Primary care renewal in British Columbia—long identified as key to health system sustainability—is finally getting the attention it needs to move from well-meaning talk to goal-directed action.
One strong indication is the Ministry of Health’s new Primary Health Care Charter, facilitating the shift from a system oriented to acute and episodic care to one based on longitudinal care for ongoing conditions. Another indication is the $382 million in last year’s agreement targeted toward incentives for general practitioners, acknowledging them as integral to primary care.
“The system and its payment structure required major changes in order to align with the needs of family physicians—and ultimately British Columbians,” says Valerie Tregillus, the ministry’s executive director, Primary Health Care.
Along with GP Bill Cavers, Ms Tregillus co-chairs the BCMA/MoH General Practice Service Committee (GPSC), originally created in 2002 but charged with significantly increased responsibilities as of the last agreement. To fulfill its mandate—finding solutions for challenges faced by full-service family physicians in BC—the GPSC has developed a two-pronged strategy: financial incentives and practice support.
“The UK experience shows incentives alone don’t work, so we’ve designed practice supports to enable evidence-based care,” says Dr Cavers. “And the key is—both government and physicians are accountable for making it work.”
Incentives in three priority areas
The GPSC’s original mandate was to allocate the $20 million from the 2002 agreement that was designated to support GPs’ care. The committee introduced a number of incentive payments under a Full Service Family Practice Incentive Program (FSFP). The following year, with additional funding, GPSC held a province-wide consultation with about 1000 GPs. The success of the initial GPSC incentives and the consultation feedback strongly influenced the outcome of the 2006 agreement.
Today, the GPSC is charged with defining strategies for how to best use the $382 million earmarked for primary care. Through this funding, the FSFP has been expanded to address three priority areas:
Chronic disease management: As of 1 April 2007 physicians receive a $125 incentive per patient per year for delivering guidelines-based diabetes and CHF care, and a $50 incentive per patient per year for providing guidelines-based hypertension management. “The result has been very positive, with over 2600 physicians billing for a $10000 one-time incentive, 2700 physicians billing for diabetes care, more than 1500 for CHF, and more than 2200 for hypertension,” says Dr Cavers. “Approximately 300000 patients have benefited.”
Maternity care: GPs are eligible for a 50% increase on the regular fee-for-service amount for up to 25 deliveries a year, including elective C-sections and postpartum care. A maternity care network program provides $1500 per quarter for GPs involved in a group approach to obstetrical care. Up to $1 million was also approved for a new maternity training program—starting August 2007—for GPs who want to update their skills.
Improved care of the frail elderly, patients requiring end-of-life care, and those with multiple medical needs: A facility-based conference fee supports GPs working in partnership with patients in a facility and with their family members, as well as with other health professionals involved in the patients’ care. A community patient conference fee supports these activities with community-based patients, families, and care providers.
Additional incentives include a complex care fee, enabling GPs to spend time with patients who have a combination of chronic diseases, and a prevention incentive. Ten million dollars have been put toward attracting and retaining recently qualified physicians in full-service family practice in underserved areas of BC.
Practice Support Program: Beyond incentives
“Independent incentives are important, but we are talking about full-system change,” says Ms Tregillus. “And just as the system needs to move from episodic to planned care, so does an individual physician’s practice.”
To support such change, a 2-year non-compensation-funded Practice Support Program (PSP) was developed to improve office practice. The program, delivered regionally by health authority change management teams, offers training modules in three areas: clinical, practice management, and information technology. Modules are developed by the BCMA, MoH, and IMPACT BC (Healthy Heart Society). Examples of topics are advanced access, developing patient registers, managing planned care, enabling patient self-management, introducing group visits, and improving access to care.
“Response has been positive,” says Dr Cavers. “We’ve already held 20 introductory sessions for more than 3600 GPs and their medical office assistants, and about half the physicians attending those have signed up for modules.”
Along with the thousands of incentives billed so far, reaction to the PSP signals an important shift in primary care, says Tregillus.
Future GPSC priorities include a mental health initiative, evaluations of the FSFP and the PSP, recommendations to support GPs in the provision of hospital care, and recommendations to enable shared care among GPs and specialists.
Members can view more information about the GPSC and its programs by clicking here, and logging in.
—Geraldine Vance, APR
Director, BCMA Communications
The BC Perinatal Health Program (BCPHP), formerly BC Reproductive Care Program, has revised the Provincial Antenatal Record Part 1 and 2. The revision was based on feedback from provincial providers as well as work from an expert working committee. The Guide for Completion for the Antenatal Record Part 1 and 2 has also been revised and is included in this issue’s polybag.
The Antenatal Record Part 1 and 2 (BCPHP [HLTH] 1582 Rev. 2007/06/05) is used by virtually all primary care providers throughout British Columbia. It is a tool developed to facilitate the assessment and documentation of pertinent information about the woman’s health and pregnancy care and provides a guide for the evidence-based components of prenatal care.
Specific fields in the antenatal record are collected as part of a comprehensive database for the British Columbia Perinatal Database Registry (BCPDR), which includes data collection from the entire suite of provincial perinatal forms. A new version of the Perinatal Database will be implemented on 1 April 2008. New data fields will be added and some pre-existing fields will be updated or replaced. The source for these data fields will primarily be the provincial perinatal forms; the antenatal record is the first in the suite of provincial forms that have been revised.
Key changes to the Antenatal Record Part 1 and 2 include:
• Deletion of the informed consent section.
• Expansion of discussion topics to differentiate first and second/third trimester topics.
• Inclusion of history on in vitro fertilization and artificial reproductive technology.
• Expanded information history of mental illness.
• Expanded information for substance use.
• Inclusion of exposure to secondhand smoke
• Inclusion of the body mass index.
• Alternate place of birth (hospital)—for planned homebirths only.
• Inclusion of HBsAg results and household exposure.
• Inclusion of postpartum rubella.
• Inclusion of newborn prophylaxis for hepatitis.
• Addition of new tools: body mass index graph, TWEAK (tolerance, worry, eye-opener, amnesia, cut down) scoring guide for assessing the risk of alcohol use, Edinburgh Perinatal/Postnatal Depression Scale scoring guide for assessing the risk of depression.
Begin using the new forms as soon as you receive them. Discard all old antenatal forms. It is important to begin using the revised antenatal record as soon as possible for new maternity patients.
The Antenatal Record Part 1 and 2 and the Guide for Completion of the Antenatal Record along with information on obtaining copies of the antenatal record are posted on the BCPHP web site at www.rcp.gov.bc.ca.
The BC Perinatal Health Program appreciates your assistance in improving and implementing a standardized antenatal record in the province. Please contact Ms Lily Lee or Ms Barbara Selwood, perinatal nurse consultants, at 604 875-3737 if you have any comments or questions.
Perinatal Nurse Consultant
BC Perinatal Health Program
ICBC agreed to increase the CL19 Medical Report fee by 3.5% on 1 August 2007 and a further 3.5% on 1 August 2008, for a total increase of 7.12% over 2 years. This increase applies to the CL19 bonus and telephone consultation as well.
Effective 1 August 2007, the new fee for a CL19 Medical Report (A00278) is $139.26. Fully completed CL19s submitted within 15 working days of the request will receive the bonus of $31.05 for a total of $170.31.
Consultations by meeting or telephone with an ICBC adjuster or authorized personnel (A00098) receive remuneration at a rate of $49.60 per 15 minutes or portion thereof, effective 1 August 2007.
If you have any questions regarding these new fees, please contact Ms Juanita Grant, manager of BCMA Professional Relations, at 604 638-2829.
Risk of transfusion-transmitted West Nile Virus
In Canada, the period of highest West Nile Virus (WNV) risk to blood safety occurs during mid-to-late summer, generally extending until the end of September. Since 2003, Canadian Blood Services has performed WNV nucleic acid testing (NAT) on every donation year-round. Routine donor WNV screening is performed in minipools of six specimens, whereas more sensitive, single-unit testing is done selectively for blood donations collected from regions of higher WNV risk. Higher regional WNV risk is based on detection of one or more WNV-positive collections during the previous week, or an incidence of public health—reported WNV cases exceeding 1:1000 in rural areas or 1:2500 in urban settings during a 2-week period. Although no case of suspected transfusion-transmitted (TT) West Nile Virus has been reported in Canada since 2002 (prior to implementation of WNV-NAT), two reported cases of probable TT-WNV reported from the United States in 2006 are reminders of an ongoing low, residual risk of TT-WNV.
Physicians’ roles in protecting patients from TT-WNV
Particularly during higher-risk WNV season, physicians who transfuse fresh or frozen blood products are reminded to discuss the potential risk of TT-WNV as part of the patient informed consent for transfusion.
Reporting suspected cases of TT-WNV
WNV developing within 4 weeks of blood transfusion may be transfusion-associated. Suspected cases of TT-WNV should be reported to CBS by phone at 604 876-7219 or by fax: 604 879-6669, as well as to your local medical health officer.
Enquiring about recent blood donation in patients with suspected WNV
Physicians should routinely question patients who may have WNV infection about recent blood donation. Suspect WNV-infected donors who have donated in the previous 8 weeks should be reported to CBS so that in-date components can be recalled as a precautionary measure.
Looking for more information?
For additional information about WNV-related transfusion practice, including this year’s provincial Action Plan for WNV and the Blood Supply, along with updates, please visit the Provincial Blood Co-ordinating Office web site at www.pbco.ca.
1. Busch MP, Tobler LH, Saldanha J, et al. Analytical and clinical sensitivity of West Nile virus RNA screening and supplemental assays available in 2003. Transfusion 2005;45:492-499.
2. Centers for Disease Control and Prevention (CDC). West Nile Virus transmission through blood transfusion—South Dakota, 2006. MMWR Morbid Mortal Wkly Rep 2007;56:76-79.
—Mark Bigham, MD
—Gershon Growe, MD
Canadian Blood Services, BC & Yukon Region, Vancouver
Vancouver Island Multiple Myeloma Support Group meets every second Monday of the month, Wellness Centre, Aberdeen Hospital, Victoria, 1:00–2:30 p.m., and the Vancouver Multiple Myeloma Support Group meets every third Saturday of the month, Vancouver General Hospital, Jimmy Pattison Pavilion, 2nd Floor, Round Room, 1:00–3:00 p.m.
These groups were formed to provide support and information to patients and their families who have been diagnosed with multiple myeloma.
A patient and family conference will be held on 3 November 2007 in Vancouver at the Morris J. Wosk Centre for Dialogue, 580 West Hastings Street.
For more information on the support groups, multiple myeloma, or to register for the conference, visit our web site at www.myelomavancouver.ca.
Did you miss the meeting held in your area last year introducing BCMA’s new health and welfare trust (the Core-Plus Plan)? If so, you have another opportunity to learn about this tax-effective method of reimbursing your health and dental expenses.
Ms Sandie Braid, assistant director, Insurance, will be holding information seminars around the province in September and October. In addition to reviewing the Core-Plus Plan, Ms Braid will answer your questions about the other programs offered exclusively to BCMA members, including how the government-funded Physicians’ Disability Insurance Plan works when you have either the BCMA Disability Income Insurance Plan or a private plan. The seminars will be cosponsored by MD Insurance Agency Limited, a subsidiary of the CMA.
The schedule of information seminars is shown below. All sessions will run from 6:00 to 8:00 p.m. and a light meal will be provided.
Personalized notices have been sent inviting members to attend the session closest to them. Information about the sessions will also be posted on the BCMA web site, www.bcma.org. If you are unable to attend a session in one of the locations listed below but would like more information on the insurance programs available to you through the BCMA, please call us at 604 736-5551 or toll free in BC at 1 800 665-2262.
Be sure to take this opportunity to find out what’s new about your insurance options through the BCMA. We look forward to seeing you soon.
|Vancouver||11 September 2007||BCMA Boardroom|
|Vancouver||20 September 2007||BCMA Boardroom|
|Kamloops||26 September 2007||Coast Canadian Inn|
|Prince George||27 September 2007||Coast Inn of the North|
|Victoria||3 October 2007||Royal Jubilee Hospital, Begbie Hall|
|Kelowna||4 October 2007||Manteo Resort Hotel|
If you are an incorporated physician and you are not participating in the Core-Plus Plan under the BCMA Health Benefits Trust Fund (HBTF), you could be missing an opportunity to save significant tax dollars. Now is the time for you to take advantage of this option—our annual Core-Plus Plan open enrollment period runs from 1 September through 31 October 2007.
The Core-Plus Plan provides extended health care and dental plans to help cover costs not paid for by the provincial health insurance plan. Members may enroll themselves (and spouse and children, if applicable) and their full-time employees.
Two distinct components of the plan enable you to customize your health care plans to suit your needs:
• Core Plan—a basic, competitively priced extended health and dental care insurance plan covering prescription drugs, basic dental, emergency travel, and other extended health care expenses (e.g., physiotherapy, psychology treatment, home nursing, medical equipment, etc.) through Sun Life Assurance Company of Canada.
• Plus Plan—a self-insured plan covering eligible medical and dental expenses not reimbursed by the Core Plan or covered by provincial health insurance. There are no up-front premiums to pay under the Plus Plan; payments are made by your corporation only when an eligible expense is claimed. Administration fees for claims processing by the BCMA are 7% of each Plus Plan claim submitted, to a maximum of $250. Since there is no restriction on the number of medical expenses that can be claimed at one time, administration fees on any claim over $3500 are limited to $250. For tax purposes, the cost of Plus Plan claims together with the administration fee is considered “premium.”
The HBTF satisfies Canada Revenue Agency’s requirements for private health services plans, therefore premiums for the Core Plan and Plus Plan are tax deductible to qualified physicians.
Details of the plan and an FAQ can be found on the BCMA web site, www.bcma.org, under “Insurance Services.”
To receive your enrollment package or to find out more about the Core-Plus Plan, call us at 604 638-2865, 604 638-2818, or toll free in BC at 1 800 665-2262, local 2865 or 2818, or send an e-mail to BCMAinsurance@bcma.bc.ca.
—Sandie Braid, CEBS
Details regarding the Early Adopter Program provided by the Physician Information Technology Office (PITO) have been announced.
PITO will provide funding and support to both new adopters of electronic medical record (EMR) systems, as well as pioneers who already have systems in active use in their offices. The Early Adopter Program provides bridge funding for up to 18 months of ongoing operation of an existing full clinical use EMR, contingent upon conversion to a PITO-approved EMR at the end of that period.
Existing users of EMRs will be able to apply to PITO for funding on a monthly basis for access to the PITO Private Physician Network. During that time, the regular monthly funding for the EMR and the one-time funding of $3500 for hardware will be queued up for disbursement upon conversion to a PITO-approved EMR. Upon conversion, the physicians will then also be eligible for the same one-time implementation and monthly ongoing funding as all other physicians applying to PITO. Details will be available on the PITO section of the BCMA web site at www.bcma.bc.ca.
Although it is preferable to wait until registered with PITO, physicians who need to pre-purchase PITO-compatible hardware can refer to eligibility criteria and instructions on the BCMA web site before proceeding.
The 2006 negotiated agreement provides nearly $108 million for the PITO program, which supplies funding toward hardware, software, and physician support specifically for physicians interested in implementing interconnected EMRs in their private offices.
A comprehensive request for proposals (RFP) process was designed to ensure the EMR vendors had the high-quality products and customer support required by this initiative. Thirty responses to the RFP were evaluated. Six successful proponents were identified and they will proceed to the next steps of contract negotiation and compliance testing with the Ministry of Health. Only upon successful completion of these two steps do they become PITO-approved EMR suppliers eligible for funding.
The RFP process was managed by the government’s Strategic Acquisitions and Technology Procurement (SATP) branch on behalf of the Ministry of Health. The process followed the steps described in the publicly available RFP document. The complete document can be obtained at www.bcbid.bc.ca, procurement SATP-219 “EMR RFP.” The process included almost 40 practising GP and specialist physicians from across BC selected by the Ministry’s Special Physician Engagement Expert Delegate Committee.
The RFP process will result in a contract between the province (on behalf of PITO) and the vendors that holds the suppliers accountable to their commitments in the RFP. This contract exists in addition to the individual contract signed by the physician group and the vendor. Many of the concerns the BCMA has heard from physicians in the past relate to EMR suppliers not meeting the physician’s expectations or the supplier’s commitments regarding support and performance of the EMR. The contract resulting from the RFP allows the ministry, on behalf of PITO, to establish and enforce contractual obligations with the PITO-approved vendors on issues such as:
• Implementation support
• Ongoing support (help desk, upgrades, etc.)
• Response time (performance) of the EMR
• Access to data in the EMR system on transition to a different system
In its initial period, PITO will be focused on the broad needs of the vast majority of physicians. As the program progresses, it will be reviewed to assess variations in the needs of BC physicians, including needs based on geographic locations, specialties, and subspecialties.
To this end, the RFP process specifically provides for an opportunity to add to the list of PITO-approved suppliers on or after 1 July 2009 should it be found, for example, that more diversity is required.
Current information on PITO and the implementation of the program, including hardware pre-purchasing options and support available to physicians interested in moving from existing EMR systems to systems provided by the PITO-approved vendors, is now available in the members’ section of the BCMA web site.
Mr Jeremy Smith is the PITO program director, and the PITO office is located on the 6th floor of the BMCA building at 1665 West Broadway in Vancouver. Information is available at 604 638-2946 or at email@example.com.
—Geoffrey Appleton, MB
(NC) September 16–22 is National Prostate Cancer Awareness Week. Signs of prostate cancer include:
• Frequent urination, especially at night.
• Difficulty in starting or stopping urine flow.
• Inability to urinate.
• Weak, decreased, or interrupted urine stream.
• A sense of incompletely emptying the bladder.
• Burning or pain during urination.
• Blood in the urine or semen.
• Painful ejaculation.
While all of these are signs of an enlarged prostate, most enlargements are not cancer. A regular digital rectal examination or a prostate specific antigen (PSA) blood test will help rule out cancer or catch it early.
Above is the information needed to cite this article in your paper or presentation. The International Committee
of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally
accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
About the ICMJE and citation styles
The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.
An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.
BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:
- Only the first three authors are listed, followed by "et al."
- There is no period after the journal name.
- Page numbers are not abbreviated.
For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org