Why doctors must start thinking like CEOs

Maybe I’m burned out, sure, but maybe I’m just sick of not getting paid for the work I do. I’m a psychiatrist, and it is shocking to me that we physicians routinely don’t get paid for work we’ve done.

In BC, the Medical Services Plan (MSP) often doesn’t pay. We get cryptic notes like “BH—This claim will be processed on a future remittance statement.” No date. No clarity. As of the time of submission of this letter, I have over $3000 in accounts receivable from BH-coded claims from MSP, spanning months. No indication of what they are doing or when the claim will get paid. Are they drawing cards from a hat to figure out when they will pay those claims?

Next time I go to file my income tax, I’m going to write “BH” on the provincial portion. And when they call me and ask me for details, I will tell them, “This will be processed in the future. That’s all I can tell you at this time.”

This is not true in all situations. I get paid for 100% of the work I do in my outpatient clinic. And I get paid on time. It’s the emergency work, the hospital work, the work I do with marginalized folks that doesn’t get paid. And there are two reasons for that.

First, we do not demand that MSP pay on time. Do other businesses have problems getting paid? Maybe, but they go after their payments. They go to collections. They don’t work with those clients anymore. Months can go by without getting paid for certain claims. And we are helpless. Try doing accrual accounting with that. Forget net 15 or net 30. In BC, with MSP, it’s net WWFLPYD (whenever we feel like paying you, doctor).

Second, MSP does not pay equitably for a lot of marginalized folks. They won’t like that I’m saying this, but it’s simply objectively true. I do a lot of free work at Kelowna General Hospital. I see this most often with folks who are marginalized and may not have the resources or capacity to keep up MSP coverage. MSP points to the Enhanced Urgent Care Coverage Program (EUCCP). But in real life, the EUCCP has worked 0/8 times for me, because to get paid, I’m supposed to collect “proof of residency”—a utility bill, an employer letter, or a signed questionnaire—from the patient, someone I am involuntarily admitting to a windowless locked room while administering antipsychotics and sedatives they do not think they need. The last time I tried to ask a patient in this situation if he had a utility bill so that I could get paid, he quickly reminded me what he thought of me at that moment. I will not be doing that again. (He also doesn’t have a hydro bill, because he doesn’t have a home.) But, as a firm believer that they would pay me for the work I did, when I first moved to BC, I submitted multiple EUCCP claims anyway. Success rate: 0%. Also, FYI, you are not contacted about the claims. They just … disappear. No call. No explanation. And when you call them? And you get transferred to the right person? They dismiss you because you didn’t get the proper documentation from the patient you were putting in four-point restraints.

Show me another business that tolerates this. Most businesses set payment terms and enforce them. But BC doctors? We’ve normalized dysfunction. Maybe because many BC physicians don’t realize that in other provinces, you actually get paid for every code you bill. On time. We are contractors providing services to the Province of BC. Why are we (physicians) taking the loss? That’s for the BC government to solve.

We are not contracted by the patients themselves. I would argue that it’s not very ethical (and certainly not very practical) to send an invoice to a patient you involuntarily kept in hospital for days while giving them medications they didn’t want or think they needed.

This isn’t just about physician pay—it’s also about care. When the system makes it impossible to be paid for treating the most marginalized patients, it creates pressure to spend less time on them. That’s not the health care system we claim to be.

We weren’t trained to run businesses. This is hugely advantageous for the system. We don’t know that this isn’t normal. Oh, and by the way, don’t contact your hospital for help. They would rather bring in their lawyers to ensure they don’t have to help you. Trust me. I have it in writing: your hospital is not responsible for helping doctors get paid.

I, like you, should be getting paid for 100% of the contracted work I do within our public system. What would fix this?

• Real timelines for MSP payments. I suggest net 15 or net 30, in keeping with insurance company standards.
• Charging interest. We (doctors) should be charging interest on unpaid claims, like every other business out there.
• A workable path to pay for emergency and involuntary care that doesn’t hinge on documents patients in crisis cannot and will not produce. We (doctors) are not contracted by patients. We are contracted by the Province. If somebody is in your province, and we are providing emergency care for them, we should get paid—even if they are experiencing homelessness, schizophrenia, or substance use disorder.
• Hospital processes that start coverage support at admission—not after discharge, and not never.

We are the owners of our practices—whether we claim the title or not. It’s time to act like it. Because honestly, in what other business would this be acceptable?
—Marie Claire Bourque, MD, MSc, FRCPC, DABPN
Kelowna

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