A Fool and His Money

I work with a multidisciplinary emergency room team that tries to stop unnecessary hospital admission of frail old people. Again and again at the busy Vancouver General emerg family doctors who go on holiday without replacement, won’t make house calls, or whose office phone number prompts a recorded “go to the nearest emergency room” outside office hours are why frail people turn up there and end up admitted, for no good reason.

Nobody can blame our hard-working capable emergency room docs for wanting to admit a confused poorly-mobile old man who turns up in the middle of the night dehydrated, urine full of pus, suddenly unable to get to the bathroom. Typically how he was functioning and how confused he was before this recent change, how much help he was getting at home, and whether his family doctor is involved in his care at all just aren’t accessible and a “short admission to sort things out” seems the only safe thing to do. But getting that sort of person back out of the hospital too often turns into a multi-month-long nightmare. An expensive dangerous nightmare.

The General Practice Services Committee (GPSC) in BC has for many years now tried to reward “full-service” family practice through dozens of fee items for primary care of patients with lots of chronic conditions, mental health problems, and frailty. In particular it pays hundreds of dollars for each “attachment”, which means taking on a difficult new patient and being responsible for their care.

You’d think this kind of incentive would result in cost-saving as well as better care as “full-service” doctors get rewarded for avoiding expensive futile hospitalization, referrals, over-investigation, and over-prescribing. Interestingly, a recent paper by UBC epidemiology researchers suggests maybe not.

Looking only at the incentive payment for patients with two or more chronic conditions, researchers found no change in primary care access or continuity, and an increase in hospital admission associated with the extra $240 million paid to doctors for billing these incentives between 2007 and 2013. The authors commented “policy-makers should consider other strategies to improve care of this patient population”.

You think?

Wondering why the incentives weren’t working and what strategies might be more effective, I emailed the Medical Services Plan (MSP) to ask whether “full-service” primary care includes availability of a physician 24 hours a day and seven days a week.

It doesn’t. MSP told me, “There are no specific requirements attached to these GPSC fees with regard to out-of-office hours coverage” and referred me to the GPSC for further information. Vancouver Coastal Health recently looked at the proportion of Vancouver family physicians who provide 24-hour coverage and it was around 40%. I spoke to an associate registrar at the BC College of Physicians and Surgeons who was unhappy about this since the College practice guidelines mandate 24-hour physician availability. He commented the College isn’t in a position to do much because they only find out about off-hours vacancy if there is a complaint about a doctor.

I’ve had lots of conversations with colleagues who have no problem directing patients to emerg outside office hours and who bill GPSC incentives on every patient who qualifies. And I see first-hand in the ER how many unnecessary expensive hospital admissions of frail people happen because the patient and their family can’t get ahold of anyone on call for their GP at night.  Would we give better care and save more money if we offered elderly patients in crisis a primary care community alternative to the emergency room?

Damn straight, in my opinion.

I’m getting old myself, pushing 70. When I started practice 40 years ago unpaid 24-hour coverage was simply assumed. In 1980 a self-respecting city family physician would no sooner leave a patient without a doctor to call at night than ignore a breast lump or tell a 50-year-old with chest pain to take an Advil. But today’s practitioner (quite properly I think) expects not to be bothered during time off, or at least to be paid for being exposed to urgent calls in the middle of the night. I believe we are dreaming if we think we can return family practice to the dinosaur model of care I grew up with.

Maybe there is another, better way. Money on the order of dozens of millions per year paid to doctors for taking on care of difficult complicated people if “care” just means putting the patient’s name on a practice roster could be redirected. Willing capable family doctors could be paid to take night and weekend call, given access to EMR of practices being covered, report contact to the patient’s family physician, and still be rewarded fee-for-service for home visits, with some of that money.

I’ll see if the GPSC will talk to me about trying to get a bit better bang for their buck.

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 40 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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1 Response to A Fool and His Money

  1. John Gile says:

    John, I am a patient of Dr. Ted Rosenberg, participating in this program. I am nearly 92

    Instead of trying to fit the program into the provincial type, which is a burden for both sides, I suggest that you design a program that “covers the bases” for the clients and the doctors, and ask the Province to create a suitable blanket payment plan for this group that avoids all the visits, referrals, coverages, etc. into one package with single monthly payment – so much less work for all, especially the Province.

    Our numbers are relatively small, turnover is automatic, and our care needs pretty constant – should fit into a package pretty well. Restricted because of age, and Physician protected against malpractice or misunderstanding.

    Doctors would sign eligible patients up, submit forms to Province, who would issue a new card, or account. One blanket payment a month, no itemizing, simple bookkeeping.

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