What is a family doctor?
A medical doctor trained to care for you as a whole person throughout your entire life. They train in all areas of medicine to diagnose and treat a wide range of acute and chronic health conditions. After completing medical school, they complete a residency program specializing in family medicine.
What do family doctors do?
Some work in general family medicine practices caring for the same group of patients (called a panel) for years. Others work in walk-in clinics, both bricks-and-mortar and telehealth. Some provide care in hospitals, long-term care, or other settings. Some work in niche practices focusing on a specific area of medicine.
What is episodic care?
Treatment obtained on a one-off basis, e.g., through the ER or a walk-in clinic. The person you see may not know you and have limited access to your medical records. Individual appointments focus entirely on why you came in that day. If you require follow-up care at a later date, it may be with another person.
What is longitudinal care?
Treatment obtained in the context of a longer-term relationship with (mostly) one person. Over time, they get to know you and your overall health history. Appointments may still focus on immediate issues, but try to balance that with longer-term or big-picture care as well. Emphasizes continuity.
What are the benefits of longitudinal care?
Doctors who know you and your entire health history can make better diagnoses and treatment decisions. They get to know you and what's important to you. You may find it easier to work with someone who knows them. It ensures proper follow-up is completed and correctly interpreted. Chronic conditions can be managed proactively. You're not responsible for keeping track of all aspects of your care, and ensuring that regular or preventative care isn't missed.
How are family doctors paid?
While details vary, the vast majority work as independent contractors, not employees. They agree to provide a service and are paid for that service. Like any small business, this generates gross income, from which they must deduct expenses. They do not receive benefits, holiday pay, pensions, etc.
What is fee-for-service (FFS)?
Physicians and government agree on a fee schedule providing a list of services, rules for providing them, and a fixed fee. When doctors perform a service on a patient, they bill the government (MSP), who pays that fee. How long the service takes doesn't matter. Services not on the fee schedule can't be billed.
Is that why so many doctors do one problem per (short) visit?
Yes. In BC, a standard office visit for a patient aged 2-49 pays the same $31.72 whether it takes five minutes or fifty. A family doctor who only sees a couple of patients per hour won't bill enough to cover their overhead, let alone have anything left to pay themselves.
What is a service contract?
An individual agreement between a doctor and an organization (often — but not always — government, e.g. health authority) to provide certain types of services at a given location. Typically expressed as fixed fee for a given number of hours (e.g. 1680 per year for three years). The contract explicitly details responsibilities and expectations of both parties.
What is overhead?
Overhead is the entire set of expenses necessary for the physician to provide care and thereby generate income, e.g., staff, rent, utilities, education, licensing fees, supplies. The difference between income and overhead is the physician's take-home pay (net income) before taxes.
Who pays for overhead?
It depends. FFS doctors who run their own clinics pay all their own overhead. Other FFS docs may pay a percentage of gross billings (e.g., 30%) to a clinic owner. Service contracts specify what fees the doctor must pay to the clinic, what the clinic will provide, and what the doctor must provide.
How many family doctors does BC have?
According to CIHI, BC had 6884 family medicine physicians in 2020, or 133.7 per 100,000 population. That's the third highest of all the provinces. We're behind NS (139) and NB (137), but ahead of NL (131), QC (129), AB (124), SK (118), ON (115), PE (110), and MB (108).
If we have enough family doctors, why does everyone say we don't?
In BC, approximately 50% of our family doctors are doing something other than traditional family practice caring for a panel of patients. That's far higher than anywhere else in Canada.
What else are they doing?
Working in walk-in clinics, for virtual episodic telehealth platforms, working as hospitalists providing daily care on inpatient wards, working in long-term care, or working exclusively in cosmetic medicine, addictions, or other niche areas.
Why are so many family doctors not doing family practice?
As indicated before, it's impossible to generate enough income doing FFS family practice to both cover overhead and pay themselves unless doctors rush through a large number of patients very quickly. That still leaves hours of unpaid work to complete. Other options pay much better for much less work.
Why are family doctors leaving?
Family doctors want to provide longitudinal care, but can't afford to. They're getting burned out. Most get little satisfaction out of assembly line episodic care. Many retire early, move to other provinces, or change careers. For many, the pandemic was the last straw. This exodus has been accelerating.
Why are clinics closing?
Same reason; it's difficult to generate enough income, and physicians are increasingly seeking other options that may pay better (e.g., UPCCs), have less overhead (e.g. Telus Health and other services), or service contracts in hospitals and other settings.
What impact does that have on patients with a family doctor?
For patients who have a family doctor, their panel sizes have increased. It takes longer to get an appointment, and appointments are often shorter. In the past, you could book an appointment within a few days. Now it's commonly several weeks.
What about patients without a family doctor?
They're not likely to get one for starters, forcing them to use walk-in clinics, online platforms, etc. Limited spots are available, and may involve long wait times. Not everyone can manage that. Only episodic care is available and there is limited continuity, which makes it difficult for patients especially with chronic conditions. Many things are falling through the cracks, increasing morbidity and mortality.
What impact does that have on emergency rooms?
Patients unable to access primary care will present to the ER for routine needs (e.g. prescription refill) or when a mild condition hasn't been treated and turns into a major problem. Cost of care is much higher. Increased demands mean ER waiting times are much longer.
What impact does that have on specialists and services like cancer care?
With less family doctors treating patients, episodic care providers refer more routine cases to specialists. That creates a backlog of cases for specialists, meaning it takes much longer for patients who need specialty care to get seen. Specialists make recommendations that require a family doctor to provide follow-up care. Without one, patients do not improve and often are re-referred. Some specialists spend their time doing work (badly) that a family doctor should be doing. Many patients can't be discharged because no followup is available.
This all creates a vicious circle. Specialty care is more difficult to access. That puts more pressure on family doctors to provide care. But the increased pressure means they have less time to do so. That leads to more referrals, further backlogs throughout the system, and patients who do not receive any treatment.
How is the government trying to fix primary care?
They've created the Urgent and Primary Care Centres, to both provide episodic care (by family doctors on service contracts, nurse practitioners, and other healthcare workers) and attach patients for longitudinal care. They're also offering bailouts and other one-off funding to clinics on a case-by-case basis. They're also trying to put more doctors on service contracts.
How is it working?
Not well. UPCCs are providing expensive episodic care to small numbers of patients, attaching fewer, and driving independent clinics out of business. Bailouts and other funding take years to negotiate, are unpredictable, and don't address the underlying problems. Service contracts have met with a mixed response (more on those below).
Why aren't family doctors joining UPCCs?
While the service contracts are financially reasonable, physicians are very unhappy about the way that the clinics are organized, are too bureaucratic, feel they actively prevent them from providing good care to patients, have concerns about the care model, and feel their expertise is neither valued or wanted.
Why is the government doing this?
You'd have to ask them. As best I can piece together, the Ministry of Health decided that it would be better if health authorities took over primary care rather than independent doctors, theoretically to provide better oversight. Cynics have claimed this is either a step towards privatization (a likely result if not likely the intent) or an ideologically-driven, big-government, expertise-leveling socialist conspiracy.
Were doctors consulted about these plans?
No. And no, they're not too happy about them.
Do doctors have other concerns?
Many. Extreme mismanagement, gross misspending on inefficient resources, utter lack of accountability for spending or outcomes, destruction of physician and patient autonomy, and silencing and gaslighting of critics. You can find out more on the rest of this site.
What are the service contracts that are being offered?
There are multiple types with different terms. Some are for people just finishing family medicine residency who joined an existing group practice. Others are with health authorities for docs working in UPCC's. Others with community orgs running CHC's. Others for things outside of primary care, e.g. hospital work.
Are service contracts better than fee-for-service?
There are tradeoffs with any compensation scheme. The bigger challenge right now is that the one most people are on (fee-for-service) isn't equitable with what people are making on contracts, to say nothing of underpaying for necessary services etc. (that's drawing people away from community practices which are generally efficient, and often into environments providing poorer quality care, sometimes at higher costs).
Why aren't more people signing up for service contracts?
There's a limited number available with different criteria and restrictions. However, many people who are on fee-for-service are reluctant to sign up on contracts for various reasons. Many are related to control of their environment (who they hire, what resources are available, how the practice is organized) which they as physicians are ultimately accountable for. There's also the risk of signing on to a 2-3 year contract which can be changed/withdrawn at the whim of the government of the day afterwards. It's a bit of a power struggle between government, who is increasingly wanting to control how primary care operates (despite not being very good at it) and physicians.
Isn't all healthcare free in Canada?
No, and it never has been. Certainly things like dentists, physiotherapy, and many other services never were. Not even everything doctors do is covered. In fact, what exactly is covered and what isn't varies a lot depending on where you go, and is subject to many, many rules. Of course, nothing is actually free. Even things that are covered are paid for by taxpayers, just not direct user fees.
Can doctors legally charge fees to patients?
Yes, but only for certain things, and in certain places, with many complicated restrictions. There is a variety of legislation and regulations from various bodies that describes this. The most important is the BC Medicare Protection Act (MPA), the BC legislation that is responsible for implementing many of the provisions in the Canada Health Act.
What is the Medical Services Plan (MSP) and how is it involved?
MSP is the health insurance plan that pays for many physician (and other) medical services. It specifies and many other medical services. It is operated under the authority of the Medical Services Commission (MSC), which has membership from both the Ministry of Health (government) and Doctors of BC (physicians). It defines what services are insured, who can provide them, who they can be provided to, various conditions, and a price for each service. When fee-for-service physicians deliver a service to a patient, they bill MSP for the service, which reimburses them at the agreed upon rate.
Didn't we get rid of MSP a few years ago?
What we got rid of were insurance premiums that patients paid to be part of MSP. MSP is still here, governing both patients and physicians. However, now patients do not individually pay a fee to participate, but now all funds come from government budgets. This includes an increase in business payroll taxes that was introduced when individual premiums were ended.
What are uninsured services?
In general, any service that is not covered by MSP is an uninsured service. We normally think of things like insurance forms, sick notes, etc. The government does not pay doctors to do these, so many doctors charge a fee. They are legally entitled to do so. Uninsured services also include services that would normally be insured (such as a doctor visit), except that certain conditions aren't met. That can include patients who aren't enrolled in MSP (e.g., patients from out of country), doctors who aren't enrolled in MSP (see below), services provided that aren't defined as medically necessary (e.g., many cosmetic procedures), or other conditions on individual services.
Are there any restrictions on charging for uninsured services?
No. Medical organizations in most provinces publish a schedule of suggested fees for different uninsured services, but individual physicians can charge anything they want.
Can doctors charge for services covered by MSP?
Here's where things start getting complicated. Most doctors are fully enrolled in MSP, and they cannot charge patients for insured services. Doctors can partially (called opting out) or fully (unenroll) withdraw from MSP, which does allow charging patients for insured services (with restrictions). We'll discuss that more below.
Can a doctor charge a fee (like a membership) needed to access an insured service?
Doctors who are enrolled in MSP cannot do so. This gets tricky in that many doctors will say they are charging for "uninsured services" offered with insured services, and the charges apply only to the uninsured services. Section 17.1 of the MPA explicitly addresses this, not allowing physicians to require purchasing an uninsured service to access an insured service, or to prioritize access to insured services to those who purchase uninsured services (i.e., queue jumping). There are some ambiguities, and enforcement of these provisions has been tricky. Also note that doctors are also under no obligation to accept every patient, though cannot discriminate against them in doing so.
What are the circumstances where doctors can charge for insured services?
Doctors who are not enrolled in MSP can charge patients, and neither the doctor or the patient will be reimbursed by MSP. Doctors who enroll in MSP can also opt out of it, in one of two ways. In a soft opt-out, MSP continues to pay the doctor a set fee but the patient is responsible for additional charges. Compare this to when you have third party dental insurance and go to the dentist. Your insurance pays the dentist for part of it, and you cover the rest. In a hard opt-out, the doctor charges the full fee to the patient, and then submits a claim to MSP for part of it, which will be reimbursed directly to the patient. In practice, opting out by doctors is extremely rare, but is common for several other professions (dentists, optometrists, acupuncturists, physical therapists). They provide services to specific groups (e.g., income assistance recipients) that can be partially reimbursed by MSP as supplementary benefits (i.e., not universally available).
Can an opted-out or unenrolled physician do anything they want?
No, they're still governed by all kinds of rules and regulations, including to keep their their license to practice medicine, overseen by the College of Physicians and Surgeons of BC. Opting out or unenrolling refers only to the reimbursement side. There are no shortage of other rules that still apply.
Can unenrolled physicians charge more than the rate MSP would pay for the service?
Yes. However, Section 18 of the MPA forbids this for services in hospitals, continuing care facilities, or facilities operated by (or contracted by) government health authorities. Most private physicians offices would not fit into those restrictions and so could charge what they wish. Also, according to Section 45 of the MPA, private insurance cannot be issued that covers services that would normally be insured by MSP (though paying out of pocket for individuals is allowed).
Can opted-out physicians charge more than the rate MSP would pay for the service?
Theoretically, no, but practically, yes. Section 18.3 of the MPA says opted-out practitioners can't charge more for a service than MSP would cover. However, this is subject to additional regulations defined in official fee schedules. Fee schedules are set by MSC for each profession and are updated frequently (they are not legislation). The fee schedule for physicians currently forbids "extra billing" (charging more for the service than MSP will pay), while fee schedules for many other professions explicitly state that extra billing is allowed. This is why opting out for physicians is so rare. In practice, the same issues and ambiguities arise as when "membership fees" were discussed previously. Opted-out physicians may bundle insured and uninsured services, as long as they tell patients how much they are being charged in total and how much they should expect to have covered by MSP. As a practical matter, there appear to be many loopholes that could be exploited with limited risk of enforcement.
Are there downsides for physicians who unenroll from MSP?
Definitely. Unenrolling means you can't charge MSP for anything (so physicians can't stay in and bill some services to MSP and some privately), so it's a pretty drastic step.
Are there downsides for patients if their physician unenrolls completely from MSP?
Yes. Outside of the obvious (being responsible for the costs), referrals for laboratory tests and specialist referrals are not reimbursable. That means you will have to pay full costs at the lab or to a specialist physician when referred by a physician who is not enrolled in MSP. Labs are covered in Section 14.1 of the MPA. Specialists not referred by a practitioner enrolled in MSP can bill MSP only for a (much lower) family doctor visit fee, with patients having to make up the difference; this is described in Section C.14 of the Fee Guide Preamble.
How many family doctors doctors have opted-out or unenrolled from MSP? Are more considering it?
Very, very few. Some are now considering this drastic step now only because they feel they can't continue to stay open and deliver the quality of care they want to patients supported only by the fees covered by MSP.
Are we on a "slippery slope" towards privatization?
No. Remember first that most physicians operate privately, like individual businesses that bill the government for services. So there's long been a huge private component in terms of operations. On the payment side (user fees), there have always been some services included, and some not. The specifics and the rules, vary depending where you are and change over time, trying to strike an appropriate balance of many factors. Some of the scenarios you're seeing play out now aren't about opening a door that's been firmly slammed shut, but taking a door that's already ajar and opening it further. How much further? We'll have to see. But as you've seen here, this is not happening in a vacuum, and there are multiple sets of rules that govern the operation and funding of our healthcare system. They aren't all of a sudden disappearing.