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How are UPCCs Performing?

FOI data from Apr/2022–Mar/2023 provides a breakdown of costs, recruitment, and visits for BC's UPCCs. This has been aggregated in the report below. There is considerable variation in costs, recruitment, and efficiency across different health authorities and individual UPCCs. Key findings:

Detailed cost or performance measures for UPCCs have been hard to come by. To date, we have mostly heard "positive" statistics about the total number of visits, e.g., this Feb/2024 media release quoting 2.37 million visits across all UPCCs as of Dec/2023. It sounds impressive. Is it?

The results of a Freedom of Information (FOI) request, released in Dec/2023 (also available locally here), provide some overall cost breakdowns for each UPCC, as well as several other entities (CHCs, PCNs, FNPCCs, NPCCs). While not a detailed accounting, and leaving many questions unanswered, what is provided gives us a better picture than we've had before. The data covers one year of expenditures, from Apr 1/2022 to Mar 31/2023. (Of note, I do not know who made that FOI request; like all such requests, the responses are published on the government's Open Information website.)

I subsequently filed another FOI request for a breakdown of UPCC visits and recruitment covering the same time period. I then created a spreadsheet (which you can download) to make exploring the data from both requests easier. That in turn was used to produce a detailed report providing a more user-friendly format view of the raw data, broken down by health authority and then by individual UPCC.

In what follows, I'll explain what the data shows us and why it's important.

Overall Expenditures

Total expenditures for one year amounted to approximately $89.7 million across 27 of the 29 UPCCs (data was not included in the FOI response for Penticton or Cranbrook).

Expenditures were broken down into seven categories: family physicians, nurse practitioners, registered nurses, allied health (e.g., counsellors), other clinical staff, administrative staff (e.g. clerks, directors, coordinators), and overhead (all non-salary expenses, e.g. equipment, lease, repairs, utilities).

The following chart shows the relative proportion of each expense category across all UPCCs, broken down by health authority. It gives us a picture of how they use their money.

Spending on Services. Different health authorities (and different UPCCs) spend their money in different ways. Some rely more on family doctors than others, some use nurse practitioners more, etc. It gives us a broad pictures of the type of services different sites provide.

Administration and Overhead. It also tells us how much they're spending on non-clinical tasks (administration and overhead). In general, we want to see most money going to clinical staff. Again, there are big differences, e.g., VCH is doing well, Island Health's UPCCs have a much higher than average overhead. The reasons why aren't clear.

Hiring Performance

UPCCs have been criticized for being unable to recruit and retain sufficient staff. This is important as staff are needed to provide clinical services. A clinic without doctors, nurse practitioners, or nurses wouldn't be much help, would it? Especially if it's still costing money for all the administrative staff and overhead left underused.

When UPCCs are planned (and announced), they are designed to provide a given level of service (e.g., visits). If they are unable to maintain adequate staff, they cannot provide that level of service. So staffing levels are a key performance metric. There are two ways to look at it, by the number of full-time equivalents (FTEs) recruited and by the cost of salaries, payments to contractors, casual staff, etc.

In the past, when data was available, it usually consisted of the number of FTEs across all clinical areas. It wasn't clear if there were enough doctors, nurses, etc. This data provides us with the breakdowns, both by FTE as well as the cost of staff in each area. It includes both actual costs and how many FTEs (or how much money) was budgeted for each staffing area. We are assuming that the budgeted amounts represent the staffing levels required to provide the level of service expected from the UPCCs. (Remember that the compensation for different positions varies, so $200k might be 1 FTE for a family physician or nurse practitioner but may be closer to 2 FTEs for counsellors. This is also why specifying total clinical FTEs as has been done in the past can be misleading.)

The data and report include both FTE and cost data. The charts below compare budgeted vs. actual costs for each staffing area.

Overall Performance. Budgets for salaries (total expenditures less overhead) was $78.9 million. Actual spending was $60.9 million, or 77% of budgeted.

Challenges by Profession. Most UPCCs have achieved staffing targets for registered nurses (hitting 99% of budgets, or 88% by recruited FTEs, indicating a lot of casual staff). They've done far less well with family physicians (70% of budget, 75% recruited FTEs) and nurse practitioners (66% by cost, 70% recruited FTEs).

The data covers a period largely predating the Longitudinal Family Physician payment model, lauched in early 2023. If it has been as successful as MOH claims, challenges with recruiting family physicians for UPCCs have likely increased since then.

Challenges by Health Authority. Some health authorities have done well with UPCC recruiting and retention, e.g. Vancouver Coastal Health and Northern Health. Interior Health and Northern Health have exceeded their expectations around physician recruitment. However, both Island Health and Fraser Health have done poorly om attracting family physicians and nurse practitioners to work in their UPCCs. This has large implications for the level of service they can provide.

You'll notice a different proportion of budgets allotted in different health authorities. Northern Health, with its two UPCCs, budgeted $200k for family physicians (about 1 FTE). Island Health, with seven UPCCs, has budgeted for $13.4 million (approximately 65 FTE), though hit less than half (46%). Is this a case of unrealistic planning? Poor management? If UPCCs are built assuming those staffing levels, we're throwing a lot of money away on empty space and non-clinical staff.

Overhead

Total overhead costs across the UPCCs are $28.8 million out of a total of $89.7 million, or 32%. This varied considerably across health authorities, from a low of 26% (Vancouver Coastal Health) to 50% higher (39% at Island Health). Individual UPCCs range from 21% (Quesnel) to over 40% (most in Island Health).

Unlike with staffing, where it has been difficult to attract staff to meet budget targets, UPCCs are spending 18% more than budgeted on overhead. As most of these are fixed costs, this is concerning and suggests management should be doing a better job at managing its finances.

As with other areas, Island Health is the worst offender when it comes to exceeding its overhead budget by over 50% ($3.4 million over its $6.6 million budget), whereas some (Northern Health and Vancouver Coastal Health) ran under budget. Curiously, the oldest UPCC, Westshore, more than doubled its expected overhead. One would have hoped they'd learned to properly budget after all this time.

Visits

The real question is what all those costs, whether for staff or overhead, are buying us in terms of health care. One way to look at that is by comparing the cost against the number of patient visits.

The average cost for a patient visit across all UPCCs is $129.

Again, this varies considerably.

For comparison, a family medicine patient visit under FFS pays $35.83.

This is the current value for billing code 00100 used by family doctors billing under fee-for-service (FFS).

A family doctor under the Longitudinal Family Physician (LFP) model would bill $57.50 for a 15min visit.

These are expected to cover all costs, including physician compensation, administration, and overhead.

What is a UPCC "Visit"?

Part of the challenge making any comparison or interpreting this data is that we have very little information about exactly what counts as a UPCC visit. This is critical information. Unfortunately, despite multiple requests, the data has deliberately not been released. It takes little imagination to speculate why that is.

What difference does it make? Consider a visit where a family doctor takes a detailed medical history, performs a comprehensive examination, creates a treatment plan, reviews it with the patient, and answers their questions. Or a 50min visit with a counsellor to provide psychotherapy. I'd consider $129 to be a fair price, if not a bargain, for either of those. But what if the visit was for a doctor to renew a simple prescription or a nurse to check your blood pressure? For either of those, $129 would seem ridiculously high.

To determine if we're getting good value from the UPCCs, we'd need to know more about the visits. Who were they with? For how long? For what? Without that, we're left to speculate.

If most of the visits were comparable to what you'd expect from a short primary care visit, you'd have to wonder why the cost is more than double what it would be outside a UPCC.

Are "cost per visit" or "overhead per visit" ideal ways to measure how effectively money is spent? Of course not. But that's what we're left with, because this wholly inadequate number of "visits" is the only performance metric the government is willing to release. And on even that, they look bad. What would things look like with more meaningful performance metrics?

And what happens if people come for primary care, but due to the staffing challenges outlined above, no physician or nurse practitioner is available to see them? Do they see a nurse instead? After all, UPCCs have a lot more nurses than most primary care clinics. And nurses are awesome and can do many valuable things. But nurses can't diagnose, order tests, refer to specialists, prescribe medications, and many other things people need from primary care.

Visits and Team-Based Care

Consider this scenario. You go to a UPCC. You first see a nurse who checks your blood pressure and asks a few other questions about your health. You then see a doctor or nurse practitioner. That's a smart use of resources, and this kind of team-based care is one of the benefits touted by UPCCs.

But does that count as ONE visit or TWO? Because if it's two, the average cost per "real" patient visit is a LOT higher than $129!

Perhaps it's not so surprising that the government has refused to release official information on who those visits are with or even how many "visits" in the data correspond with real patient visits to the UPCC. So, we're left to speculate.

But we've also heard from multiple insiders that the situation above — one patient visit resulting in multiple visits in the data — does happen. Without the data, we can't confirm this or know how often.

This should raise many questions about UPCC performance and the choices that have been made.

I hope many people — politicians, executives, and most importantly, the public — ask them. And demand real answers.

I've posted some of my own questions at takingaction.ca/upcc.