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Family Physicians Frustrated with ‘Fee-for-Service’ Billing

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Pandemics are mirrors.

Not the kind that are placed above bathroom sinks or inside stores to beautify the beholder. These are sharp shards, broken and browned, scattered carelessly on the path to recovery, forcing us to pay attention to what they reflect.

One such mirror is being held by healthcare providers. Some family physicians in Newfoundland and Labrador are bringing to light a pertinent issue that they say impacts the quality of patient care: fee-for-service clinics

“When you look back at what was going on in the 60s, we had a lot of baby boomers going through that needed acute care… there was very little chronic disease management,” Dr. Sonny Collis, President of Newfoundland and Labrador College of Family Physicians, told the Independent. “If [people] had a problem, they found a doctor and they got something for it. So, [fee-for service] kind of naturally fell that way.”

Fee-for-service physicians, as the name suggests, are small business owners that bill the provincial government for the services they provide to their patients. They are responsible to pay their own staff, office rent, medical equipment and supplies and any other costs that may be associated with running a business.

Like Dr. Collis, Dr. Nicole Stockley is a FFS family physician and the Past President of the Newfoundland and Labrador College of Family Physicians.

“The FFS model encourages quick visits with large numbers of patients,” Dr. Stockley explained to the Independent “It unfortunately does not reflect the time required to care for complex patients, or patients with multiple concerns. It does not encourage high quality of care, instead it focuses on quantity of visits.”

Physicians across the country—not only in Newfoundland and Labrador—have felt the need for this model to be overhauled.

Eight years ago, a study conducted by the National Centre for Biotechnology (NCBI) determined that “newly practising physicians in [British Columbia] preferred alternatives to fee-for-service payment models, which were perceived as contributing to fewer frustrations with billing systems, improved quality of work life, and better quality of patient care.”

Dr. Collis added that not only did this bring down the quality of patient care, but in today’s time FFS struggles to meet challenges associated with changing demographics and an emphasis on preventative care. With the average time given to a patient being anywhere between 10 and 15 minutes, and with the model encouraging physicians to see a certain amount of people per day, FFS can create situations where an individual needs to be seen two or three times for the same illness as opposed to dealing with all the issues at once. This translate to longer wait-times, physical and mental stress for patients, and higher costs to the healthcare system.

In terms of dollars, the Canadian Institute For Health Information, for the year 2017-2018, reported that the average gross clinical payment for family medicine physician was $211,000 in NL, the lowest in the country (with data from the Northwest Territories and Nunavut being unavailable).

Virtual Reality

Apart from dealing with an antiquated system, the lack of direction around virtual care (and its associated billing) since the public health emergency was declared has been further salt in the wound for family physicians across the province.

During the early stages of the COVID-19 situation in NL, Dr. Stockley and the Newfoundland and Labrador Medical Association (NLMA) had raised questions regarding the billing of virtual care.

Family physicians were using virtual methods of communication to provide patient care while encouraging physical distancing. But an appropriate billing code hadn’t been implemented, that would allow physicians to bill the province, pay themselves and their staff, and run their practices. Such a code had already been in place in other provinces such as BC and Ontario.

On March 20th, Premier Dwight Ball and Minister John Haggie announced that they had reached an agreement with NLMA to provide virtual care. A billing code for this fee-for-service was introduced and family physicians were promised that payments would be retroactive to the start of the public health emergency.

While happy and relieved that the government supported virtual care, Dr. Stockley was disappointed with the way the message was delivered.

“I was very disheartened to hear the Minister of Health announce to the public that doctors could start virtual care immediately, when those doctors had not yet been informed,” she said. “Surely, the NLMA should have been allowed to notify physicians first, so that we could prepare for a public announcement.”

Catching the Early Signs

Virtual care seems to be a hit with Dr. Collis’ patients. Open to the idea and garnering positive feedback, his patients have wondered why this wasn’t in place before. But while virtual care may become a staple in healthcare, what it cannot fix are the inherent problems with fee-for-service.

In a pandemic, family physicians are usually the first point of contact for what may appear to be a minor ailment such as a cough. What happens if quantity is given preference over quality?

“Honestly, I don’t know if we can speculate at this time what impact ongoing FFS will have,” Dr. Stockley said. “I expect that we may get to the point where physicians will be asked to go where they are needed, regardless of billing modality.”

When asked what the chances are of cases slipping through the current FFS model in the nascent stages of a pandemic, Dr. Collis was unwavering in his faith in the physicians of the province.

“I don’t think the payment model will change that. Physicians, we will do what they need to do to take care of people. But I think another form of payment, certainly, would be better for the physicians.”

Hard Decisions Bring Wins in the End

Prior to COVID-19, changes have been made to the compensation models for family physicians across the country. Slowly but surely, fee-for-service is giving way to blended models that may include a base rate payment, associated basket of core services, and access to bonus calculation.

But in Newfoundland and Labrador, family physicians largely continue to be paid via FFS. Why hasn’t there been an overhaul in the billing modality here?

“I’ve been talking about this since 1996. I asked myself that question every day,” Dr. Collis told the Independent.

Boiling it down to two main reasons, he explained that there has been a push for primary care reforms. But due to the lack of infrastructure and the apathy of most governments—past and present—to bear a financial investment up front, the efforts haven’t created the tangible change that physicians and patients need.

“Most governments are going to have to put a financial investment up front to get wins in the end,” Dr. Collis stated. “And I think I think a lot of governments, especially our government right now with this horrible fiscal restraint, which is probably going to be much worse, how do you justify putting more money into the health care system to save some? Hard financial decision to make.”

In the wake of COVID-19, it remains to be seen what healthcare reforms and restructuring may occur—and if billing systems that prioritize quality patient care will finally be implemented.

Photo by Hamid Tavakoli.

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