BC’s new FP billing model: ‘Seismic’ enough to save primary care?

Doctors of BC, BC Family Doctors and the British Columbia Ministry of Health just announced a radical therapy for the province’s primary care crisis: a generous and completely new family physician payment model that Doctors of BC president, Dr. Ramneek Dosanjh said will be “seismic” in its impact and unique in Canada.

“The goal is not only to stabilize family medicine but to make it sustainable and rewarding,” Dr. Dosanjh said in a news release accompanying the announcement.

What’s being called the Longitudinal Family Physician Payment Model (LFPPM) is an independently negotiated part of a $708 million physician master agreement (PMA) being discussed in town hall meetings and voted on this month across B.C.

There are percentage increases within the $708 million PMA (over three years) covering everything from overall fee increases, specialist income disparity, increased funding for rural disparity, physician benefits and Medical On Call Availability. 

As such, family doctors are not the only ones to benefit, but those broader details are still confidential. But the LFPPM has already been publicly announced—by Doctors of BC and the BC Health Ministry at an Oct. 31 press conference—because unlike the rest of the PMA, it’s a done deal. A collaborative solution achieved under huge public pressure to do something about the hemorrhage of doctors from family practice in B.C. About one million people are without doctors in the province. 

B.C. family doctors are paid $32 per patient visit, the second lowest in Canada, while real estate and overhead are amongst the highest. For a couple of decades now, FP graduates have been sidestepping community practice for better paid sub-specialties like working as hospitalists and emergency departments. Retiring family practitioners have not been replaced. More recently, walk-in clinics and group practices have been closing—to say nothing of strain caused by the pandemic? 

Having sought input from members, Doctors of BC hopes the new payment model reflects and addresses their concerns. 

And there is some evidence already that it’s done just that. 

Since the announcement social media posts have been filled with anecdotes, providing hope that many doctors who were on the point of quitting family practice in B.C. have decided to stay.

Here’s why.

Presented as “an alternative to FFS” which FPs can choose to take up, beginning at the end of February, the new LFPPM model:

• Preserves the FP’s autonomy, enabling them to continue independently billing BC’s Medical Services Plan (MSP) as independent contractors like they do under FFS. They’ll just be billing differently as it won’t be volume based. 
• FPs will continue running their own practices. They will not be working under the umbrella of a health authority.
• The new model pays doctors according to factors that include the time a doctor spends with a patient; the number of patients a doctor sees in a day; the number of patients a doctor supports through their office; the complexity of issues a patient is facing.
• Details are still a bit sketchy but the base pay for FFPs seems to be  $130/hour, with $25 per patient “encounter” whether that be in person or on the phone. Fees for long-term care are not yet determined, with more info expected in the new year. 
• There is a rural retention fee, like under FFS. But there remain many unclarified details such as how rural docs will be paid for the hospital and ER work.
• On the issue of paperwork, under the new model, FPs will be able to bill an hourly rate for indirect patient care such as tasks like insurance forms, lab reports and phone calls to specialists.
• Docs will also get paid for hours spent on quality improvement and education. (At present, it appears that the $130 hourly rate applies across the board).
• There is no set number of required hours, nor limit on how many hours a doctor can work. A doctor can work as little as one day a week under this plan—which Vancouver FP and researcher Dr, Rita McCracken told CBC News will increase the pool of available doctors by encouraging retirement-age doctors and doctors with young children to continue working.
• There is no money for office overhead. However several doctors told the Medical Post the increase in reimbursement is significant enough that their overheads—in the $80,000-$100,000 range in BC—will be covered by the increases generated by the new model. Doctors of BC said at the outset that their goal was for community FPs paying high overhead to achieve parity with hospitalists, who pay no overhead.
• Doctors will receive additional money for complex patients but full details have yet to be announced as to how complex will be defined.
• A full-time panel of patients is 1,250. Doctors’ panels may be larger or smaller. They will receive a payment once-a-year, related to their panel size and its complexity. Health Minister, Adrian Dix, announced there will be a provincial patient roster (replacing the current fragmented system) which is expected to be up and running next spring.

Overnight, family doctors’ spirits have been lifted in BC.

Dr. Goldis Mitra—a young Lower Mainland family doctor who published a paper earlier this year that showed young doctors have been avoiding longitudinal FP because of its outdated FFS models—said on Twitter, “(The new payment model) is an absolute game changer. It will change the landscape of primary care here in BC & inspire change elsewhere. Best of all, family doctors like me who don’t yet care for a panel of patients over time will be encouraged to do so.” 

While the sentiment is encouraging, it’s notable that research on young FPs in B.C. found that distaste for the FFS payment model isn’t the only deterrent to running a family practice. A significant number choose to work in community health clinics or as hospitalists because they do not want to have to run a business, the way community-based family doctors do. So this new payment model won’t necessarily win over every potential family practitioner. 

Dr. Jennifer Lush, an FP and BCHCM member from Victoria said on Twitter: “Thank you @adriandix. @DoctorsOfBC for offering an equitable payment plan that recognizes the value of community longitudinal care and will allow us to recruit more excellent physicians into doing this work. At last reason for optimism in the future of primary care in BC.”

And in an interview with the Medical Post, Dr. Bridget Reidy, a family physician from Saanich said, “For me, it’s going to be huge because I’m drastically underpaid doing geriatrics and complex care. I believe this is going to triple my net income! I entered quick numbers into the calculator (on the DOBC website) and it didn’t say, ‘Oh no, you couldn’t possibly spend twenty hours on direct care and thirty hours on indirect care with your patients.’”

“It’s great, it’s going to attract people from all over Canada,” she added. 

In an interview the night before the payment model was announced, Victoria FP Dr. Steven Keeler said, “Fee for service needs to be vastly elevated to achieve equity with a hospitalist’s take home pay, after expenses.” It boiled down to about a 30% increase—about $100,000—for a physician working full-time in Victoria and he was discouraged. He didn’t expect it to happen. 

Now Dr. Keeler is doing the math and wondering if it would be a good idea to switch from his contract, which is already quite favourable, to the new deal. And he isn’t the only contract FP in BC making those calculations this week, out of curiosity.

This bevy of changes might not have been pulled off without the fierce efforts of a Victoria-based citizens’ group called BC Health Care Matters.

As more and more walk-in clinics closed in the Victoria area this year, and patients heard from their doctors about rising overhead, local public advocacy swung in the doctors’ favour.

Camille Currie, is a young mother with a heart condition. Her two kids and husband have a rare congenital disease. They lost their family doctor in January and Camille decided to start BC Health Care Matters (BCHCM).

The grassroots organization grew with each public demonstration. BCHCM members stressed they wanted to be attached to a specific practitioner, advocating for doctors with lawn signs. Its leaders did interviews on radio and in local newspapers, wrote letters to their members of legislative assembly and generated petitions. 

The group remains active, working to make sure the government lives up to its promises and is transparent about outcomes, as well as continuing to maintain important dialogue.

BCHCM contributor Mark Roseman posted some questions on the group’s Facebook page—questions to which the province has yet to hash out answers. 

Some of the BCHCM questions, quoting from the agreement: 

• “How will the (stated) requirement to ‘Work with other physicians and healthcare providers in your community to provide care’ be operationalized?”
• ”How will physicians need to document their time?”
• “What about family doctors ‘providing a mix of care?’”
• “What happens if the model is ridiculously successful and payments under the new compensation model exceed the limit?
• “How will success of the overall system be measured and reported on?”
• And finally, “Where is the actual ‘agreement’?” 

Because the LFPPM was negotiated by Doctors of BC and the Ministry of Health outside of the master agreement process, the BCHCM also wonders whether this new FP payment agreement will be protected by the PMA?