Abstract
Objective To analyze the economic effects of policies created by the Alberta government to address the shortage of family physician (FP) services following the COVID-19 pandemic.
Design Starting with the government’s statement of the shortage (between 600,000 and 700,000 persons with unmet primary care needs) and using current caseload measures, a measure of the number of FPs and nurse practitioners (NPs) needed to fill the gap was developed.
Setting Alberta.
Participants FPs and NPs.
Main outcome measures The cost of meeting unmet needs based on provincial payment data.
Results The government set 2 priorities to meet the shortage: to increase the number of FPs and to establish and implement a framework for NPs as independent primary care practitioners. Based on the defined shortage and excluding population growth, an estimated need was calculated: 715 additional FPs with 100% coverage, or 715 additional NPs covering 80% of the needed services (893 added NP-equivalents). The cost of each alternative was calculated as $245.9 million for FPs and $176.3 million for NPs. The time needed to achieve either of these alternatives is more than a decade.
Conclusion The time to address the current doctor shortage is substantial and needs to be factored into government primary care policies.
In 2023, Alberta Health estimated that between 600,000 and 700,000 registrants in Alberta did not have access to a primary care doctor.1 Family physicians (FPs) have traditionally provided primary health care in Alberta, but a substantial shortage of FPs has developed following the COVID-19 pandemic. Factors influencing this shortage have included reduced practice income,2 physician burnout, retirement or relocation to other health care jurisdictions, and reduced working hours.3 From 2019 to 2022 the number of FPs who were billing through a fee-for-service model in Alberta increased by 1.9% from 5268 to 5371.4 During the same period, the number of registrants (REG) in the universal provincial public plan increased by almost 2.7% from 4.78 million in 2019 to 4.91 million in 2022.4
In the wake of these conditions, the Alberta government organized the health care system by dividing it into 4 components: primary care, inpatient care, continuing care, and mental health and addictions.5 To address access problems in primary care, the government set up an advisory panel to examine primary care. The Modernizing Alberta’s Primary Health Care System (MAPS) advisory panel report6 provided a number of recommendations to enhance the delivery of primary care in Alberta. One major recommendation was to expand the roles of nurse practitioners (NPs) and pharmacists as independent primary care practitioners. The role of NPs would include the provision of a full spectrum of primary care services, including the diagnosis and management of complex chronic health conditions, comprehensive health assessments, and the ordering and interpretation of diagnostic investigations. The role of pharmacists would be more limited, but they would be able to diagnose and prescribe for some common medical conditions, such as urinary tract infections. In addition, the provincial government agreed to increase FP compensation by changing the method of payment. However, this initiative as a whole will require a substantial increase in provincial funding, and the Alberta government will need sufficient time to recruit or train these additional primary care practitioners.
Although the goal of this program is to improve the provision of primary care and provide all Albertans with access to a primary care provider, there is little information available to determine the economic implications of this initiative. Policy-makers and the public will require this information if they are to assess these policies and the potential benefits of these initiatives. The purpose of this article is to comment on the economic implications of this initiative to reform primary care.
METHODS
We define a shortage as an absence of a primary care provider, which assumes that each registrant “needs” to be attached to a primary care practitioner. If someone has not been attended by a primary care provider, the government assumes this person has exhibited an unmet need. The average family physician serves a volume of registrants (RV)—also called patient load—which is calculated as RV divided by FP. The provincial shortage of FPs is measured by the number of unattached registrants (based on provincial registry) divided by the average patient load.
RESULTS
In Alberta, there were 5121 general physicians or FPs in 20224; this number includes full- and part-time practitioners, which was equal to 4569.5 full-time equivalent (FTE) physicians. The average provincial billings per FTE FP was $332,923, which covered overhead expenses and income (billings minus overhead expenses), for a total of $1.52 billion (4569.5×$332,923). This translated into an average FP billing of $297,069 ($1.52 billion/5121) for each of the 5121 FPs. We used this figure to measure FP revenue.
The number and cost of additional primary care practitioners needed are based on 2022 Alberta data.4 The number of additional FPs needed is calculated as the number of unserved registrants divided by the current patient load. According to Alberta’s Health Minister and Premier, between 600,000 and 700,000 registrants did not receive services in 2023.7 We assume the number of unserved patients who needed to be attached to a primary care practitioner is the midpoint of this range, or 650,000. The average patient load per FP is 4.91 million REG served divided by 5121 practising FPs,4 resulting in 959 REG per FP. Therefore, there is a need for 678 additional FPs (650,000/959) to serve the 650,000 unserved persons. The additional cost to the province would be $201.4 million annually (678×$297,069).
In 2022 there were 613 active NPs in Alberta.8 Of these, 170 worked in the community. Some of the community-based NPs worked in primary care networks, but there are no data on how many focused on primary care. According to the Alberta Health Minister and the Premier, each NP can manage 80% of the health issues that are addressed by an FP.9 The 20% of services not covered by NPs would need to be delivered by FPs. The cost of an NP in an independent, primary care practice has been set out in the Alberta Health’s Nurse Practitioner Primary Care Program guide.10 An NP with a panel size of 900 registered patients would receive compensation of $246,662 annually.
If NPs were used to fill the primary care shortage, the province would also need to hire 722 NPs (650,000/900), costing $178 million to meet the need. There would remain a gap for the 20% of services that NPs could not cover. If the number of NPs remained at 722 and the deficit occurred evenly in the NP service area, then the equivalent of 130,000 people (650,000×0.2) would need FP services in addition to NP services. To provide these services, 136 FPs (130,000/959) would be required at a cost of $40.4 million (136×$297,069). Therefore, the total cost of NP services to fill this shortage would be $218.4 million ($178 million+$40.4 million). An announcement by the Alberta Health Minister in November 2024 indicated that about 55 NPs had signed up to operate independent primary care practices.11,12
DISCUSSION
The number of primary care practitioners needed to fill the health care gap with a constant population is substantial, totalling 678 FPs, 722 NPs, or some combination of these. When we consider the increase in the needs of primary care, we should also consider the growth in the population, the actual requirements of the population, and changes in the primary care workforce. Between 2022 and 2023 the Alberta population increased by more than 3.8%; between 2023 and 2024 the population increased by 4.3%,13 the latter amounting to an increase of about 200,000 REG.13 The primary care increase needed for this population growth alone would be about 209 FPs (200,000/959) or 222 NPs (200,000/900). Based on data obtained from the College of Physicians and Surgeons of Alberta, the number of new FP registrations was 314 for 2023 and 354 for 2024.14 The number of NPs starting primary practice was 56 in 2024, so they will contribute much less to fill the gap.3 Unfortunately, there is an expected increase in the number of FPs leaving practice: This reduction will result from retirements, transfers out of the province, and additional reductions due to FPs’ reductions in hours worked. This will generate an even greater unmet need for FPs and NPs.
Not all members of the public seek or require primary care. There are no data on those who do not require primary care, but their presence does moderate the need for primary care services. In particular, the residents moving to Alberta will be younger and require less care than the average person.15
In order to meet these needs, the Alberta government is increasing the supply of medical school seats from 312 to 430, and the total number of residencies (for all specialties) from 400 to 500.16,17 This includes an increase in foreign medical graduate residencies from 30 to 70. The cost of implementing these policies will be $6.6 million annually for the added medical school seats and $113 million for the residencies. Some of this increase will provide for an increase in FPs but the number of FPs resulting from these changes is not known because the demand for FP residency positions in not yet known.
The size of the increase in the number of primary care NPs is also uncertain. Of the 623 NPs who were practising in Alberta in 2022, only 170 were in community care and a small but unknown portion of those were independent primary care practitioners; the other NPs were practising in hospitals or long-term care.11 In 2021, the 2 Alberta NP training programs graduated 145 NPs.11 If 25% of these graduates went into the community sector, then, ignoring interprovincial migration, 36 NPs would be added to the Alberta primary care workforce each year. It would take 26 graduating classes to cover the current total shortage gap of 944 NPs ([722+222]/36).
The Alberta Premier, following a recommendation from the MAPS initiative,5,18 stated that pharmacists in Alberta will also contribute to primary care, since they are already able to change drug dosages, prescribe for minor ailments, and order and interpret laboratory tests, in addition to filling prescriptions.18 The Canadian Pharmacists Association, in a cross-provincial survey of pharmacist activities,19 showed that Alberta pharmacists were licensed to perform a number of primary care activities. This scope of practice has been criticized18 on the basis that pharmacists are not trained to take patient histories and confirm diagnoses, which are based on physical examinations. Although pharmacists will help moderate the need for primary care, we do not know how much they will contribute to filling the primary care gaps. In addition, the Alberta Health Minister has suggested that primary care might include homeopathy and other forms of alternative medicine.20 This suggestion was criticized on the grounds that there is no scientific evidence for the effectiveness of homeopathy.20
The above costs will be subject to revision because of a change in FP compensation that was announced near the end of November 2024.20-22 Starting in 2025, payment for FP services will be divided into 3 components, rather than only 1 fee-for-service category. The 3 components are encounter fees (similar to the current fee-for-service category but at reduced rates); time fees for indirect care and practice management; and complexity or panel payments.21-23 It is expected that total compensation for FPs will exceed current levels, with the Alberta government hoping this will increase the supply of FPs.
Conclusion
The time to address current FP and NP shortages is substantial and needs to be factored into government primary care policies.
Footnotes
Contributors
All authors contributed to conceptualizing and designing the study; to collecting, analyzing, and interpreting the data; and to preparing the manuscript for submission.
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
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