Inconvenient truth

I thank Dr Warren Bell for his letter to the editor in the January issue of Canadian Family Physician.¹ I am so relieved and grateful to see this inconvenient truth addressed.

The other missing piece of payment model reform is the simplified measurables approach to our top-down silos of accountability; within these, the quantification of assumptions about patients seen and problems “addressed” are just as flawed as the ”quality” of care measurables apparently assured with guidelines and chronic disease or complex care tick boxes. There is nothing more complex than nature, including human nature and living systems. Unexamined and unknown components affect the therapeutic relationship, the understanding of the unique nature of each problem and carrier thereof, and the outcome; examples of these components include nonverbal signals, adverse childhood experiences, whether the patient feels heard, and disappointment with misunderstood science and with authority or change. Without the time and patience to build this kind of relationship the tick boxes are about appearances and run contrary to free-market incentives.

Fee-for-service thus functions at odds with the best outcomes and obtaining the most meaning and satisfaction for participants. Yes, the underlying need to resolve so many years of accumulated debt among younger colleagues needs to be addressed. When I started in practice an average rural house cost $35,000 and the fee-for-service was $16 per visit. One has increased 20-fold and the other has doubled. Family physicians are responsible for everything and are overwhelmed—even more so where there is no easy and quick access to specialists (eg, in rural locations). Little surprise that we are retiring early and replacements are not available.

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