Ruth Lavergne, Rita McCracken, Lindsay Hedden, Damien Contandriopoulos, and Andrew Longhurst are Canadian primary-care services researchers who study how health care policy affects patient access.
On Oct. 31, family doctors in British Columbia were offered a 54-per-cent raise. Family doctors are the backbone of Canada’s health system, yet are paid less than other medical specialties. This change will bump their pay closer to that of other specialists and surgeons – many of whom earn more than $400,000 annually. There are about a million people in B.C. who don’t have a family doctor; what will this change mean for those patients?
Unfortunately, there is no guarantee that increasing doctor pay will result in better primary-care access. In fact, past experience suggests it may make the shortage worse.
The main problem is not that this model will be costing more. The new model will see doctors paid a $130 hourly rate plus $25 per patient visit, no matter how long they spend with a patient. For someone with a simple concern this could be just a few minutes. For someone with more complex needs, this could take a lot of time, but the amount paid won’t change. Patient complexity will be compensated for only in a one-time annual fee, starting at $34 a patient per year. At best only a small percentage of total income will reflect the amount of time needed to address a patient’s health conditions. This could make it even harder for people with complex needs to find a family doctor.
While the shift away from classic fee-for-service makes sense, the problem of a lack of primary-care access is owing to the lack of infrastructure and team-based clinics, and requires co-ordinated health care reform.
Let’s use education as an example. Our public-school system must make classroom space for every school-age child. Our primary-care system should do the same. We don’t require teachers to open new classrooms using their salaries – rather, we directly fund schools and all the staff required. Primary care deserves the same approach. We need to separate compensation for physicians and other providers from the operational and capital-funding requirements to build successful primary-care systems in B.C. and across Canada.
Previous increases to physician pay, without structural change to how services are delivered, have routinely decreased patient access. When Quebec increased doctors’ pay over a short time period to bring compensation closer to the Canadian average, it caused a large drop in the amount of care provided, meaning patients had a harder time accessing care. (In Ontario, changes to physician payment models were of benefit to some populations, but not to those more likely to be poor or new immigrants.)
Most family doctors in Canada are independent contractors who can decide where they work, how much they work, which patients they see and what kind of care they provide. With sudden increases to fees, doctors typically maintain or increase their income while working less. In an environment with lots of exhausted clinicians, this is an understandable choice. However, from a health-system perspective, it means higher costs, fewer services and less access for patients. The phenomenon has a technical term in economics: the target-income hypothesis. If you google it, chances are you will find examples based on physician compensation.
It is possible that this new payment model will keep some doctors in family practice who would have otherwise chosen other work, or to retire. It may also draw some new doctors to B.C., but this just makes the situation worse in other provinces. Ultimately, though, any gains in numbers may be dwarfed by physicians scaling back patient visits in response to higher incomes. This would mean fewer patients are able to find regular primary care, and patients who already have a doctor may find it harder to get an appointment.
B.C. is taking a big risk with its new model, at a substantial cost to the taxpayer. At the very least there needs to be a transparent public evaluation that determines if these changes are increasing or reducing access to primary care. Otherwise B.C.’s new experiment may be a giant leap for physician payment, and a step backward for patients who need access.