William Cavers, MD, is the president of Doctors of BC (formerly the BC Medical Association) and a former co-chairman of the General Practice Services Committee.
A culture change has been quietly transforming health care in the British Columbia, replacing past animosity and rancour between doctors and government with a new climate of co-operation – and B.C. patients are the winners.
As a Victoria family doctor for 34 years, I have witnessed this transformation firsthand. A decade ago, relations between the B.C. government and the medical profession were at an all-time low. Back then, health-care spending had been growing by an unsustainable average of 7 per cent each year. The number of new medical graduates going into family practice was declining sharply and walk-in clinics were exploding in number, while doctors and government blamed each other for the problems.
While similar tensions were being felt all across Canada, in B.C., a new approach was taken whereby doctors and government decided to work together as partners to build a stronger primary-care system. A small portion of the negotiated funds for doctors’ incomes was held back from the Physician Master Agreement and applied to positive change. It’s important to stress that this was not new investment of taxpayer money, but rather a repurposing of money already earmarked for doctors’ incomes. In essence, it was doctors agreeing to invest their own negotiated money to support positive change.
A joint committee of government and doctors, called the General Practice Services Committee (GPSC) was formed to oversee this investment. Past rancour was overcome by focusing on the question: What is best for patient care? This created a collaborative, consensus-driven relationship that has been unprecedented in B.C. This new co-operative culture has now existed for close to a decade and has fostered more joint committees and collaborative processes, focusing on shared care with allied professionals, more teamwork and integrated care, and addressing gaps in patient care in the specialist care system and across the entire system.
The GPSC, which oversees improvements to the primary-care system, established incentive payments for GPs to reward care that evidence shows leads to better patient outcomes. Another GPSC creation has been the Practice Support Program, which develops modules for training and reimburses doctors and their office staff for attending the programs. Training includes everything from how to better run their offices and better manage various chronic diseases to difficult issues like end of life care or youth mental health care.
Recent commentaries that have criticized the B.C. approach have looked only at patterns of administrative billing data. Such analysis shows a lack of understanding of the full range of B.C.’s programs.
Independent evaluations, however, have found that B.C. patients who received incentive-based care had lower costs, and fewer hospital admissions, re-admissions, and lengths of stay, compared to those who did not receive incentive-based care. In addition, GPs reported that the system of incentive payments has increased their ability to take better care of their patients and provided enhanced continuity of care, among other positive findings.
Moreover, according to 2013 national data collected by the Canadian Institute for Health Information, B.C. has the best results of any province for a number of key health indicators that assess health care system performance, such as the lowest rate of avoidable mortality for treatable cause and the lowest hospitalization rates for “ambulatory-care sensitive conditions” in Canada. These measures show that appropriate primary care for conditions such as diabetes, heart failure or congestive obstructive pulmonary disease is leading to the fewest hospitalizations and deaths.
Now, fewer GPs in B.C. are leaving the profession and more newly graduated doctors are choosing family practice, up from 23 per cent in 2003 to 39.7 per cent in 2014. Moreover, the B.C. health system has been able to bring down annual spending on health care to 2.6 per cent growth per year. This is something to celebrate, not criticize.
Health care policy in B.C., as in the rest of Canada, will always have its challenges and will always be needing robust, comprehensive evaluations to ensure we are spending money wisely and getting the best patient care for our dollars. We welcome that robust evaluation. However, accurate meaningful evaluation must include not just a measure of fee-for-service billing data, but the whole picture such as physician engagement, physician education, cost effectiveness, and most importantly, patient health outcomes.