I wrote this for True North News. I wanted to share it with readers here, too.
The headlines (including mine) use dollar signs for attention. But the BC offer pivots on control, not money.
Here’s what’s behind the big raise offered to B.C. doctors
Family doctors in British Columbia seem to have struck gold this week. The province offered a $135,000, 54% raise in return for a change from fee-for-service to a rostered – or what’s known as capitation-style –practice. This means average total billings for an individual physician will increase from $250,000 to $385,000.
Dr. Ramneek Dosanjh, President of Doctors B.C., called the six-figure offer a “seismic shift” and a “new dawn” in the physician-government relationship.
Governments rarely offer such raises. It reminds us of the British Labour Party’s push to build the National Health Service in 1948. British doctors had long opposed state medicine. But overnight, they did an about-face and embraced it. Aneurin Bevan, Minister of Health, was asked how he got the doctors to flip. He said by “stuffing their mouths with gold.”
The Ontario government likewise stuffed family doctors’ mouths with gold in 2002, offering a 30% raise for family doctors if they signed contracts for capitated practice models.
Capitation offers government cost certainty without having to pay doctors a salary. Doctors receive a set fee to provide all the care a patient needs for a whole year. For instance, $140 for a healthy 40-year old, or $400 for a frail 90-year old.
Performance details remain vague in the BC offer. For now, it looks like doctors are getting a raise for what they do already. Government needs doctors on contract; details can be outlined later.
James C. Robinson, health economist at UC Berkeley, has previously written, “There are many mechanisms for paying doctors; some are good and some are bad [sic]. The three worst are fee-for-service, capitation, and salary.”
The question though is, “Worse for whom?” Fee-for-service rewards service without limit or certainty for government: patients demand care, doctors provide, and government pays.
“Capitation rewards the denial of appropriate services,” writes Robinson, “the dumping of the chronically ill, and a narrow scope of practice that refers out every time-consuming patient.”
Ontario solved capitation hiccups by increasing regulations. For example, in 2008 the College of Physicians and Surgeons of Ontario created a policy stating that family doctors must accept any patient who seeks to join their practice, unless the practice is formally closed. But this created a race for doctors to close their practice, so they did not have to accept all the difficult or drug-seeking patients who had been fired from other practices.
The BC offer might have anticipated this issue. Apparently, patients will be “linked” with a practice in their area. No choice. No connection. Just linked.
This works well for public schools and emergency departments. It even works for cholesterol checks and childhood vaccines. But it fails when patients have private concerns. Patients need someone they can trust. They need to choose their clinician based on mutual outlook, not a linkage to the closest available clinic.
The BC deal offers a trifecta. Government can claim to have fixed primary care. The province loses the cost-risk of fee-for-service and transfers the risk to doctors with annual fees. Finally, capitation promises a level of control over doctors’ practices which is impossible under fee-for-service.
So, BC doctors face a fascinating choice: Take the money and run or stick to your principles?
Doctors can refuse the offer and go out of business. Or they can accept the offer and hope for a few decades of golden income, before the government turns off the tap. But the tap will turn at some point. A government never continues investment in anything, if they can get it for free and use the funds to solve another political problem.
Most doctors in Ontario took the gold the government offered with Primary Care Reform. BC doctors will probably do the same. Let’s hope it ends well for patients.
How’s it working out for family MDs in Ontario? As a specialist I don’t understand the various F-ing designations and the advantages and disadvantages. FHGs, FHNs, FHOs etc
I suggest the BC family docs speak to their colleagues.
Brad
Great suggestion, Brad.
It was wonderful at first. All the ‘F-ing’ models, as you say, offered giant raises without much change in how docs practiced, at first. Over time, accountabilities tightened without the same massive bump in pay we saw at the start to entice sign-on.
As a friend of mine said, “The gravy train is ending.” In the mid-2000s and 2010s, the road to financial bliss lay with rostering as many patients as possible. Now that most GPs are in rostered models — primarily FHOs (pay almost entirely from capitation) — government has been tightening the screws. The last contract offered sub-inflationary increases (1%) and a significant increase in the expected after-hours service.
Again, capitation is a major raise. But docs lose control. And instead of patient visits being a vital source of billing, patient visits become a drain on a relatively fixed income package.
It’s like being on salary, but with the option to work more/longer (sign up more patients) and the pleasure of paying your own rent/heat/hydro/phone/employees/etc/etc/etc
It should help recruitment short term. Not convinced it ‘fixes’ anything long term.
Thanks for posting!
Cheers
The attraction of a FHO position appears to be over. Several years ago FHO positions were being sold for tens of thousands of dollars. Today the many that are being advertised for free, do not attract attention. We have one MD who relocated elsewhere and we are not able to recruit anyone to take over. A second FHO position will open up next spring when another of our physicians will stop doing comprehensive care in a FHO and concentrate on pain management (recent new restrictions of FHO positions does not allow an MD to do both). We’ve been approved to add to our number of FHO positions, but chances of filling that are slim to none.
Thanks for posting this, Leo! I’m seeing the same in my area. Primary Care is suffering/in crisis (again) in Ontario.
Not all FHO spots are created equal!
True, FHO positions in a FHT are more attractive but in my view they are very expensive, so the reluctance of governments to fund more of them. Same could be said for CHCs. At our FHO we have leaned on the ability to create queries through SQL to provide superior care to our population of patients. For example, we use queries to identify patients who have an upcoming appointment but have not have diabetic reviews, or need a tetanus shot, or an MMR, mammograms, or various other services. We offer these when they come in for their ‘headache’ or backache. We believe these extra services we perform leads to fewer visits, but the MOH thinks we’re simply reducing numbers of visits…go figure…the point of moving to a FHO structure was to be able to reduce patients’ need for frequent visits.
I get chest tightness reading this. THIS is exactly what we were arguing with government about several years ago.
FHOs reward fewer visits. Good docs, such as yourself, figure out ways to get more work done (screening etc) in a single visit. But government turns around and accuses you of shirking services. So frustrating.
Last I heard, patients registered to a FHT cost 60% more than those seen by a FFS doc. This might just prove that FFS is underfunded and dead. But a FHT-FHG gap exists also. I’d be surprised if any government jumps to expand FHTs.
Aneurin Bevan was a Welsh coal miner, the son of a miner who died of pneumoconiosis …suffering from a stutter , he took elocution lessons to become an orator, received a miner’s sponsored scholarship to become a leader of the South awakes miners, eventually to end up in the British parliament verbally fencing with Winston Churchill.
Bevan had a keen insight into human nature and he “ stuffed the mouths “ of the hierarchy of the British Medical Association with “gold “ and titles ( Lordships, Knighthoods and sinecures) appealing to their greed and vanity , so having them betray all following generations of British medical practitioners, who have been raised to revere their chains.
We , as a profession, haven’t learned what has evidently become standard practice in the education of the governmental politico bureaucratic class in dealing with the medical profession…medical doctors can be depended to be be greedy and vain…that they can be depended to function as Judas goats to lead their colleagues into the slaughter house.
The strategy works…however , the long term consequences will not be positive for anyone one, neither the medical professionals nor their patients…only the bloated over compensated health care bureaucracy will benefit.
Andris, thanks for this history. I did not know about Bevan’s upbringing or handouts to the BMA. Fascinating!
Greed and vanity. Ouch! I fear there’s more truth in there than I care to admit. Humbling to hear it.
For some reason, doctors in administrative or political positions often find that a deep lust to be loved by the managerial class wells up in their souls. I’ve felt it myself and been guilty of trying to win the PMC’s favour. Fortunately, the icky feeling after compromising to win favour lasts a long time. It immunizes you against sychophancy next time.
Thanks again for posting!
Cheers
HR 101 says that in motivating ‘employees’, compensation ALWAYS works…in any field. Suggesting that compensation works on doctors and therefore they are greedy is blatantly false. I’ve been in this field for 25 years and I’ve seen greedy doctors, some that I wish would lose their license, but my conclusion is that doctors, in general, are incredibly motivated by other variables that are unmatched in other fields. For example, in construction, the motivation is to make sure the project DOES NOT go as planned and agreed…that way the contractor can charge outrageous fees to get the project back on schedule…ever wonder why publicly-funded (and privately-funded, though I would not be able to give examples for these) projects ALWAYS goes over budget? In a similar vein, MDs are constantly being asked to waive their fees for reports or other services by lawyers, particularly Legal Aid lawyers. The notion is that the poor patient cannot afford the fees. I get that, but in those scenarios, everyone is getting paid, the lawyers, the judges, the stenographers, the cleaning staff , the secretaries etc. but the MD is the ONLY ONE that should volunteer their services. Huh?
Brilliant comment, Leo.
Hi Shawn
The “realist with experience” within (as opposed to the cynic) has learned to “trust but verify”, particularly when the Provincial Minister of Health and the President of BCs Doctors Union both wax lyrical about the benefits of a new deal. And even more so when we on the outside don’t yet know all the details.
So yes, I think the tentative agreement could be very important, not only for family doctors in BC but for their colleagues across Canada. So important, I believe, that the very least Doctors BC can do is hire an independent economist …. like a retired Emeritus Professor of Economics …. to analyze the deal for the benefit of its own members before the ratification vote …. and then publish the analysis for the broader Canadian medical community if the agreement is actually ratified.
There are a number of concerns that BC doctors would be wise to clarify. For example, what guarantees do doctors have that BC won’t simply close down access to the new pay scheme after a year or two, say …. as happened in other jurisdictions like Ontario. This is a classic “divide and conquer” tactic by the employer which will leave Doctors BC (the Union) in a much weaker position than it is at present.
On a completely separate topic, the conception, the gestation and then the birth of the National Health Service in Britain in 1948 was a little more complex and even dirtier politics than you suggest. Aneurin Bevan was quite the silver tongued devil. I know this because my own dad was one of the many young family doctors who were de-mobilised from the British Army en masse in 1948 …. and then paid back for their wartime service by forced conscription into grossly underfunded fee for service primary care within the National Health System (NHS) …. GPs were paid 1 Pound Sterling per rostered patient PER YEAR to start, and were on call 24 hrs per day …. meanwhile specialists were offered decent salaries, fixed hours of work with Pensions and decent benefits. Divide and conquer at its finest …. but that’s another story for another day.
Be well ….
A colleague of mine’s father was an English GP who owned the building in which his practice was established..along came 1948, his practice/ building was nationalized…they undervalued his practice/ building and told him that they would pay him back plus interest on his retirement.
By the time he retired the market value of the building / real estate had multiplied several times at great profit to the government ….with him being paid the original valuation of around £4000 plus puny interest , a fraction of the market price…he could have retired “ in style”, he didn’t.
Excellent comments, Mike. Agree with them all.
I hadn’t thought about the divide and conquer issue. Perhaps, it happens by accident when government runs out of money?
Thank you for the details on Bevan! Wow. Did not know any of that. This explains why the mostly British expat doctors in Saskatchewan were so violently opposed to Tommy Douglas’ plan in 1962.
Sure good to hear from you! Crystal clear thinking, as always.
Nothing which happens when Government is in charge happens by accident, Shawn! If an unintended consequence benefits government they will ignore it. If an unintended consequence harms them they will fix the problem, including breaching contract if necessary.
And Governments can always print more money when it suits their purpose, or when their friends or financial supporters of the political party want more money.
Best
Too true! Well said.
I was offering a gentle pushback on the idea that government actually designs all the devious twists and turns that seem to fall out of what we thought was a benign contract. You have captured what happens in reality: unintended harm gets fixed, unintended benefit gets ignored (brilliant).
Thanks for bringing out this point!
Cheers
Aneurin Bevan was a Welsh coal miner, the son of a miner who died of pneumoconiosis …suffering from a stutter , he took elocution lessons to become an orator, received a miner’s sponsored scholarship to become a leader of the South awakes miners, eventually to end up in the British parliament verbally fencing with Winston Churchill.
Bevan had a keen insight into human nature and he “ stuffed the mouths “ of the hierarchy of the British Medical Association with “gold “ and titles ( Lordships, Knighthoods and sinecures) appealing to their greed and vanity , so having them betray all following generations of British medical practitioners, who have been raised to revere their chains.
We , as a profession, haven’t learned what has evidently become standard practice in the education of the governmental politico bureaucratic class in dealing with the medical profession…medical doctors can be depended to be be greedy and vain…that they can be depended to function as Judas goats to lead their colleagues into the slaughter house.
The strategy works…however , the long term consequences will not be positive for anyone one, neither the medical professionals nor their patients…only the bloated over compensated health care bureaucracy will benefit.
Shawn you should learn about the plan. Capitation is the smaller of the three payments, FFS and pay for time being the greater part. Plus it does not change how attachment happens, and could bring enough doctors back to attaching that patients would actually have a choice, which they don’t now because no one is attaching. You are well known enough to make it fail so please write again after learning about it, or at least once it’s finished. The more you learn the more you will see that the intent is to attract doctors so that goal is not going to change very soon.
Hey Bridget,
This sounds promising. Do you have any links to summaries or pros-cons lists? If you do, I’d be happy to check them out and promote them in a new blog post.
It seems wise to “trust but verify” as you say. Has the province and BCMA stopped gushing about it? Piling on superlatives isn’t how docs think. We always want to know all the side effects and ways an intervention could cause harm before we endorse something. Hearing that some new treatment or policy or physician contract is THE BEST THING EVER! usually makes docs pause.
Happy to review the info if you have links. Feel free to email them or post them here.
Thanks!
You can start with this: https://www.cbc.ca/listen/live-radio/1-91-the-early-edition/clip/15945956-province-bc-launching-payment-model-family-doctors
I have crowd sourced your question of how you can get details without logging in as a member at DBC. In brief, it is $130/hr for direct and indirect patient care and administration, $25 per encounter, at least, when finalized some encounters will pay more (and still with the hourly rate added), and average $34/year for attachment of at least enough to consider the work as one day a week. We provide the evidence of attachment, at least for the second year, meanwhile they’ll be using a bad old formula that does greatly underestimate it. Already they are looking into ways to accommodate new doctors on that, but as soon as one has attached enough, one would still get the 25 plus 130/hr while attaching most, and that is quite time consuming. The way complexity affects the capitated part and the variation in amounts are yet to be determined. It should all be completed by Feb 1 when we can choose to use it.
If we see unattached patients in our offices, we still get the 25 plus 130/hr. Here the attachment crisis got so bad that no one wants to do walk in anymore due to the complexity of patients with only that choice, so it has become a crisis in episodic care as well. Bad for politicians because most voters realize they sometimes need at least episodic care.
It is a direct result of grassroots groups taking over the messaging of why the attachment crisis is so bad in BC, a patient group with an amazing leader and a few of us family doctors. The government is doing an about face, from planning to make us all quit due to low pay and no pay for a great deal of our work, to having to admit pay is the problem and creating a plan that takes care of that problem. The only thing doctors wanted that the government refused to consider was just improving pay through FFS though they kept it as an option with no major changes for those few high billers who say the new plan is not better. An informal poll on a large Facebook family doctor group shows that over 90% of us plan to sign up as soon as possible. But we need unhappy doctors from elsewhere and/or those who switched wholly or in part to corporate telehealth to consider joining because it doesn’t make us able to attach more than we already have if we’re already full time longitudinal care.
Oh and FYI. Our local press long ago stopped gushing on it. The press thrives on controversy. It’s full of the few high billers takes on it so no, we don’t need more dissing right now. The vast majority of us in an informal poll are planning to use it. Yes we’re still complaining about FFS not being improved as an alternative, and other details. The major one of course being that it is not negotiable and could be changed over time without our agreement. But this crisis and the public response to it here was so large that no one is going to want to change the intent any time soon, to get attachment to be worthwhile for doctors to do.
Thanks Bridget.
With 90% of docs supporting it, I can’t imagine it won’t go through.
If you have documents to post, review, or comment on, I’d be happy to take a look at them. I don’t find radio shows the best way to review contracts, but I’m sure some readers will appreciate it — thanks for posting the link!
It sounds like a very generous offer indeed. I hope it works out well for you.
Best regards,
It’s non negotiable, there’s nothing to go through. Sorry I still haven’t found a good written link for you. The 1.5 hour explanation from DBC for members is on you tube though.
https://www.youtube.com/watch?v=xCCv6ofaXrA
We were quite disheartened as well not having any written information until 1/2 hour prior to the press conference on a Monday morning. But it is still unfinished and no one could wait any longer to find out something.
Thanks again for this, too.
For sure, it’s always just a ratification vote. The negotiation takes place before the offer comes to the membership.
I’ve no doubt the increased funding will help in the short term. As Kenny Rogers said, “You never count your money, when it’s sitting at the table. There’ll be time enough for counting, when the dealing’s done.”
Since we’re relying on pop culture for wisdom …
In Episode 5 of The Peripheral, Billy Ann asks Jasper why he took Corbell’s dirty money. Jasper says it was a “gesture of gratitude” for all his effort. Billy Ann chides him for being so stupid. No one gives you money for free.
Provinces always offer doctors a stark choice: take the money “while its sitting on the table” or ask why the government is giving you the money.
Government never gives you a substantive raise for doing exactly what you did last year.
I’m sure it will ratify. Primary Care in BC can’t survive without a substantive injection of cash.
Cheers
Family Physician here.
I like factual reading not hearsay based on social media rants.
1. BC Family doctors who “choose” to bill under the new payment model are not guaranteed a $135k raise in income. It’s dépendant on the hours they work within this model. Work outside of this model is billed differently ie. Working at a different walk in clinic, long term care facility etc etc.
2. “The BC offer might have anticipated this issue. Apparently, patients will be “linked” with a practice in their area. No choice. No connection. Just linked”
So not true ! 👆👆👆please don’t stir up public panic !
Hey Natasha
Thanks for correcting some of the details reported by the BCMA and province. That’s all I had to go on at the time.
As for stirring emotion, I’m flattered. Stirring readers remains the goal of every writer. Thank you.
Readers are smart. We can trust them to sort fact from hyperbole and form their own opinions.
Thanks so much for taking time to read and post a comment! If you have any resources you’d like to share, please do.
Best regards,
Shawn
Here’s another link Shawn ….
The writer/critic is apparently the self employed husband of a BC family doc
https://bcupcc.ca/newmodel/?fbclid=IwAR23BG7P_szxp6N_kbR_xMMM3mH57A4wrQoLMinWj8ZLOd42c58NS2MhrEM
Thanks Mike!
I missed this comment, sorry. Will check it out. I hope you are well.
Cheers