitals. And with the support of public health to help us track how we’re doing, perhaps we can incite a renaissance of innovative and cost-effective primary care reform in B.C.

Vanessa Brcic is a family physician and a research associate with the Canadian Centre for Policy Alternatives, and serves as a board member for Canadian Doctors for Medicare. Follow her on Twitter @vanessabrcic