In 2015, 16.2 per cent of British Columbians aged 12 and older did not have access to a primary healthcare provider. Four years later in 2019, that number rose to 17.7 per cent. According to Statistics Canada data, Canada is experiencing a shortage of healthcare providers, and provinces like B.C., Saskatchewan and Quebec have a “higher proportion of residents without a regular health care provider.”
Many worry that B.C., along with the rest of Canada, is experiencing a shortage of physicians.
In 2015, B.C. had 232 physicians for every 100,000 residents. By 2019 that ratio had decreased to about 228 for every 100,000 residents while the province’s population increased by around 327,300 people. Canada’s average throughout the provinces was approximately 227 physicians per 100,000 residents.
One of the possible reasons for B.C.’s shortage is tied to the model in which physicians are paid.
B.C. gives physicians the option of receiving their payment through the fee-for-service or alternative payment program. Through the fee-for-service payment method, the provincial government pays doctors for each patient visit or medical service given. The province’s Alternative Payment program refers to any other way doctors get paid for their work outside of the fee-for-service model.
Dr. Ramneek Dosanjh, president of Doctors of BC, an organization that works to advocate for doctors across the province, says the fee-for-service model is one that still works for some, but as time has passed it hasn’t always worked well for every clinic.
Dosanjh says the province needs to look into creating various other payment models and allow physicians to pick what works best for their practice.
A recently published study from the British Journal of General Practice found that resident family physicians and early-career family physicians in Canada are choosing to work in a “focused practice.” B.C. is one of the provinces the data was gathered from.
According to the study, one of the reasons physicians were choosing a “focused practice” was out of a need for “self-preservation” in the current health care payment system, as well as the support they would receive from their colleagues.
With the payment method B.C. uses for its health care system, Dosanjh says it’s challenging for doctors to maintain the business side of their practice as well as the clinical aspect.
“When you have to manage your staff, your human resources. With the increased risk of business cost premiums, running your business, and providing clinical care, that can be challenging for some people,” Dosanjh says.
“Some people just want to be paid with a salary or an alternative payment model that works for them and the way they choose to practice.”
Dosanjh says creating multiple payment plans protects the autonomy of physicians working in clinics. She says not every physician wants to think about running a business, and many would rather focus on helping patients.
According to a report published in Canadian Family Physician and written by Renee Fernandez, the executive director of B.C. Family Doctors, the fee-for-service model impacts the quality of service doctors can provide to their patients. At times, physicians can only focus on “one problem per visit” and patients from marginalized communities are not served as well as they sometimes need.
Due to some problems deriving from this payment model, the alternative payment plan is one The College of Family Physicians of Canada reportedly wants the government to look into, including capitation, blended compensation models, and salaries are some of the payment methods.
With capitation payment, physicians are compensated a certain amount for every patient they attend to in a year, and the amounts are adjusted to account for the complexity of the patient’s health conditions. Other factors like their age can also play a part in the total amount the physician is paid.
The blended compensation model combines this with fee-for-service payments.
Sometimes the fee-for-service payment results in physicians getting paid less even while their workload increases.
Dr. Anthony Fong, an emergency room doctor and clinical assistant professor at the University of British Columbia says for patients between the ages of two to 49, doctors are paid $31 for an average visit. That amount has increased by just three percent over the past five years, and has been outpaced by inflation.
Fong says in the 1990s seeing a patient in that age range may have been simpler, and the fee-for-service model went further in supporting family doctors financially.
“Nowadays, because of the aging population and the increasing expectations of family doctors, they have to do more work per patient to earn that amount,” he says.
Increasingly, physicians are choosing to spend time working in hospitals instead of family practices because of the way in which fee-for-service payment works.
“The payment systems for those services are much different, especially for hospital-based care,” says Fong.
“The fees are higher, the overheads are lower. And they find that it’s a much more sustainable lifestyle if they take off those competencies, as opposed to just working in a family practice clinic for 100 per cent of their time.”
Dosanjh says doctors are also feeling the burnout from other factors of their job like completing paperwork and charting, which is usually completed after their workday with no compensation, and other work which takes up time that could otherwise be spent helping patients.
With more British Columbians not having regular access to primary healthcare providers, Fong says emergency rooms are feeling the brunt of the family physician shortage and that the workload has increased, especially for nurses.
There are only so many patients that emergency room doctors can see in a day, so when they see patients they try to stick to one to three health concerns, and spend five to 10 minutes on each health concern.
Fong says he’s been practicing as a full-time emergency room physician in B.C. for the past eight years, and he’s noticed the trend of people coming to the emergency room for health concerns that are important but aren’t categorized as an emergency.
People are waiting for hours in the emergency room for a health concern that can turn out to be a minor problem. He says in the next decade there are fears of more people in the province being without a general practitioner.
“This is what we’re seeing in the ER. It’s just higher and higher volumes of people having nowhere else to go,” he says.
The report by Fernandez estimated around 38 per cent of current family doctors will be retiring in the next 10 years. According to the report, family doctors that will be retiring spent most of their time managing clinics. Whereas, the new doctors will split their time between family medicine and other specialities.
“The province has to listen to the evidence which overwhelmingly says that family doctors are not happy with the system as it currently stands,” Fong says.
“In 10 years … British Columbians may mostly not have family doctors and I think that the consequences of that on the health of the whole population is dire. I think family physicians do a lot in terms of preventive care and they should be valued just as much as cardiologists or surgeons,” he says.
“The state of family medicine in B.C. and the rest of the country really affects … every other domain of the health care system. If we lose our family doctors, there may be no turning back, and we may be stuck in a system that is dependent on acute care to fill those gaps. That’s neither cost-effective nor good for people’s health,” Fong says.
Data in Fernandez’s report shows that doctors aren’t deterred from opening and running a practice, rather they want a healthcare system that allows them to do it for the same level of compensation as other areas of medicine.
“We’re going to medicine to try to heal people. It’s hard to heal people in a broken system,” Dosanjh says.
She sees the number of people in B.C. without family doctors rising if the province doesn’t create ways to support the system. She says while a temporary solution is needed to help balance the current system, the ministry of health needs to create long-term solutions.
This instability in the healthcare system is not something that just appeared suddenly. Dosanjh says it’s been affecting the rural and remote communities for some time, and the urban centres are just now seeing the effects of it.
She suggests investing in more community-based care and having preventative care for patients so they don’t have to go to the emergency room unless it’s a true emergency.
“I think a healthier tomorrow begins and starts with all of us. The doctors can only do so much in their influence and I want to remind everybody that we are truly committed to our patients and their best outcomes,” Dosanjh says.
In order to begin taking the steps towards repairing the current healthcare system, Dosanjh wants the government to collaborate with the Doctors of BC, and external stakeholders and partners to hear what current physicians have to say and listen to the solutions they suggest for supporting the healthcare system.
“We’re at a time when our burnout is so high and the risk of us losing more people in our profession is a true and tangible real feeling. We need to re-imagine healthcare and remind ourselves that it belongs in the community. A healthier population starts with a healthier system,” she says.
Editor’s note: a previous version of this article included a quote saying that family doctors are responsible for delivering most of the babies in Canada. This is no longer the case, and obstetricians are responsible for delivering most of the babies in the country.