Concerned about primary care in BC? Learn more below.

New Compensation Model

In what follows, I'll step through what the new model means, how it was perceived, the reality, the unknowns, the implications for the future, and how it will affect patients, different groups of doctors, and government moving forward.

Context

This new compensation model was negotiated between MOH and DoBC. DoBC got an earful from family doctors who've been fed up for too long about what was needed. They needed a way to be able to afford continuing in family practice, providing ongoing care to a set of patients. The usual approach to funding this, fee-for-service, had been left to stagnate for decades, and was no longer viable, leading to all kinds of compromises. Continuing on this way was not an option.

At the same time, alternatives supported by the government, including contracts to work at UPCC's, were unacceptable for different reasons. Most physicians felt the structures they were required to work under did not allow them to provide high-quality patient care that they want to (and are obligated to). This led to the suboptimal decision to develop a new compensation model.

It's job was to provide another option for family doctors to practice longitudinal care, alongside other options like various contracts for docs at UPCC's or elsewhere. The government has been reluctant, to say the least, to improve the broken fee-for-service system in BC that has led to a large exodus from longitudinal care. Most doctors would prefer it be fixed, using solutions that are well understood, for a variety of reasons including practice autonomy.

The government was under pressure. But so too was Doctors of BC. They needed to deliver something substantial for angry family doctors, who have long felt they were out of touch and ineffective, as much a part of the problem as part of the solution. This need to please their members played a large role in how this was rolled out, and I imagine was well-leveraged by the government team during the negotiation process.

Announcement

The messaging that came out of this announcement, lapped up by most media, was over-the-top positive. The solution to all our problems! A monumental deal! A seismic upheaval! DoBC was just as wildly enthusiastic for their audience (doctors) as the government was for theirs (public).

Doctors got a 55% raise! They'll make at least $385k/yr! They're now the best paid in Canada, properly rewarded for all their valuable work, and the deal will attract doctors to community practice in droves!

The perception was — by design — astounding. The reality is very different.

That will also likely contribute to the "rich greedy doctors" trope and impede further progress on both turning this deal into reality and also tackling the wider issues still left unaddressed. There's a lot hear to read and understand. If you're looking for simple answers like "how much will family doctors make a year?" they do not and will not exist.

Also announced at the same time was the tentative Physician Master Agreement (PMA) negotiated between DoBC and government. It's a much broader, longer-term agreement renewed every few years that applies to all physicians. It needs to be ratified by physicians. It's best to think of this completely separately from the family doctor compensation model.

Summary of New Model

You can find more details in announcements from the government, Doctors of BC, and BC Family Doctors. I recommend avoiding most of the media coverage, especially that immediately following the announcement, which was wildly inaccurate.

Briefly, this is a brand new compensation option available to family doctors providing both in-person and virtual care to a panel of patients, i.e. traditional family practice, at least one day per week. Under this model, the bulk of the compensation is a combination of time spent at work ($130/hr, including for many administrative tasks, charting, reviewing labs, etc.) plus a fee for each patient "encounter." There's also an annual amount for the number of patients "attached" to the doctor; patients can be attached to at most one doctor (though can see others), and these annual payments will factor in patient complexity.

What's important, and what most media coverage missed, is that doctors who adopt this model are not being paid a salary. The amount they can bill varies with the amount of time they work, the number of patients they see, and the overall makeup of their panel. You'll hear talk about family doctors now making $385k for 1680 hours. But just like now, family doctor income under this model will vary wildly. And all of this is before overhead costs (clinic, staff, etc.) which they are still responsible for.

The 1680/$385k is a useful comparison against some other compensation options available to family doctors, such as contracts for those who work as hospitalists or at UPCCs (1680 is the usual annual time commitment, and is fixed, as is the annual compensation). But it's just one example of how the new compensation model could work, based on a certain panel size/complexity, certain number of patient appointments, and other factors that still vary. And again, before overhead. Doctors who have estimated their earnings under the new model if they followed existing practice patterns have come up with very different numbers, many of them well below $385k.

A few more important points:

1. This is not a "raise," i.e., a percentage increase on top of current compensation.
2. It asks them to throw out an existing complex system of compensation and replace it with a brand new one.
3. Many important details of how all this will be implemented, rules, specific fees, are still to be decided. It's an outline more than a final agreement.

This met the criteria set out by DoBC: it's fairly simple, it pays for non-patient contact time spent (in effect, $130/hr becomes a floor on hourly gross billings), it rewards increased time spent and increased patient volume, it doesn't require approval of health authorities, and it preserves practice autonomy.

Questions About the New Model

I've tried to fill in answers when they've been made available. But there are still a lot of unknowns which will ultimately affect adoption of this model and its impact.

There's a lot of "trust us" and "we'll work it out later" which I find completely unacceptable and naive. In light of how even simple things like the recent bribe stabilization funding were made so complicated by rules and processes, it's important that these things get addressed.

Structure of Agreement

Q: Is this a "complete" agreement?

No. A myriad of details, including many specific payment amounts, rules, processes, and details of implementation are yet to be decided. It's best to consider it as an outline of an agreement, akin to a memorandum of understanding rather than a firm contract.

Q: Where is the actual "agreement"?

This is starting out as an independent agreement (i.e. not part of the PMA). What is the term of the agreement? Longer-term, will it be incorporated into the PMA?

Q: Does this model need to be ratified by doctors?

No. Unlike the PMA, there is no ratification. It will take effect separately, pending actual details being sorted out, with implementation targeted around Feb/2023. Individual docs can choose to sign up on the new model if they wish.

Q: Do the fees that were described ($130/$25) go up over time?

DoBC says that the increases included in the PMA (if ratified) would apply to these amounts as well.

Q: How are changes to this agreement managed?

This would include everything from changes around rules to payments, future increases, addition or removal of encounter codes, etc. DoBC claims that changes would be negotiated.

Q: What happens if there is disagreement?

DoBC states there is a dispute resolution process that provides for arbitration. However, no details have been provided. If not carefully considered, this agreement could become subjects to changes based on the whims of the government of the day. Or scrapped altogether. Incorporating this agreement into the PMA would provide some protection, as the PMA is the only "too big to fail" agreement we have.

Eligibility

Q: What about family doctors providing a mix of care?

There needs to be some clarification around "agree to provide community longitudinal care" a minimum of 1d/week. What about a scenario where someone works in a conventional family practice 1d/week, and then does walk-in clinics another, and Telus Health episodic telehealth the other 3 days a week? Presumably the Telus work shouldn't be compensated under the new time+encounter model. Is that still billed fee-for-service?

How does a doctor register for both? How is work under one model differentiated from another? DoBC has indicated if you service a panel and provide walk-in or other services from the same clinic that they would all fall under the new model, but services offered at another location would be fee-for-service. Is this based on service location codes?

This is important because many doctors have hybrid practices which has been necessary to accommodate inadequate fees. While ideally they would be drawn back to predominately longitudinal care, this won't happen overnight. Yet, making the new model only open to longitudinal care could help accelerate this transition. We also need to avoid a situation where large corporations structure arrangements to explicitly work around the system, providing 1d/wk work for massively large groups of family docs managing a large "panel" between all of them, while doing high-volume episodic care the rest of the time.

Q: Can you jump on/off the new compensation model?

For example, sign on for part of the year, then work a few months somewhere else, then back to...?

Time

Q: Is the $130/hr a good rate?

Remember first that this is gross billings, i.e. before overhead. For comparison, most paralegals will bill out at $150/hr or more, and lawyers $300-600/hr or more. There is no per-hour rate for fee-for-service, so in that respect it's certainly better. But remember, this is one part of the compensation mix.

Q: What will count as time spent?

This encompasses patient contact time, non-patient-contact clinical work, and some administrative work. But not everything. What exactly doesn't count? What "stops the clock" in other words? And what about people who don't work 100% in their off-hours; some are "always connected," intermixing checking on work with other tasks. What counts as time spent? Ideally, some scenarios will be created to illustrate what is appropriate in these sorts of circumstances, rather than trying to nail down hard-and-fast rules, which has been the usual approach and would lead to an onerous process. This is more important here than with contracts, given we're not talking about a fixed amount of time (1680 hours) but more time billed has an effect on income. It's likely that rules will initially be few, but may be added over time.

Q: How will physicians bill for time?

Specific details have not been decided, including granularity. Ideally, this would be as easy as billing for a service. You'd enter day, start time, end time, number of units (e.g., hours) claimed - may be less than end-start if you were doing things intermittently, had gaps, etc. Presumably this is billed under a dummy patient code.

Q: How will physicians need to document their time?

Existing MSP rules for fee codes require certain types of documentation to be kept, a subset of which is submitted with billing records. What exactly will the documentation obligations for justifying time be? This is important because unless they are extremely minimal, this could add to administrative burdens.

Q: Are there any limits on amount of time that can be billed?

This one should be obvious. What happens when someone bills 24h/d x 365? While there appear to be no specific caps, it's likely that billing patterns significantly outside the norm would serve as audit triggers, like with current billing. I would not be surprised to see more rules introduced around this, however.

Q: What happens to private patient billing? Driver's medicals, doctors letters, forms, legal reports, etc.

Will such charges be allowed for physicians enrolled in the new compensation model? DoBC says yes, noting that one particular form (death certificate) can be included in the $130/hr time. Presumably other things can't. I'm guessing there will be some sort of rules against "double dipping". How will those work? For example, exclude time spent on doing forms from time payments? Enforcement? How does that complicate tracking time?

Encounters

Q: Is $25 an encounter a good rate?

The existing fee for service rates are about $31 for a simple visit, but more complex visits can be more, with limitations. The old model wasn't working so well, so a fee that is less than that may seem odd. Again, remember that this is just part of the compensation mix. But is it a good rate? No.

Q: What are all the fees and rules around encounters?

Right now this is described as "$25/encounter for standard visits." What defines a standard visit? Is there any type of time with patients that doesn't count as a standard visit? A quick phone call with a patient? Again, this will need to be defined and done so in a way that isn't onerous. And there is an allusion to encounters with "higher values." Again, specifics needed.

Without details, we run the risk of "robo-doc" care, where doctors benefit more from seeing a high-volume of patients and are effectively penalized for spending more time. The structure of this deal provides a "floor" but does not eliminate the problem. The rationale for time-based fees was to incentivize spending more time as needed. Providing higher encounter fees for longer visits would be one approach to deal with this. However, there appears to be little incentive for government to agree to adding such fees.

Q: What about current codes for complex patients, mental health, etc.?

These cannot be billed under the new model. In theory new codes may be added to address longer appointments, specific procedures, etc. but the government is under no obligation to do so.

Panels

Q: Are patients and panels attached to an individual physician or clinic?

DoBC says that patients are attached to an individual physician. Unlike with the previous CLFP payments, there are no obligations that the patient sees that physician more than other physicians. Are there models where groups of physicians share a panel? If so, presumably there are limits on the size of that group to prevent abuse, i.e. 1000's of doctors sharing a panel as a workaround.

Q: What does panel maintenance look like?

What is required to (annually I presume) report on patients in your panel? What reporting is required when patients are added or removed? What will happen when patients show up on two panels? Is reporting required by patients? What happens if doctor and patient reporting conflict?

Any constraints on the patient panel?

For example, minimum or maximum size? Degree of complexity? How does that impact the ability to tailor for particular areas of practice? Will having certain types of patients be an advantage?

Q: How will complexity be managed to counter-balance cherry-picking patients?

While there is a fee associated with the complexity of each patient, there are still risks around gaming the system to cherry-pick the easiest patients and leave the most complex unattached. How will this be monitored and measured? What exactly will the payments for complexity look like? Will they be sufficient to support complex patients or will cherry-picking easy patients still predominate?

Compliance and Evaluation

Q: How will physician "compliance" with the rules of the system be monitored, audited, and enforced?

Historically, this has been contentious and not evenly applied.

Q: How will the success of the overall system be measured and reported on?

Again, overall measurement and accountability has historically been weak. This needs to be addressed to avoid further repeats of the situation we've been in so many times.

Other

Q: Does signing on to the new model affect other payments?

Yes. The rural retention premium is maintained. However, this model replaces the annual CLFP payment (currently used for attaching patients). The business cost program (a capped surcharge to offset overhead, particularly in high-cost locations) is also excluded. As noted, various GPSC codes for complex visits will also no longer apply for those who adopt this compensation model.

Q: What does "encourage patient participation... in surveys" mean?

Again, specific requirements? Minimum number of patients who comply, etc.? DoBC says there is no specific requirements, just posting a flyer in the office or asking patients will be sufficient. Which begs the question, why is this part of the agreement? I think this opens the door for government justifying their lack of health system reporting. If participation is the responsibility of physicians, government can say they didn't fulfill their obligations, and that's why it's impossible to report.

Q: How will the requirement to "Work with other physicians and healthcare providers in your community to provide care" be operationalized?

According to DoBC, this does not mean mandatory participation in PCNs or any other obligations or administrative responsibilities. It's just "keep doing what you always do." Which again begs the question, why then is this part of the agreement?

Q: Are there global capacity limits?

The PMA is generally structured as $X million for Y (i.e. pools of money for specific projects). How much is allocated for payments under the new compensation model? What happens if the model is ridiculously successful and payments under the new compensation model exceed that limit?

Larger Primary Care and Healthcare Ecosystem

This model also needs to be seen in the context of the broader situation, recognizing that it's only one piece of the puzzle.

It still coexists with health-authority controlled UPCCs, understaffed, and costing astronomical sums. These are delivering smaller amounts of care at 5-10x the cost of independent clinics, while driving them out of business. In an environment where resources are finite, that situation still needs to be addressed.

At the same time, we also have a completely inadequate fee-for-service system (at least for family doctors). Does the new payment model provide a viable alternative for everyone who has remained on fee-for-service? If no, will there be changes to fee-for-service to accommodate them? No signs as of yet.

This also doesn't address the issue of team-based care, other than ensuring family physicians have some amount of income for time spent participating in team-based care initiatives. Actual funding for other professionals within a team-based environment as well as the role of family physicians within those teams is outside the scope of this agreement but needs to be addressed.

Finally, we've got the corporate episodic telehealth platform part of the ecosystem, e.g., Telus Health. It's been providing sub-par primary care services while draining both financial and human resources away from longitudinal care in the public system. All of which has served to degrade quality of care available to the public and thereby build demand for a private, for-fee premium service. How does the new payment model affect that sector?

Discussion

I still think this has promise. However, right now it's more of a requirements checklist than an implementable model. No surprise as I'm sure it went down to the wire to get to this, so hasn't been fully fleshed out.

It combines many different things so as to not exclude any big items. All have other ways they could have been achieved, with various tradeoffs. This likely addresses the imminent exodus of a few hundred community FPs, but benefits beyond that may be slim. A missed opportunity?

It doesn't do a lot for patients, other than not making the situation worse as those with doctors now watch them leave. It's a "stop digging" solution. But it doesn't provide the infrastructure and measures in place to build new capacity in a concrete way. In theory, that may come later. Unlikely, and certainly not in a timely way.

From the community FP perspective, the real win was that it maintained practice autonomy while putting a floor on income that wasn't there before. It doesn't ensure a large income. Like existing fee-for-service, there will be a wide range of incomes.

Many FPs would not be further ahead, especially as they've come up with enough workarounds in their practices tailored to meet the dysfunctions of the existing fee system. Those who benefit most are those (few?) now doing "traditional" family practice.

The model is designed to incentivize more to do traditional family practice, but if it doesn't stack up against the workarounds people have in place, it will slow the transition. The closer the pay, the more it would swing. Early evidence says it's better but not great.

A payment model is a set of incentives, and there's always a temptation to "game" the system. There's a cost to that. But there's also a cost to cracking down on it, in terms of complexity, auditing, and so on. A real concern here.

The time-based portion is one area to watch, as it's open ended and so looks more ripe for abuse. There's a risk that will lead to a slew of rules, reporting requirements, limits, and exclusions. That will obliterate the simplicity which is its main strength.

The encounter billing component is fee-for-service by another name. After the initial dust settles, we're likely to see the same wrangling for increases and proliferation of new fee codes for specific circumstances as we've always seen.

Again, it's a missed opportunity, because the initial version will likely incentivize volume and short visits but penalize spending more time. It's muted given the time-based component but still there. We've moved the baseline but haven't addressed the perverse incentive.

The same solutions that have been talked about for modernizing fee-for-service still apply. Time-based encounter codes would be a simple way to fix this issue and compensate those who spend sufficient time with patients as those who rush them through.

We're also missing the critical tools to help us evaluate how well this will work for improving patient care, impact on the health system, and so on. Government lack of transparency remains a huge obstacle to building an accountable and effective system.

This will likely address a horrible shortfall for a very specific practice model, but I'm less and less convinced that it will stack up as strongly as it could with the many doctors who have found alternative practice models that compensate them better.

There's still potential for this to move more docs to traditional family practice faster, which is what we need to improve patient care. It will take careful attention to detail and implementation, and a different approach to management than has been used in the past. I'm not optimistic.

At the same time, so much is missing. Many of the answers still lie in the same solutions that doctors have been calling for for years but that government has refused to consider. Is this yet another case of kicking the problem a year or so down the road?

And after spending on this, will there be money left to implement these other things that lead to improving primary care? If so, we'll need to tackle the massive waste in health bureaucracies, UPCC's, and elsewhere. That's still going to be a hard sell. And in the public eye, doctors got "everything they wanted in an outrageously good deal far better than any other collective agreement" which leaves them with little leverage going forward.

I think everyone's expectations were very low, so the initial announcement was a pleasant surprise. But really, I think MOH had their back against the wall to deliver on this. The more I look, the more holes I see, and the more work still to be done.

Verdict

This (very incomplete) agreement is not the solution to the primary care crisis. It marks only the beginning of a process to provide primary care to the 1-2 million people in BC without it. It will take years to both transition current docs to longitudinal care as well as attract new ones to meet that demand. Much work is needed. This agreement is nowhere near enough. But it provides a potential starting point. It's the response to the proverbial "if you're in a hole, stop digging."

It accomplished three things:

1. It keeps a few hundred family doctors who were about to close their practices from doing so.

For the hundreds of doctors who were doing community family practice, hadn't adapted their practice to the perverse incentives in the existing system, refused to give up on providing the best care the best way they knew how, this was a lifeline. They literally could not have afforded to keep going because their billings barely covered overhead and didn't come close to what they could make in other settings. Now they can. It may not be truly on par with other options, but it puts them in the ballpark. That means a few hundred thousand people still have a family doctor now, who otherwise wouldn't (though they may not have known it). It cannot be overemphasized how important this is.

2. It instantly rehabilitated the image of the BC NDP on healthcare from villain to saviour.

Going into this, largely as a result of grassroots efforts of groups like BC Health Care Matters, as well as considerable grassroots efforts by family doctors themselves, the government definitely looked like the bad guy. The public understood that compensation for community family docs was grossly inadequate which affected care and access. That gave the doctors a ton of leverage going into this. The announcement effectively flipped that on its head. The government, with DoBC's enthusiastic cooperation, sold the idea that (all) family doctors got a 55% raise (far exceeding anything that one would expect from any collective agreement), make at least $385K/year (an unfathomable number for most people, and perceived as usual as net rather than gross earnings), and as a result, BC doctors are now the best paid and the envy of all of Canada.

In other words, big bad government gave the family doctors every single thing it wanted, a grand gesture on unprecedented scale. It comes out looking like the hero. But what happens when in a year or two the primary care crisis isn't much better? When few of the people who don't have a family doctor now still don't have one? The government now has the perfect scapegoat — family doctors. The same doctors who just got an unbelievable deal with everything they asked for, and even with that, they let BC down. The government will no longer take the blame, the doctors will. Between turning around their image and having someone to credibly blame for failure, the BC NDP took their greatest weakness going into the next election and turned it into a strength. Bravo.

3. It killed our best chance to make any substantive changes or deviate from failed approaches to primary care.

The government got everything it wanted already, and the doctors agreed this was a "seismic" over-the-top deal with everything they wanted. What do you think happens when it comes time to finalize some of those details that weren't included? Like what encounter codes look like, or how complexity works, or how time is accounted for and documented.

Let alone anything else we need to fix primary care. The government will come back with "we gave you everything, the best deal in Canada, a raise that was five times bigger than any other collective agreement, and still you want more? Greedy bastards." Doctors and patients aren't going to see a single new thing that the government doesn't want to provide.

So what hasn't changed in primary care?

1. Most family doctors will still do better offering niche practices, working as hospitalists, etc. for telehealth platforms, etc. That means attracting enough family doctors to community practice for the 1-2 million now without a doctor has only gotten a tiny bit easier. There's not enough incentive to switch, nor is the deal compelling enough to attract large number of physicians from elsewhere.
2. Family doctors are still rewarded for short, one-problem-per-visit appointments, and discouraged from providing longer appointments when needed. They'll no longer go broke with longer appointments, but the incentives continue to greatly favour short visits.
3. Companies like Telus Health will continue to siphon off public funds, provide wholly inadequate care that increases burdens on the rest of the healthcare system, and builds demand for for-fee premium offerings.
4. Health authorities remain just as entrenched in primary care as they were at the start of this process. The bureaucracy, inefficiency, and ineptitude that we see in UPCCs, top-down PCNs, and all the rest hasn't changed. Family doctors continue to be sidelined when it comes to team-based care.
5. The onerous requirements for coverage, inability to take time off, excessive and unnecessary paperwork, and all the rest of the struggles facing family doctors haven't changed. Only the compensation has.
6. There continues to be a fundamental lack of transparency and accountability when it comes to system outcomes, spending practices, and so on. The bureaucracy will continue to grow, and billions more that could be used to provide needed patient care will be squandered.

In other words, the government remains just as involved and in control of primary care as they were to start. To the detriment of doctors and patients.

There's a lot of rhetoric that this vapourware agreement signals a change in tone, and that the government is finally willing to recognize and value the expertise of family doctors. Government and doctors are aligned and will fill in the holes to ensure patients get the best care. They understand now. Stay positive! A bright future is just around the corner!

As the last two "accomplishments" suggest, I don't share that view. This reaction continues to remind me of a trauma response from someone who's been abused for years ("Oh, he took me back! He loves me! I know it will be different this time, I know it will!").

I think the government got exactly what it wanted.

I think DoBC, and several hundred family doctors, got a not unreasonable deal, albeit less than they should have.

I think the few hundred thousand patients who were about to lose their doctor got a reprieve.

I think we squandered the best chance we had to fix primary care, and traded it for more of the same.

The crisis continues.