Chaos in primary care

As all family physicians in BC can attest, we are living in a swamp of chaos in primary care. My patients can go to any clinic, real or virtual, for care. I am expected to receive third-hand information and incorporate it into the patient’s chart with no financial remuneration. Any other provider can order tests and they may or may not be sent to me. If I receive them, I am expected to store the information and act on it if needed with no financial remuneration. Pharmacies can request repeat prescriptions of me without me seeing my patients. These same pharmacies are paid to review and fax requests to me and I receive nothing for my part in renewing these drugs. Insurance companies inundate me with requests for completion of ridiculously complex forms concerning my patients. Patients themselves can come to see me with two-page-long lists of concerns and expect to have them all handled in a 15-minute office visit.

As this situation evolves, it is apparent that I, as the primary provider for a specific patient, am burdened with increasing responsibilities for my patient and diminished financial resources to carry them out. This is the main reason why family medicine is in its death throes. Yes, it is all about money. If I am not deemed to be valuable to society, then why should I participate in the system? This question has been answered by the dearth of new family physicians willing to take on the traditional role of provider in our society.

We have played this game with governments for 40 years and now the jig is up, so to speak. When I retire, my 1850 patients will have nowhere to go because I will certainly not find a replacement for myself unless there is a drastic change to how I am paid. I have written to the BCMJ in the past outlining this very point but will now reiterate the message.

If I am to be the primary provider for a patient, then I deserve to get an annual fee or stipend specifically for this task. This fee must be great enough for me to be incentivized to actually take on the role of organizer and main health provider for my patient. Also, if I am the main primary care provider for my patient, then it is my patient’s duty to see me and not an anonymous provider for their primary care. If they choose to use another provider, then MSP should not pay for this privilege.

If I am this designated and remunerated provider, then it is my duty to be organized into a provider group that can guarantee 24/7 access to primary care for my patient. I have outlined this arrangement of designated provider working within a group and offering 24/7 primary care in articles I have written, published in the BCMJ.

This idea still does not have any traction in the new primary care networks (PCN) being pushed out the door by the Ministry of Health. This is why the new networks will fail. Let me be clear: these new networks will fail because they do not give this dedicated money to the specified providers as outlined above. A lot of money is being spent to develop these networks, but since it is not going to benefit primary providers the networks will not, in my opinion, get the necessary uptake by primary providers.

I recently hired a lawyer in Vancouver for some professional work. He did a good job and charged me $425/hour for his services. Just think what life would be like for family physicians if we were remunerated at this rate! It is what we deserve, but governments have beat on us for so long that we actually believe we are not worth very much.

I was involved in our PCN development on South Vancouver Island until it became evident that the ministry wanted family physicians to lead and organize medical homes for their patients and not be remunerated for their efforts. My suggestion was that participating physicians should receive an annual capitated stipend for participation based on their individual patient panels. I had worked this out to be $62 a year per patient. This would mean that if a physician had 1000 patients, that physician would be paid $62 000 year to be part of the PCN.

Even this amount would not really compensate for the added work that family physicians do, but it would be a start. This was rejected out of hand by the ministry. This amount would have almost put BC family physicians on par with Alberta, but still a long way behind those in Ontario. So, good luck to all the people who want to improve primary care. Babylon Health, pot clinics, and Copeman Healthcare Centres beckon. There is always an alternative to the suicide of family medicine as it presently exists in BC.
—Robert H. Brown, MD, CCFP
Sidney