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British Columbia British Columbia’s doctors incentive program fails patients: research

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British Columbia has spent hundreds of millions of dollars doling out incentives to doctors while failing to improve the quality of care for patients who face multiple health problems simultaneously, new research claims.

The province launched its Complex Care Initiative almost a decade ago, allowing doctors who take on patients with two or more possibly interacting health issues to charge an extra $315 each year a patient.

From the program's inception in 2007 until last year, B.C. had spent more than $397-million paying for the Complex Care Initiative.

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But new research published Monday in the Canadian Medical Association Journal concluded the incentive program didn't work. Instead, the research team says B.C. should consider doing things differently if it wants to improve care for patients facing multiple health issues.

Ruth Lavergne, an assistant professor at Simon Fraser University's faculty of health sciences, looked at more than 155,000 patients in the province who were eligible for complex-care incentive billing over a two-year period. Doctors billed the province in just over 60 per cent of those cases.

Dr. Lavergne's team looked to see whether hospital and admission costs had gone down and whether primary care had improved for these patients.

They found that while none of these things happened, doctors did get paid more.

The initiative is one of a handful of targeted incentive programs available to doctors practising in B.C., allowing them to charge extra when providing patients with palliative, mental health and chronic-disease care.

The Ministry of Health says it has been working with doctors in the province to try new and innovative approaches to compensation, though some researchers say that precise intended outcomes for these incentive programs remain unclear.

Shelley Ross, the co-chair of the General Practice Services Committee, a joint organization with representation from Doctors of B.C. and the province, believes that, contrary to Dr. Lavergne's findings, there is "absolutely no doubt" that the Complex Care Initiative has improved care for patients in the province.

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She says Dr. Lavergne's research is flawed – that the time period examined was too short and the research was too narrowly focused.

"There is no doubt that having a family practitioner who knows you, who sees you proactively, who has a care plan for what they want to achieve in consultation with the patients, is absolutely improving care and the patients feel like they are getting better care as well," Dr. Ross said.

Dr. Lavergne says there has been a lack of clarity about exactly what the incentive aimed to achieve. She suggested the government should be more diligent in outlining the intended impacts of its policy.

She said more research and evidence is now available to inform policy on incentives programs than was available when B.C. launched the Complex Care Initiative in 2007 and that now it's time to question whether this is the best path forward for the province.

The information available online about the initiative explains that it exists is to "compensate GPs for the time and skill needed to work with … complex care patients," but does not state anywhere that it intends to improve patient care by doing this.

When asked about the intended outcome of the incentive program, Stephen May, a spokesperson from the Ministry of Health wrote in an e-mail, "In 2007, in partnership with the Doctors of B.C., we began the work to improve primary care by creating better access to care providers and increasing quality of care."

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Dr. Ross says it is important to consider the province's physician shortage when looking at the impact of the incentive program.

She said that doctors have a wide range of patients that walk through their doors: Sometimes it's someone with a runny nose and sore throat, or it could be an 85-year-old with diabetes, who has had a stroke, has high blood pressure and a not-so-great memory.

"So you can see the difference," she said. "It is basically a time issue, it is not a knowledge issue. It's not that we don't know what to do, it's just a matter of being able to spend the time to do the quality of care."

She said patients with simple ailments go more frequently to walk-in clinics, leaving family doctors with the remaining complex cases – which take more time to care for, but were previously not compensated more.

As a result, Dr. Ross said, many family doctors shifted gears and left the general practice for walk-ins and fewer medical students were going into family practice where they felt they would not be adequately compensated. She said that if it weren't for incentives such as the Complex Care Initiative, the province's doctor shortage would be much worse.

The Ministry of Health says incentives have helped with retention – that according to statistics from the College of Physicians and Surgeons, the number of general practitioners in the province has increased 11 per cent from 2009 to 2016.

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Dr. Lavergne's team did not focus on physician retention within their study, but looked primarily into the initiative's impact on quality of care.

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