The current fee-for-service (FFS) system pays family doctors the same for a 5min appointment as a 45min appointment. That incentivizes very short appointments and episodic care, which leaves patients unwell and overwhelms ERs and specialists.
Some people would tell you the only way to change this is to put all doctors on salaries. It's not. We can modify the current FFS so that doctors are paid more for longer appointments. That removes the barriers to offering longitudinal care, which benefits both patients and the health system. All while retaining the advantages of FFS: incentivizes more care over less, encourages efficiency, and discourages wasteful spending.
Time-based FFS could incentivize 1000s of robo-docs to start providing better, more valuable care overnight. And over time, bring them back to traditional family practice.
Other provinces pay family doctors this way. And we already use time-based FFS in BC (e.g., that's how psychiatrists get paid), just not for family doctors. Here's how it could work.
I've already explained what episodic and longitudinal care look like, the consequences on patients and the healthcare system, and why family doctors in the current system are incentivized to provide episodic care, despite the many shortcomings.
In this piece, I'll dive a little more into the numbers, and also show how time-based FFS can get us out of this mess. It adjusts the incentives to encourage better care, and then lets the people who know best how to deliver it — family doctors — take control of delivering it.
It doesn't require large structural changes, government micromanaging, or huge investments. It's efficient, scalable, and fast.
This is more or less how family doctors bill the government now:
|Appointment Length||Current Fee|
As we saw before, that encourages doctors to make appointments very short, so we get things like the "one problem per visit" policies at many clinics, and doctors who cycle through patients very quickly. They don't take the time needed to provide good longitudinal care. Patients and the healthcare system suffer as a result.
To illustrate this, let's look at profiles of three theoretical family doctors:
What would a typical daily schedule look like for them?
|# 10min appts||26||13||6|
|# 15min appts||14||10||10|
|# 20min appts||2||5||5|
|# 30min appts||0||3||4|
|# 40min appts||0||1||2|
|Avg appt length||12.1||15.9||18.9|
|Hours per day||12.5||12.5||12.5|
So all three are putting in a 12.5 hour day (including two hours of paperwork and administrative work, all unpaid, and that's probably on the low side). Robo-doc sees more patients because their average appointment time is much shorter.
How are each of the three compensated for seeing patients under the current FFS system? Using our fee schedule from above, let's figure that out.
Let's assume each works five days a week for 48 weeks each year. Which is completely insane if every day is 12.5 hours of work! That amounts to 3000 hours per year, which is almost double what is considered a normal full-time equivalent (FTE) of 1680 hours. But for the sake of illustration, let's go with it.
And did you know that doctors are required to spend what amounts to an average of 80 hours on continuing education each year? This is on top of seeing patients, and at their own expense. Doesn't leave a lot of time for holidays, does it?
|Gross Annual Fee||$302,400||$230,400||$194,400|
So for the same amount of time spent per day, our robo-doc, providing what we can probably all agree is worse care, is making over 50% more than our ideal doctor, and still a large chunk more than our typical doc.
But of course, it's even worse than it appears. Remember, doctors have to pay overhead from those fees (staff, office space, utilities, license fees, education, supplies). If you're running your own office, that adds up quickly. Around $100,000 per year wouldn't be out of line. So let's factor that in, and also remember how many hours each of them is working.
|Gross Annual Fee||$302,400||$230,400||$194,400|
|Net Fee (pre-tax)||$202,400||$130,400||$94,400|
|Net per hour pre-tax)||$67.47||$43.47||$31.47|
Yikes! No wonder most people have never met our ideal family doctor!
No, $31.47 isn't bad by itself. But also factor in the years of schooling and resulting shorter number of years in the workforce, as well as the massive debt most doctors finish medical school and residency with. Then ask yourself if you'd be happy if someone else with the same training and putting in the same amount of work deserves more than double the pay.
The idea behind time-based fee for services is that doctors bill larger amounts for longer appointments. Not exactly rocket science. Here's one theoretical example of what that could look like:
|Appointment Length||Current Fee||Time-Based Fee|
And this is what compensation for each of our family doctors would look like using these fees:
|Gross Annual Fee (Current)||$302,400||$230,400||$194,400|
|Gross Annual Fee (Time-Based)||$312,400||$303,600||$295,200|
For many doctors, the basic ideas of FFS are sound. It gives them flexibility to adapt their practice to suit their own needs and those of their patients.
For the government, it's a remarkable bargain, and they don't have to worry about things like managing clinics, which to be honest, they don't do very well and waste a ton of money doing it.
FFS works. But it needs to be updated. Time-based fees are the way to do that.
Now we pay too many doctors to provide shitty episodic care that frequently doesn't help patients and clogs up our health system.
For the same money, patients could have a regular family doctor and receive better longitudinal care.
(Sure, they're seeing fewer patients per day, but the value to patients and the healthcare system of each visit is much higher.)
I'm confident things would start to improve somewhat very quickly once time-based FFS was implemented. We're not going to fix everything overnight. It will take time for doctors and practices to transition. But as we saw with COVID, changes don't have to take years.
It's still very important to work out the details of time-based FFS before pulling the trigger. These sorts of changes have ripple effects and you want to try to anticipate the consequences. At the same time, there are many things we can also correct as we go. And this is only one part of the solution.
Want to play with these numbers on your own?
Here's an Excel spreadsheet for you to download: ffs.xls.