Increased doctor incentives do not improve access to care
A version of this commentary appeared in the Globe and Mail, the Huffington Post and Ottawa Life
Primary care — access to doctors and nurses for general health concerns — forms the backbone of our healthcare system. Good primary care means we can quickly and easily access services and get referrals to more specialized services when needed. We also rely on primary care providers to maintain a patient record, monitor chronic conditions, such as diabetes or high blood pressure, help prevent disease, and coordinate care with specialists or in hospitals.
Difficulty finding a doctor or getting a timely appointment means patients very reasonably turn to walk-in clinics or the emergency room. However, a lack of follow-up and coordination can mean new problems aren’t caught early, and ongoing conditions aren’t well managed. This is bad for patients, and costly for the health system.
Other provinces have recognized this problem, and changed how primary care is organized, introducing group practices and inter-professional teams (including physicians, but also nurses, pharmacists, social workers, and dietitians). They have also worked on building stronger systems for coordinating care, and new models of paying healthcare providers intended to encourage quality rather than volume.
BC, on the other hand, has focused on trying to change the behaviour of individual family doctors. How? Largely through a sizable carrot: incentive payments totaling more than $700 million of the $1 billion spent.
Dozens of new fee codes have been introduced since 2003, so that family doctors now receive additional payments for the management of patients with chronic diseases, providing mental healthcare, maternity care, palliative care, and health risk assessments, and communicating with other care providers about patients. The new payments are on top of the regular fees paid to doctors for patient visits.
The aim is to encourage family doctors to return to a traditional model of “full-service family practice,” where patients are connected to a single doctor who meets all of their primary care needs. This means relying on fee-for-service payments and not building inter-professional teams. There are clinics in the province where such teams exist and physicians work on salary, but these are exceptions, not the norm; Recent BC reforms did nothing to encourage their development.
The General Practice Services Committee estimates that incentive payments in BC have increased the annual incomes of participating doctors by $32,000. So it is clear that doctors’ earnings have increased sizably, but what is less clear is whether patients are receiving higher quality care as a result.
Our recent study on the care provided by BC family doctors, published in Healthcare Policy, does not provide encouraging results. We used 20 years of data to look at services provided by family doctors in BC. We found that the number of patients who receive a majority of their services from one doctor continues to fall, which implies that patients are seeing more individual physicians each year.
Access to care after hours, and in settings other than the office (home, hospital, and long-term care), declined in the period leading up to investments, and then continued to fall at the same rate after. In 1991, 96% of family physicians saw patients outside of office hours. This fell to 79% by 2001, and after investing in reform, reached 59% in 2010. In 1991, 92% of BC doctors saw patients at home, falling to 76% in 2001. In 2010, only 55% made a home visit.
In other words, patients do not appear to have improved access to their primary care physician, and their care continues to be fractured, handled across a range of individuals and settings.
An Auditor General report released in February concluded the BC government could not demonstrate that physician services are high quality or that compensation for those services offers the best value for taxpayers. Family doctors are highly skilled and deserve to be fairly compensated, and pay disparities with other specialist physicians need to be addressed. However, a growing body of research, in addition to our study, suggests that incentive payments are not a reliable way to improve quality of care.
Research also tells us that the majority of newly practicing physicians in BC would prefer alternatives to the traditional fee-for-service system. Perhaps the time is ripe for change.
Ruth Lavergne is a Doctoral Candidate in the School of Population and Public Health at UBC. Kimberlyn McGrail is an Associate Professor at the Centre for Health Services and Policy Research and the School of Population and Public Health at UBC, and an expert advisor with EvidenceNetwork.ca.
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