Details released: What does the new B.C. FP longitudinal care payment plan actually offer?

British Columbia family doctors finally got the details of their new payment model that becomes active on Feb. 1. The B.C. Ministry of Health has released a 34-page document: The Medical Services Commission longitudinal family physician payment schedule. The payment model was first announced Oct. 30, 2020. It is an optional alternative to fee for service (FFS) that will raise the average community FP’s income from $250,000 to around $385,000 (as long as they practice longitudinal care). FFS codes were updated as part of the Physician Master Agreement B.C. physicians ratified at the beginning of December 2022. It will be up to individual doctors to look at the payment models side by side and calculate which one suits them best. (Physicians currently on contract might also be doing the math and making decisions about whether to switch.) Only the new model—called the Longitudinal Family Physician (LFP) payment model—will pay family doctors $130 per hour for at least a sizeable portion of the hours they put into indirect patient care. That is the LFP’s key attraction. Read: New Doctors of BC prez vows to push against forms, work on other issues What does the LFP actually offer? The LFP was developed collaboratively between Doctors of BC, B.C. Family Doctors and the B.C. Ministry of Health. Doctors of BC past-president Dr. Ramneek Dosanjh predicted the payment model’s impact could be “seismic”—helping FP’s whose practices have become unsustainable, and drawing FPs from specialized areas of practice, and perhaps from all over Canada, to practice longitudinal care in B.C. There are over a million people without a family doctor in B.C. who really need that to happen, and whose expectations were raised by the media attention that accompanied the LFP’s announcement. In a Jan. 23 news release, the new Doctors of BC president, Dr. Joshua Greggain, said the LFP will help alleviate the healthcare crisis. “We really feel like by lifting up family medicine, our primary care, and leaning into team-based care, the expectation and the aspiration, is that everything will get better in due time.” Dr. Greggain is a family physician. “This is an opportunity to transform the healthcare system by simply flicking a switch,” he said. To be clear, LFP does not pay physician overheads, nor is there an embedded provision which helps to fund team-based care in their practices. But Doctors of BC is separately collaborating with the Ministry of Health to make desired improvements to the province’s Primary Care Networks—a system that does provide and fund a certain number of nurses and allied health workers to support participating physicians. Dr. Greggain said there are currently 6,500 physicians in B.C., with only around 3,500 providing some amount of longitudinal care. During the pandemic, many B.C. doctors were either retiring early or leaving to work in other provinces where pay may be higher and/or office overheads lower, said Dr. Greggain. The LFP option will see family physicians paid $130 per hour whether they’re meeting with patients in person or virtually, reviewing test results, or managing their practice. With different billing codes for direct patient care, indirect patient care, clinical administration time, etcetera, doctors will have to develop efficient systems for tracking their time, with start and end times in 15-minute increments. But one could argue that that is preferable to working those hours for free. Physicians will also receive an annual amount per paneled patient, depending on complexity. While the standard amount is $34 per patient per year (higher for complex patients), “the methodology to determine complexity and the definition of ‘active patient’ have not yet been determined,” according to Part VI (19), page 16 of the MOH document. While this was not included in the calculation tables on the web page that accompanied the initial LFP announcement, there are caps on how much time physicians can bill for. See Part IV (12) of the schedule, on page 9: (a) Maximum daily time—The maximum amount of time payable under the LFP payment model is 14 hours in a single calendar day. (b) Maximum two-week time—The maximum amount of time payable under the LFP payment model is 120 hours in any 14-day period. (c) Maximum clinical administration time—The maximum amount of time billable as clinical administration time … is 10% of the total amount of time claimed by the physician in a calendar year for direct patient care ….and indirect patient care …and clinical administration... It is anticipated that clinical administration time for most physicians will be in the range of 5% of the time claimed under the time codes. Will these time increments and schedules clash with certain physicians’ practice style/habits—or even just personalities? Physicians will still bill for each patient interaction (like they do in FFS) receiving between $25 and $110 per interaction depending on its type and complexity. A house call, for example, is $100—plus it’s portion of the $130 hourly rate. The smallest unit of time for a direct patient interaction is 15 minutes. Who is eligible? The services required of physicians to be eligible for the LFP are as follows, in Part II (6), page 2: “A physician enrolled in the LFP payment model must: (a) commit to provide all the required services; (b) develop and submit an accurate list of active patients for whom they have accepted responsibility by July 1, 2023 or within three months of enrolling in the LFP payment model, whichever is later; (c) provide timely, accessible, comprehensive, and relationship-based care to patients by working and collaborating with other physicians and healthcare providers when appropriate; (d) provide LFP practice services for a minimum of one day per week to a panel of at least 250 active patients, distributed equitably over the course of a year. This minimum is based on the physician’s usual work arrangement. It does not include temporary absences or decreases in days worked related to illness, vacation, parental leave, caregiving, military deployment or other reasons. (e) ensure that non-panel services are no more than 30% of the total of LFP practice services and non-panel services. (f) provide community longitudinal family physician services, aligned with the attributes of a patient medical home; (g) provide patient care consistent with any interim or permanent guidance on the appropriate use of virtual care in physician practices endorsed and/or issued by the College of Physicians and Surgeons of B.C. Unless CPSBC guidance on the appropriate use of virtual care states otherwise, the physician must provide both in-person and virtual visits to patients in their LFP clinic. (h) encourage patients to participate in a provincially administered patient survey about primary care experiences; (i) create and maintain adequate medical records; and (j) agree to the audit and assessment authority of the Medical Services Commission as set out in the Medical Protection Act.” Item (e) above may impact walk-in clinics—whose clients are generally “non-panelled” in B.C., even though College of Physicians and Surgeons of B.C. regulations require the legal doctor/patient relationship to be the same as in a regular medical clinic. Some clinics are currently mixed—having a walk-in clinic to provide service to unattached patients as well as a regular panelled practice. Either way, the new 30% rule (and the hourly limits on patient numbers) will likely affect how walk-ins are managed in B.C., and how much volume they handle. Dr. Bridget Reidy is a family physician practising on Vancouver Island. “I expect most (walk-ins) will attach all the unattached that they care for (with the exception of tourists and such),” Dr. Reidy said in an email exchange with the Medical Post. “Those who want to increase attachment and are doing some walk-in care will likely use the walk-in to find more to attach.” Her observations are echoed in comments posted on the BC Healthcare Matters Facebook page—where there has been a lively discussion surrounding the release of the LFP payment schedule. “I can see the max 30% income from walk-in to be encouraging docs taking patients and not do walk-ins … however the issue is we are critically short on docs so pure walk-in clinics will cease to exist,” opined one family physician. It is important to point out that for many “unattached” B.C. residents—other than lining up at the emergency room or their local urgent and primary care clinic, walk-ins are the only option for care right now. Will it work to keep and attract doctors? The original announcement was skinny on details. Now that the whole cat is out of the bag, so to speak, how are physicians responding? Is the new payment model attractive enough to actually lure FP’s from hospitalist jobs, emergency shifts and other areas of specialized family practice they have fled to, into longitudinal care where they are critically needed? Will it draw new grads into longitudinal care? Or will it just improve work conditions for physicians already working in longitudinal care, but under huge financial duress? Dr. Reidy’s decision has been easy because she has a panel of mostly chronic, complex care and geriatric patients, with a major amount of indirect care that has been unpaid, until now. “I plan to sign up in time to start the first day,” she said. But many other physicians—especially the young physicians the LFP-designers hope to attract—are maintaining a cautious approach, and choosing not to go on the record. One young Vancouver family physician—who is connected with many mid-career physicians her age, (who are working as hospitalists, emergency physicians and other specialized areas of family practice) said this in an email: “While many colleagues are feeling more optimistic about longitudinal family medicine, the new fee structure’s impact on accessibility and sustainability of family practice remains to be seen. There are many promising components to the new fee structure—particularly the ability to be compensated for non-clinical time which is a very significant part of a family doctor’s day. However, for my colleagues who currently do not practice longitudinal primary care, they are not jumping back into traditional family practice. There is definitely a careful eye being kept on whether this will make primary care more sustainable as a business model and career option, but the success of the new fee structure will determine whether those not practising longitudinal care return to their offices.” What these words may suggest is that improving pay for doctors who are already practising longitudinal care is one thing—an important step toward helping to ensure their practices are sustainable, in a province that has some of the most expensive business real estate and housing in Canada (and until now was said to have the second lowest FP remuneration). But as a career and lifestyle choice for a young family physician, taking on a longitudinal practice compared to, say, working as a hospitalist still means having to be available or make arrangements 24/7, versus working shifts and going home. It still means being legally responsible for your patients’ medical records in B.C., versus the hospital taking care of that. It still means having to pay the salaries of your staff, and the business overheads, versus just showing up for work and collecting a paycheque, hassle free. It is, for a young physician, a complicated choice. Only time will tell whether the LFP is a comprehensive enough draw to start filling B.C.’s doctor/patient gap.

Details released: What does the new B.C. FP longitudinal care payment plan actually offer?

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