Longitudinal pay: B.C. plan acknowledges value of family physician admin time

The deluge of paperwork that is wearing down doctors only seems to be getting worse. Doctors of BC past-president Dr. Joshua Greggain estimates it is 20% to 25% of what family doctors do.But British Columbia has found that overstretched FPs are way more accepting of the long hours soaked up by indirect care if they can see their time is valued. Launched on Feb. 1, 2023, B.C.’s new Longitudinal Family Physician (LFP) model does that, paying eligible FPs $32.50 per 15 minutes for patient care—direct and indirect—with a cap of 120 hrs per two weeks.“It’s a complete shift in how we do things,” said West Vancouver family physician Dr. Maryam Zeineddin, one of five young FPs who helped to negotiate the LFP (along with then Doctors of BC president Dr. Ramneek Dosanjh, Dr. Greggain, board chair Dr. Adam Thompson and BC Family Doctors past-president Dr. Renee Fernandez).“Now, physicians are getting paid for the administrative work that they’re doing after they see their patients. And that’s a huge win for physicians because they were just doing that paperwork at night after they went home,” Dr. Zeineddin said.Blended pay modelDoctors of BC describes it as a blended payment model that compensates FPs practising longitudinal care for:physician timeinteractionsthe size and complexity of a physician’s patient panel.There’s also a $25 fee billable per patient encounter per direct interaction. LFP is optional. Some FPs work on contract, some have chosen to remain on fee-for-service (FFS). But for the more than 80% of eligible FPs who have opted in, the LFP has boosted income at a critical moment when there were reports across the province of FPs leaving their practice. Numerous walk-in centres had already closed.“I was on the brink from burnout and lack of having another colleague, as well as the financial strain of not being able to make ends meet,” said White Rock, B.C., family physician Dr. Tahmeena Ali. “There were many, many, many doctors like myself, who were on the brink,” she said. “I think we would have really seen the collapse of primary care if it wasn’t for the LFP. Because it was a breaking point.”Dr. Ali said the LFP has made her practice financially sustainable again. Elated that it seems to have changed the whole recruitment environment in B.C.—for the better—she is about to welcome two new FPs to her practice, one from the U.S. and one from the U.K. “We’re hoping that each of them will attach another 900 or 1,000. So we’ll probably be at just under 3,000 patients,” she said.The boost in income for FPs in the plan is substantial. “It’s hard to give you an exact number, but anecdotally, what we’ve seen is (doctors now earning) about 30% more,” Dr. Greggain calculated. “Over the last 20 years, family medicine in B.C. had been underpaid, so although that sounds like a lot, 30% was just getting back to where many other provinces were.”700 docs to longitudinalIn its short life so far, the LFP has drawn 700 additional FPs to longitudinal care, according to the BC Ministry of Health.Who are these doctors? Some may have been hospitalists who switched to longitudinal care as there is now reportedly a shortage of hospitalists in some hospitals. But as to whether they are new FP grads or IMGs the data only records them as new FP registrants and doesn’t source them beyond that. For now, with about a million people without doctors in B.C., that’s probably meaningful enough.How did this change of paying doctors for the indirect care they were previously providing for free come around? B.C. was at a breaking point, with overstretched FPs like Dr. Ali struggling to pay their overhead, and the number of unattached patients had become too critical to ignore. Those were preconditions for the LHP, but not the trigger, with many provinces experiencing an identical crisis.What made the government uncomfortable enough to create a new solution in B.C. had a lot to do with a grassroots citizen movement that was applying huge pressure: BC Health Care Matters (BCHCM).Still active and vigilant to this day, BCHCM advocated on social media and the lawn of the provincial legislature for better pay and better work conditions for FPs. Central among their expressed goals: to create an urgent plan of action that would recruit and retain FPs and attach them to patients. They kept real stories that illustrated the consequences of not acting on the front pages of newspapers, on community radio and on TV—not just a couple of times but relentlessly.It was good timing. As whole families carrying placards demonstrated, together with healthcare workers, Doctors of BC was in the thick of renegotiating its master agreement with the province. “The timeline really was (the BCHCM) protest in May of 2022,” Dr. Greggain recalled. “That day was when (B.C. Premier) John Horgan and Health Minister Adrian Dix met with Drs. Thompson (and) Dosanjh. They committed to doing this. And then in June of that year, we started to meet as a cohort.” After that, there was a summer of a lot of work before the LFP was announced on Oct. 31, 2022.Dr. Greggain credits B.C.’s health ministry with realizing they needed a different future. “Too many times in history there’s been this, ‘I’m going to solve a problem and tell you the answer.’ This truly was humility from the ministry, and I’ll point specifically to Stephen Brown, the deputy minister. He said, ‘Let’s solve this together.’” Dr. Greggain said of the process: “It wasn’t adversarial, it wasn’t fighting. We (saw we had) a common goal. And that’s why this was successful.”The ideaDr. Fernandez is widely credited with being the plan’s first architect—but much of the initial work was done by five Gen X female physicians brainstormingone spring weekend in 2022, sketching out the first iteration of the LFP. Besides Dr. Fernandez, that was Drs. Ali, Zeineddin, Dosanjh and Goldis Mitra (a Lower Mainland FP).“Every innovation starts with an idea,” Dr. Fernandez wrote in an email to the Medical Post. “We blended three different payment models together (mainly drawing from two non-profits in the U.S.), informed by evidence from other health systems. We combined our knowledge as health leaders and our personal experiences as family physicians.“In just eight months, the LFP journey moved from a whiteboard in one sunny office to thousands of family physician clinics around the province. It has shown us that we can be nimble when faced with a crisis. We can be bold when physicians and government work together for a common purpose. It has shown that we can make a difference for patients and physicians today while also creating a better tomorrow,” Dr. Fernandez wrote.Next generationDr. Greggain said the LFP’s impact is being felt at the University of British Columbia’s medical school.“It’s hard to equate (monetary) compensation with joy, but the payment model fundamentally honours the work that you do with patients (and pays you for it),” he said. “And so I think people have both first felt relief, but also then some admiration, and then some gratitude for the payment model, which made them stick around.“Ultimately, when FPs stick around and they share positive vibes or positive ways, that encourages others. Whether that be medical students or residents, they say, ‘Oh, this is not only a viable profession, but something I want to do, because these physicians are really quite content.’”That’s different from what we’ve been reporting in recent years, in Saskatchewan, for example, where third-year medical student Nima Hamidi Toussi (who is from B.C.) observed last year that—at least at his school (University of Saskatchewan)—students exhibit a bias against family practice practically from day one. (He did an informal lunch room survey).But Toussi said the uplifting impact of the LFP is being widely felt amongst his generation. “I think the dynamic around family medicine, at least in B.C., has changed significantly by changes to the LFP model,” he wrote in an email to the Medical Post. “Case in point, I’ve shadowed a brilliant family doctor in B.C. for part of the past two summers, and in her words, the introduction of the LFP has completely changed her morale and her future career plans. Amongst students in my school, there’s openly expressed interest in completing family medicine residency in B.C. because of the LFP. As far as how family medicine is advocated for as a career, I can’t say if it has changed much here, but in my limited experience with B.C. family physicians, there is certainly more of an endorsement—rather than defence—of selecting family medicine as a career.”There is early feedback from other young doctors. Earlier this year a group of five UBC family medicine residents (Drs. Kristie Chau, Spencer Cheyne, Philip Green, Matthew Lum and Kristen Wiemken) completed a survey on the impact of the LFP on family medicine residents. The survey found:65% of eligible residents responded that they would sign onto the LFP model upon practicing in comparison to 4% who plan to sign under the FFS model and 12% who plan to practice under an alternative service agreement.44% of residents responded that the LFP model very much influenced them to increase the percentage of weekly clinic hours they spend in longitudinal primary care.“When I speak to the residents who graduated just this last June, they will have started in family medicine in July 2022 and finished this year. So they got to see what family medicine was like pre-LFP, and then they got to see it during LFP,” Dr. Greggain said. “They tell me, in no uncertain terms, that their preceptors are happier and more engaged, which inspired them to choose longitudinal family practice as much as anything.”Other provincesJurisdictions across Canada—competing for FP recruits—have begun scrambling to factor indirect care into their own payment models.Nova Scotia was the first to follow B.C.’s example, a year ago tweaking its FFS model to include a set hourly fee for time attending to patients, direct and indirect. Similarly, it has introduced quarterly remuneration calculated in accordance with each FP’s panel size and patient/demographic complexity.Are N.S. family doctors—like their B.C. counterparts—earning more under the new payment plan? There’s been about a 10% to 15% increase in earnings, according to Doctors Nova Scotia past-president, Dr. Heather Johnson. “And for some people, depending on how you work, it could be substantially more.”Manitoba has also established a plan using its existing FFS framework but with payment for indirect time. The Manitoba model caps indirect time at three hours per doctor per week.Prince Edward Island has jus signed a new contract that gives FFS doctors a way to bill for indirect care.

Longitudinal pay: B.C. plan acknowledges value of family physician admin time

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