Payment model reform requires a frank exploration of values

I read with interest the commentary on alternative payment plan (APP) models in the September issue of Canadian Family Physician,¹ and I was struck by the discordance between my own field observations of attitudes toward APPs and the attitudes of the early-career physicians reviewed in this article.

As a long-time (45 years) family physician in British Columbia in a solo practice (with shared coverage with other solo and paired practices through most of that time), I have been interested in APPs for decades. However, the BC government, while having introduced APPs nearly 2 decades ago, has made them available only to physicians in large group practices. The government has also been relatively uninterested in setting up multidisciplinary primary care units, most of which have been organized by private societies or other community-embedded entities.

Recently this has changed with an initiative to set up structures called Primary Care Networks, in which physicians would work alongside nurse practitioners, registered nurses, dietitians, physiotherapists, psychologists, and other health care practitioners.

I attended a planning meeting a few weeks ago, and the first thing the representative of the local Division of Family Practice stated was that all the physicians in our small town in south-central British Columbia had made it clear they would not surrender their fee-for-service (FFS) payment scheme. In fact, as the evening wore on, it became clear this was the only point on which there was unquestioned agreement.

I believe the reason for this stance, which is sharply different from the attitudes in the commentary, is that the FFS system allows one to earn more; you can structure your practice to make far more money with far less multi-leveled patient engagement under FFS than you can in a system with a salary-based or other fixed-payment scheme. In other words, it’s not just that APPs are not available; it’s that doctors are drawn to a system that is highly remunerative—even if it brings them less meaningful involvement in their patients’ lives.

A remuneration system that is publicly financed but includes, in essence, no meaningful control over where and how physician and other resources are deployed, or whether those resources are even relevant in a given setting, is a dysfunctional system and ultimately unsustainable.

I reviewed the earnings from the BC Medical Services Plan in our community, as recorded in a government document called the Blue Book.² Apart from a few outliers, Canadian-born physicians earned between $250 000 and $350 000 per year. Non–Canadian-born physicians, perhaps more utilitarian in their approach to the Canadian health care system, earned an average of $350 000 to $500 000 per year, and 3 family physicians who have specialized in pain management (primarily injection therapy) earned between $500 000 and just under $1 million in the past year, according to the Blue Book.

While a few practitioners in all 3 categories earned less (of whom some were family physician couples with a shared practice) it is quite clear that if a practitioner wishes to do so, they can earn an extraordinarily good living—in strictly financial terms—under FFS.

For doctors graduating from medical school with a massive debt burden, the incentive of using a system that rapidly and securely generates income—especially if practised in a walk-in clinic, where hours are strictly defined and continuity of care (with its added need for attention to detail) is rarely a consideration—is almost irresistible. Once a physician is embedded in an FFS system, where big earnings are possible with many small visits, it is likely that offering them a payment system that fixes their income, and sets it at a lower level than noted above, holds little attraction. It takes a certain stubbornness and firmly established (pre-medicine) mindset to resist the siren call of massive FFS earnings.

The medical profession in British Columbia, including its professional bodies, has not embraced APP with enthusiasm, as far as I am aware, and the relationship between community physicians and government often appears to be somewhat confrontational. If the recent Primary Care Network system that is proposed for this province is to succeed, it requires a frank discussion of professional values, principles, and responsibilities on all sides.

Physicians will need to look further and deeper into what it means to be a good doctor and not allow the financial attractiveness of the FFS system to push them off course and away from a more intimate and meaningful involvement with their patients’ lives. Governments will need to be more forthright in discussions of the costs and benefits of services, with a degree of independent clinical decision making required on the part of physicians.

There must be an all-inclusive dialogue about the delivery of care that is more fulsome and comprehensive than simply a discussion of fees and who does what.

We live in a world in necessary transition from a human-centred way of doing things (the Anthropocene) to a more collaborative engagement with all life-forms and with one another (the Symbiocene).³ Doctor policy makers can be major players in this transition if we accept that collaboration is better than competition, that horizontal hierarchies work better than vertical ones, and that we need to create, ultimately, a system with the primary function of serving all our families, friends, and neighbours.

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