Concerned about primary care in BC? Learn more below.
Build Your Own UPCC
It's easy, fast, and fun—anyone can do it!
Unlimited public funds available!
No expertise providing primary care required!
For ages 6+
You've seen how time-based fee-for-service (FFS) works. Now it's time to try out your business planning skills to build your own UPCC. The spreadsheet below lets you adjust various parameters that affect its cost and performance. How does adding one more NP change things?
The staffing levels, costs, etc. are meant to be illustrative. The model is there to help people appreciate the types of areas where money goes and what it provides. It's obviously over-simplified. Where possible, I've tried to obtain something close to real numbers through a variety of reputable (and other) sources, but that's not always easy.Dear Friends at Ministry of Health and Health Authorities...
If you're able to provide some real data on costs, productivity levels, patient volumes, etc., I'm sure a lot of people would really appreciate it. Going off the press releases hasn't lined up with reality so far...
Play around. What happens when your UPCC can't find enough doctors, as is so often the case? How much is it costing if it is only able to see 30 patients a day? What would things look like if it could staff up? Don't worry, whatever you choose, nobody is going to die.
When done, how might the UPCC you built compare with FFS doctors? If you had the same budget as your UPCC, how many family doctors could you pay for how much work?
For example, here's my UPCC:
And here's how it stacks up:
Hmm, I guess I didn't do very well.
I'm paying more each visit for overhead (facilities, support staff) than FFS doctors would charge in total. And that's before factoring in costs for the doctor or nurse at my UPCC who is seeing the patient. Oops.
At just over $3m for a single site, If I had 25 identical copies of my UPCC across BC, the annual operating costs would be $75m. With that $75m, I'm providing 630,000 patient visits per year.
Apparently, if I spent that same money on FFS docs instead, they could provide just under 1,640,000 patient visits per year.
That's over one million more visits I could have provided had I spent it on FFS family docs instead of my UPCCs.
And that's after the FFS rates were adjusted to allow family doctors to spend enough time with their patients to deliver good longitudinal care.
It's a good thing nobody is paying me to manage anything in our healthcare system!
How much money is being spent on actual UPCCs?
How many patients are actually being seen?
How many more patient visits could we be getting for the same money?
Will we ever know?
Here's the Excel spreadsheet for you to download: byo-upcc.xls.
Want to share your results? Improvements to the spreadsheet? Actual data? Let me know!
This isn't exactly slick and polished, so be warned. And if you do have a 6 year old who can work their way through this, I'm pretty sure someone in MOH may have a job for them.
Notes:
- There are a few comments on individual cells in the spreadsheet explaining in more detail what certain items are about. I'll add more over time as well as add more interpretation notes here.
- For comparison purposes, I've used the revised average FFS rate of $46 which factors in larger payments for more time, vs. the current fixed fee of a bit over $31 no matter the length of the visit.
- The spreadsheet doesn't capture the initial capital costs ($3-4 million?) needed to create each UPCC in the first place. To offset this somewhat, I've assumed that premises are leased rather than owned, which has the effect of accounting for some of the capital as annual costs (rent). Facilities operating costs (heating, electricity, cleaning, property taxes, etc.) would be the same, as most commercial NNN leases pass those on to tenants.
- At the end of the day, we're using money to buy patient care. The sample UPCC shows 72 patients per day from a doctor or nurse practitioner. Many of the current UPCCs are understaffed and are seeing 30 patients or less per day, which makes the fixed costs of facilities and support staff a huge portion of costs. Others see many more patients per day, so the fixed costs are distributed across many more patient visits.
- This model, and the discussion on time-based FFS, uses average length of appointments as a placeholder for care, i.e. better care in longer appointments. That's a drastic oversimplification of course. The model assumes that all MD/NP time in the UPCC is used for direct patient care, which is definitely not the case. It isn't in the FFS scenarios either, but there, nobody is getting paid for it. So in the UPCCs, actual patient contact time is shorter than the spreadsheet will indicate. We also know from anecdotal experience that frequently patients at UPCCs are getting episodic care visits akin to a traditional walk-in clinic, vs. longitudinal care akin to having a regular family doctor. We also know that if you're seeing a different provider every time, you're not getting as good care as if you see the same provider for every visit, even if the appointment lengths are the same. In the latter scenario, they get to know you and can make more informed decisions in less time.
- The spreadsheet model differentiates between MDs and NPs who provide direct patient care (thereby assigning them as variable costs, related to number of visits provided) and support staff who don't. I've included RNs in the latter category, even though they will see some patients, especially when there are no doctors or NPs working a particular day. Again, this is an oversimplification. But at the same time, they're not able to provide the same level of independent care as a MD or NP; it's outside their scope of practice to do so.
- Specifics of individual MD and NP contracts do vary somewhat in terms of gross and net compensation, responsibilities for overhead, clinical responsibilities, expected throughput (patients/hour seen) etc. We don't know to what degree expected performance targets such as throughput are actually met.
- You'll note that the cost model for independent family doctors running their own offices is very different. They're paid a fee and any costs come out of that fee. In strict FFS, the government isn't paying for their overhead separately. There's sometimes a parallel arrangement that may provide some support, as we've seen with the recent government bail-outs of several walk-in clinics which were about to close. They may also fund e.g. a nurse for an individual clinic. While it's not common for family doctors, specialists who work FFS out of hospitals will also have their overhead covered, which gets them (limited) administrative support, an office, IT, etc. Government also supplies some common services (e.g., a mechanism to be paid for FFS billings, if not the actual software to enter and submit them).
Here's the Excel spreadsheet for you to download: byo-upcc.xls.
Want to share your results? Improvements to the spreadsheet? Actual data? Let me know!
This isn't exactly slick and polished, so be warned. And if you do have a 6 year old who can work their way through this, I'm pretty sure someone in MOH may have a job for them.
- There are a few comments on individual cells in the spreadsheet explaining in more detail what certain items are about. I'll add more over time as well as add more interpretation notes here.
- For comparison purposes, I've used the revised average FFS rate of $46 which factors in larger payments for more time, vs. the current fixed fee of a bit over $31 no matter the length of the visit.
- The spreadsheet doesn't capture the initial capital costs ($3-4 million?) needed to create each UPCC in the first place. To offset this somewhat, I've assumed that premises are leased rather than owned, which has the effect of accounting for some of the capital as annual costs (rent). Facilities operating costs (heating, electricity, cleaning, property taxes, etc.) would be the same, as most commercial NNN leases pass those on to tenants.
- At the end of the day, we're using money to buy patient care. The sample UPCC shows 72 patients per day from a doctor or nurse practitioner. Many of the current UPCCs are understaffed and are seeing 30 patients or less per day, which makes the fixed costs of facilities and support staff a huge portion of costs. Others see many more patients per day, so the fixed costs are distributed across many more patient visits.
- This model, and the discussion on time-based FFS, uses average length of appointments as a placeholder for care, i.e. better care in longer appointments. That's a drastic oversimplification of course. The model assumes that all MD/NP time in the UPCC is used for direct patient care, which is definitely not the case. It isn't in the FFS scenarios either, but there, nobody is getting paid for it. So in the UPCCs, actual patient contact time is shorter than the spreadsheet will indicate. We also know from anecdotal experience that frequently patients at UPCCs are getting episodic care visits akin to a traditional walk-in clinic, vs. longitudinal care akin to having a regular family doctor. We also know that if you're seeing a different provider every time, you're not getting as good care as if you see the same provider for every visit, even if the appointment lengths are the same. In the latter scenario, they get to know you and can make more informed decisions in less time.
- The spreadsheet model differentiates between MDs and NPs who provide direct patient care (thereby assigning them as variable costs, related to number of visits provided) and support staff who don't. I've included RNs in the latter category, even though they will see some patients, especially when there are no doctors or NPs working a particular day. Again, this is an oversimplification. But at the same time, they're not able to provide the same level of independent care as a MD or NP; it's outside their scope of practice to do so.
- Specifics of individual MD and NP contracts do vary somewhat in terms of gross and net compensation, responsibilities for overhead, clinical responsibilities, expected throughput (patients/hour seen) etc. We don't know to what degree expected performance targets such as throughput are actually met.
- You'll note that the cost model for independent family doctors running their own offices is very different. They're paid a fee and any costs come out of that fee. In strict FFS, the government isn't paying for their overhead separately. There's sometimes a parallel arrangement that may provide some support, as we've seen with the recent government bail-outs of several walk-in clinics which were about to close. They may also fund e.g. a nurse for an individual clinic. While it's not common for family doctors, specialists who work FFS out of hospitals will also have their overhead covered, which gets them (limited) administrative support, an office, IT, etc. Government also supplies some common services (e.g., a mechanism to be paid for FFS billings, if not the actual software to enter and submit them).