Doctors see fewer patients in move to end fees

Posted on September 14, 2011 in Health Delivery System

Source: — Authors: – news
Jul 20, 2011.   Tom Blackwell

Doctors in P.E.I. reacted indignantly this month when the provincial government sent many of the island’s salaried physicians an unusual letter, informing them in no uncertain terms that they had to see more patients.

Salaries have become an increasingly popular replacement for the traditional practice of paying Canadian MDs a fee for each service they perform. But, the province complained, many doctors are simply not scheduling enough appointments in exchange for their $150,000 paycheque.

The conflict underscores a little-discussed fallout of Canada’s wholesale shift toward new ways of compensating physicians. As growing ranks of doctors move to salary or other pay alternatives, the productivity of the medical workforce is plummeting. Evidence suggests that doctors receiving less-conventional types of remuneration see as few as half the patients as colleagues still on fee-for-service.

Advocates of alternative payment say it leads to longer patient visits, more preventive care and generally healthier people, who will ultimately end up costing the system less. Critics say there is little empirical evidence confirming those theoretical benefits, while the fewer patient visits only exacerbate the country’s continuing doctor shortage.

“It’s human nature: If you put someone in a job and you say, ‘The harder you work, the more money you make,’ then they’re going to work harder,” said Dr. Mark Baerlocher, an Ontario radiologist who headed a study on productivity in the new systems. “The flip side is if you start putting people on salary, you take away their incentive to see more patients and work harder.”

One P.E.I. family physician who is now on salary conceded Tuesday she may have fewer patients rotating through her office than many fee-for-service colleagues. Dr. Rachel Kassner said she works just as hard, however, is able to spend longer with people — hearing more of their complaints on each visit — and is avoiding the burnout that came with her fee-charging years.

“I was seeing about 40 patients a day and was going home totally exhausted and questioning a lot of what I did,” said Dr. Kassner, who is also president of the Medical Society of P.E.I. “When you’re exhausted, you can make mistakes.”

For decades, most Canadian doctors billed for each service carried out, using the payments to cover their office expenses and pay themselves. Much research, though, has pointed out the system’s pitfalls, including rushed visits, scant preventive medicine and an emphasis on carrying out procedures that generate billings rather than more holistic care.

Lately, doctors have been moving toward new payment schemes, often part of government-sponsored reforms that, for instance, group doctors together with nurses and other health professionals. The latest National Physician Survey of 18,000 Canadian doctors showed the portion who receive just fee-for-service has dropped to 42% from 51% in 2004.

Yet relatively little attention has been paid to what effect the trend has had on the number of patients each doctor treats. The issue has consequences: an estimated four million Canadians still have no family physician, while shortages persist in almost every specialty.

In fact, fee-for-service doctors see twice as many people per week as those on alternative payment schemes, according to a 2007 study spearheaded by Dr. Baerlocher, based on responses to the National Physician Survey.

A more statistically exhaustive analysis of the same survey data by a health economist at the University of Western Ontario concluded that doctors on alternative payment plans see up to 30% fewer patients per week than their fee-for-service colleagues.

Prof. Sisira Sarma said the ideal is probably some mix of different ways of paying physicians, but argued the shift to alternative payment has occurred with virtually no scientific examination of whether one system delivers better service to patients than the other.

“We need more study to find out if the reduction in productivity … is compensated by a larger improvement in quality of care,” he said. “Because we are spending millions and billions, essentially, across the provinces, and we don’t have very rigorous evaluation.”

In P.E.I., a move away from fee-for-service over the past decade has resulted in 70% of physicians going on salary. The government recognized those doctors would see fewer patients, and increased the number of family physicians to 92 from 75 to compensate.

Even so, some of the new salaried doctors did not have the expected 1,500 patients in their rosters, and the number of islanders without a family physician has stayed the same over the past few years, said Dr. Richard Wedge of Health P.E.I.. So, the agency mailed letters recently to 20, telling them they had to fit as many as 450 more patients into their practices.

“Their colleagues are all complaining because they’re working side by side and one guy is seeing 25 people a day and the other is seeing 15 and they’re both being paid the same,” said Dr. Wedge.

Dr. Kassner complained, however, many of the offending physicians did have enough patients, or were never told they had to have a minimum number or have many complex, time-consuming cases.

Still, the issue seems to be causing concern elsewhere, too. Many of the government officials interviewed for a 2009 study by a team at Dalhousie University worried about salaried doctors who spend longer with patients — but see fewer of them.

“The concern was that the model cost more money, while not leading to a greater level of service, as defined by access for all patients,” said the paper co-authored by Prof. Dominika Wranik.

Many experts, however, argue alternative payment and related reforms have been a clear success. In Ontario, two million people are now served by family-health teams, where doctors work with other professionals and receive a combination of “capitation” — set yearly payments per patient — fees and incentive payments to do preventive and other enhanced care.

They see fewer patients than those just on fees, but potentially provide more comprehensive treatment and better preventive care, while curbing the number of emergency-department visits, according to a study published this year. It admitted, however, that no research has yet proven those benefits are being achieved.

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