From the obvious to the insidious: Reflections on unintended consequences of the BC fee-for-service system in family medicine, and perspectives on the new payment model

In this blog post, I share my reflections on the unintended consequences of the current fee-for-service (FFS) model in BC and my thoughts on the new payment model. They are based on my experience as a family physician in BC, where I’ve worked for 16 years in a variety of settings and payment models (sessionally, under a service contract, FFS, and under the FP group contract).

The new Longitudinal Family Physician Payment Model has been announced, the Physician Master Agreement has been ratified, and both provide exciting routes for the transformation of care delivery and improvement of the physician experience. The new payment model is being fleshed out and the current FFS model will be modernized and simplified. We have an opportunity to examine the current FFS model and name some of the unintended consequences. Having done so, we can move more clear-eyed toward compensation models and fee codes that will better meet the needs of patients, physicians, and the health care system.

Fee-for-service model

Let’s consider some unintended consequences of the FFS model. 

Perhaps the most interesting risk of the current FFS system is how it can harm patients. Although the incentive fees (chronic disease management, care plan fees, etc.) were created to support family doctors providing quality longitudinal care, they can lead to overdiagnosis, inappropriate investigations, and decreased access to care.

These codes incentivize family physicians to find all patients who could possibly fit the criteria for diabetes, hypertension, COPD, chronic kidney failure, frailty, etc. Indeed, this has led to a new job market (and cost) for staff who help physicians find eligible patients. This leads to more investigations that may not otherwise have been ordered. Patients are then labeled with a chronic disease for which they technically meet the criteria (certain lab value cutoff, or finding on imaging) even though they may not have clinical consequences. A cascade of additional physician visits and investigations follows.

This leads me to wonder:

  • Has the incidence of these incentivized conditions increased since the chronic disease management and care plan fees were introduced in BC? 
  • How many of these additional cases were clinically significant?
  • How many additional investigations and visits have been generated to satisfy the billing requirements?
  • How many of these were clinically indicated and consistent with the patient’s values and goals?
  • How many appointment slots are taken up by visits done to satisfy the billing criteria?

There is increasing awareness of the harm caused by incidental findings on clinically indicated testing and screening investigations, but what about billing-indicated testing? What is the cost to the system, the patient, and the environment? And what is lost?

As it stands, the poorly paid basic FFS model leads to short and frequent visits and the policy of one problem per visit. Additionally, for complex diagnoses, FFS family physicians are advised to complete the assessment (history and physical) over multiple appointments. These patterns of practice are chosen not because they provide the best care, but to fit the payment model. At times, short and frequent visits make sense, but there are many times when they don’t. I’ve found it is often more efficient for patient and physician alike to address multiple and often interconnected issues at the same time. Perhaps we will know if we have achieved a more commonsense approach to compensation when physicians don’t need to shoehorn good care into the fee structures.

The current FFS model leads to more referrals. For example, when the care needed is within our scope, but we cannot provide it within a 10- or 15-minute visit, a referral is made to someone who has more time. This leads to the creation of specialized sessionally paid clinics staffed by family physicians who deal with patients and conditions that take time, not necessarily further expertise. This leads to the further fragmentation of care. How many referrals could be saved if family physicians were paid to spend the time needed? How much health authority/ministry funding would be saved? Why not pay the family physician such that they are able to give the patient the time they need when they need it?

Team-based care isn’t well supported in the FFS model. Team-based care includes connecting with other physicians and care providers on the patient’s team. The only part that is currently paid for under the FFS is the actual number of minutes spent talking to the other provider—not the thoughtful prep prior or the required documentation and paperwork after. Furthermore, the underfunded FFS model has led most of us to structure our day full of patient visits to generate enough income. Financially, it doesn’t make sense under the current FFS to schedule time to communicate with other team members, review charts, and think deeply about patients.

Just using the FFS billing systems takes up physicians’ time. Physicians have to learn the complex billing system, likely attend multiple billing seminars over the years, and then, because the codes vary only slightly in their requirements, they will need to review it frequently. Family medicine residents spend a considerable amount of time learning how to bill. Couldn’t that time be better spent?

Complicated billing systems distract physicians from providing care. To survive financially as an FFS family physician in BC, you have to approach each interaction with a patient from a billing lens. While you see the patient for their presenting concern, you also have to ask yourself: 

  • Does this patient qualify for the personal health risk assessment, a chronic disease management fee, complex care/palliative care or mental health care plan, or the COVID-19 vaccination discussion? 
  • If so, what do I need to order/address to have met the billing requirements?
  • What documentation do I need to complete?
  • Exactly how many minutes do I need to ensure I see the patient for? 
  • Do all of those minutes need to be face to face, or not?
  • How many places do I need to document that?
  • Have I seen the patient frequently enough to bill this, or do I need to recall them for another appointment? 

This shifts the work of the physician from meeting the patient’s needs to meeting the billing structure’s needs.

Our current FFS model is rigid and prescriptive. It details when, where, for how long, and what must be done. It leaves little room for the variability that necessarily arises in providing patient-centred care or the creativity in how that care is delivered. Best practices change. Guideline-driven care isn’t appropriate for all patients. Prescriptive, rigid fee codes lead to inappropriate and unnecessary care being given or to physicians being underpaid for providing good medicine in a different way.

Care for conditions or the completion of tasks for which there is a fee code will more likely get done (whether or not it should be done). What about the care for which there aren’t codes? For example, gathering collateral history; reviewing the chart, the literature, and thinking about a patient’s care; or for patients whose multiple comorbidities don’t meet the complex care criteria. There are many important but unquantified/unnamed care tasks that are left undone (or done for free, contributing to burnout) because the FFS model is too narrow and defined.

I’ve found myself wondering, is the payment structure being used as an indirect tool to ensure quality care? It makes sense that the funder would want to ensure there is quality in the care they are paying for, but the structure should be general and flexible enough to allow physicians to adapt the care they provide in response to new evidence, patient centredness, or pandemics even. The quality and professionalism of the care provided by family physicians is already attended to by other bodies: the College of Physicians and Surgeons of BC provides licensing, regulating, auditing, education, and discipline if needed. The College of Family Physicians of Canada provides certification and requires ongoing education. Doesn’t it make sense that the payment structure leave those responsibilities to those bodies? 

I would also argue that the FFS system decreases physicians’ joy in work. Feeling valued for doing meaningful and skilled work is one of the privileges physicians can experience. However, the current FFS billing system chips away at that by requiring physicians to provide care in ways that often don’t make sense, while recording and documenting the care down to the minute. This is not an insignificant contributor to burnout and family physicians feeling undervalued.

Payment models affect the care delivered. Let’s ask ourselves: does this billing structure, fee code, etc., enable good patient-centred care? The following questions could help clarify that.

Does the payment model:

  • Give the physician room to provide that care in a range of ways that make sense to the patient and the physician given their contexts?
  • Increase the risk of overdiagnosis? And conversely, underdiagnosis in other areas?
  • Incentivize inappropriate care?
  • Provide compensation for all the skills physicians bring, including the relational and cognitive skills?
  • Require significant physician time to learn and use?
  • Have a mechanism to identify the few who are abusing it, while minimizing the cost (financial, time, morale) to those who aren’t?
  • Create space for providing good value care at a reasonable cost?

Group Contract for Practicing Full Service Family Physicians

The Group Contract for Practicing Full Service Family Physicians has significant administrative and compensation issues. However, it does the essential thing well—physicians are paid for the patient care they provide, full stop. This includes all indirect and direct patient care (other than private). There is freedom to provide the care patients need in a way that fits with the patient and the physician’s context. For my practice, this means quick patient-care tasks can be done quickly and complex ones can be given the time they need. My decision to see a patient virtually, in person, or at all, is based on what is required for patient care, rather than how I will be paid. I schedule time to review and think about my complicated patients and to discuss their care with specialists. I make fewer referrals, order fewer inappropriate investigations, and do more deprescribing where appropriate. My patients’ care is less fragmented. I’ve had hour-long visits with patients that have accomplished more than a year’s worth of monthly short visits and an annual complex care plan. I am providing more patient-centred care. And, importantly, I have more joy in my work.

Longitudinal Family Physician Payment Model

The new payment model for longitudinal care decreases barriers to improved experiences for patients, providers, and the health care system. It appears simpler to use. The hourly base rate creates room for physicians to continue the important work not previously compensated (valued) in the FFS model. That the bulk of a family physician’s pay is based on their hours is a significant stride toward acknowledging the cognitive and relational expertise of family medicine specialists. I note the hourly rate is less than the sessional rate for family physicians/hospitalists, and this is before overhead. Encounter payments for patient visits will perpetuate the incentive to increase the number of services and to see less-complex patients. More encounters equals higher pay; it does not equal better care provided or necessarily that more patients will be cared for. The payment for patient panel size includes an adjustment for complexity. My hope is that it will be adequate to ensure fair compensation for physicians with complex patients. Overall, I think the new payment model is an improvement on the FFS model and the group contract, and I plan to switch to it.

As my family medicine colleagues choose which model to work under, they should consider how each model affects the patient care they provide, whether it will increase their joy in work, and whether it is best for our health care system.
—Jill Norris, MD, CCFP

Dr Norris is a family doctor in Victoria who is interested in questioning the assumptions, beliefs, and structures that shape current medical practice. She is exploring how practising slow medicine might better meet the needs of patients, providers, the health care system, and the environment.

This post has been peer reviewed by the BCMJ Editorial Board.

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Eugene Leduc says: reply

Thanks Jill Norris for your thoughtful summary of the cons of FFS care. There are some pros (like incentive to efficiently see more patients per day...important in an under-doctored environment and to see patients on-call, out of regular hours, or at home, and to do procedures) but I too think the cons outweigh the pros. I switched to the Group Family Practice Contract and am finding it much less stressful. I am looking forward to the new Longitudinal Practice payment model as well.

Sarah Chritchley says: reply

Well said Dr. Norris! I have often pondered these same things as I go about my day. With contract, which I do prefer, I may do up to 10 different patient medication refills a day without seeing the patient. At times that is absolutely appropriate and I appreciate being paid for the time I do that without unnecessarily wasting my time or my patients. At times though, I feel it would be better to see the patient, but as I already overwork my contract hours I just don't have time to do what I think is ideal. Again, how you are paid influences your pattern of practice. Thanks for this interesting article.

Al Neufeld MD says: reply

I have recently retired from family practice at age 73 after 0ver 40 years. I think that the new LFP contract is generally a good thing but I think there will be some unintended consequences. We always practiced with an RN on our staff. She did many of the things that weren't paid for by the ministry. Now these things are paid for if the physicians do them. I am already hearing comments from my former colleagues that it doesn't make business sense to continue paying an RN $45 an hour when an MOA at $22 per hr. can do the unpaid work. So much for team-based care incentives. It appears that there are no longer any tray fees. I can't imagine why new physicians would purchase surgical instruments and sterilization equipment when they can't recoup their costs. In fact, why do childhood and adult immunizations if they can't cover their costs? I'm afraid we will see a lot more referrals to ER and specialists for things that primary care physicians are trained for but are now money loosing activities. More unintended consequences.

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