B.C.’s billion-dollar investment fails to improve access to health care
By Ruth Lavergne and Kim McGrail EvidenceNetwork.caNews
July 16, 2014 – Since 2006, British Columbia has spent more than a billion dollars to improve primary health care. So have B.C. patients benefited from such a massive investment? Sadly, it appears not.
Primary care — access to doctors and nurses for general health concerns —
forms the backbone of our health-care 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 health-care providers intended to encourage quality
rather than volume.
B.C., 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 health care, 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 B.C. reforms did nothing to
encourage their development.
The General Practice Services
Committee estimates that incentive payments in B.C. 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.
recent study on the care provided by B.C. 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 B.C. 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 per cent of
family physicians saw patients outside of office hours. This fell to 79
per cent by 2001, and after investing in reform, reached 59 per cent in
2010. In 1991, 92 per cent of B.C. doctors saw patients at home, falling
to 76 per cent in 2001. In 2010, only 55 per cent made a home visit.
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.
general report released in February concluded the B.C. 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 B.C. would prefer alternatives to the
traditional fee-for-service system. Perhaps the time is ripe for
Ruth Lavergne is a doctoral candidate
in the School of Population and Public Health at UBC. Kim 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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