The easiest and most efficient way to reform primary care is to develop and implement a service agreement between physicians, patients, and the Ministry of Health.
Physicians, patients, and the Ministry of Health all have expectations, rights, and responsibilities. Currently, primary care is not meeting the expectations of any of the three players. Patients do not have the needed access to full service and comprehensive primary care. Full-service physicians are underfunded and burned out because they often practise in small, isolated groups and lack proper information systems. Government sees there is a lessening of value for service rendered and too many patients go without adequate access to primary care.
A well-formed service agreement would, I feel, offer incentive to all three parties to produce a better system of primary care. It could be structured along the following lines:
Ensure patient access
Ensure the availability of access for all primary care needs to the recipient by having the physician provider work with an association of providers linked together through one or more office locations. Extended-hour and weekend clinics and 24/7 telephone access to an on-call physician or health professional would be offered. The physician and her or his associates would provide hospital-based primary care to the extent necessary in each community. The physician groups would be linked with ancillary community health services such as palliative care, nursing homes, and public health. This form of comprehensive primary care group has been endorsed by all provincial health ministers at their 2004 Health Accord. The College of Family Physicians of Canada is on record as advising that the optimal size of a primary care practice is about eight to ten physicians.
Employ electronic health records
The physician would agree to install an integrated computer health record and have this record available to other associates in the call group. This record would successfully interface with other information technology in the province. This record would be secure and conform to current industry standards.
Implement doctor-patient exclusivity
The patient would agree to exclusively use the physician provider or her or his associates for all of their primary care health needs. The recipient would also agree to the use of nurse practitioners or other certified health professionals deemed by the provider to be beneficial in the provision of services.
Negotiate a per capita monthly fee
The ministry would recognize an enormous benefit in such an agreement and would therefore negotiate a per capita monthly fee to the physician for fulfillment of this agreement. This fee would pay for computer costs to develop an integrated health record and for costs associated with the hiring of any allied health professionals. It would pay for costs needed in the amalgamation of individual providers in their efforts to form larger physician provider groups. The fee would be substantial enough to induce current physician providers to make the effort and assume the responsibility to ensure their group meets the performance required.
The per capita fee is not meant to disrupt or replace the present fee-for-service arrangement. Anticipated savings through elimination of double doctoring and improved efficiency in the medical record would offset costs.
Re-establish the doctor-patient relationship
The most important aspect of primary care is the time-honored doctor-patient relationship. To that end, this service agreement seeks to re-establish and protect this relationship. It keeps the physician clearly in charge of her or his medical practice and would not require any administrators to make it work.
Funding the service agreement could be initially done with the proposed $70 million pool created presently for primary care reform. This would allocate about $20 per person per year for all BC residents. A busy full-service doctor with 2500 patients would receive about $50 000 per year to participate.
As well, government should bear additional costs to break existing leases signed by physicians so they could amalgamate into larger provider groups. Government should also bear renovation costs to make clinics comprehensive and well stocked to act as mini-emergency centres to take pressure off existing emergency rooms. Government should also pay one-time costs to install comprehensive computer systems in these larger clinics. This is all infrastructure investment and would pay off in the long run.
Participation among physicians would be voluntary. When a physician group decided to sign on, the patients would be notified by the ministry that this was occurring and that patients were therefore mandated to exclusively use that physician group or pay for the service out of pocket if they went elsewhere. The duty of policing this is between the ministry and the patient.
As more physicians signed up and had their patients exclusively use these comprehensive provider groups, visits to walk-in clinics would dry up. This would tend to have a snowball effect with more physicians coming on board to support their income base and capture their patients.
It is conceivable that within a short time physician providers would start to compete for patients. This would be a very good thing, as the level of service given would improve.
As well, the advantage from a governmental point of view is that it would create a mechanism whereby orphaned patients would be snapped up by physician provider groups.
This agreement is not really capitation or rostering as we currently know it, but it has some resemblances to it. While resistance initially from patients may certainly be there, the immediate successes of the service agreement would overtake any negativism. Patients would soon feel the benefit of having a comprehensive provider group and understand that they are not really losing anything by not going to walk-in clinics. Before long there would not be any doc-in-the-box walk-in clinics in BC. All the walk-in docs would either belly up to the bar and become real doctors or they would go hungry.
If patients used an average of one less visit per year because they didn’t use walk-in clinics, the process would be revenue neutral.
Finally, this service agreement could be done with a minimum of difficulty from an administrative standpoint. Unlike the current situation, which has alpha and beta test sites to look at primary care reform over the course of years, this could be fully implemented within a year or so. Immediate acceptance by full-service family physicians would be pretty much guaranteed.
This service agreement correctly puts an onus of responsibility on all three players, namely doctors, patients, and government. It also generates an incentive for all three to create an improved system.
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