Primary Care in BC – providing quality care for patients

Doctors of BC has been working in partnership with the BC government over the last 10 years with a unique approach to build a stronger primary care system for patients. It has shown significant success in a number of evaluation research reports that can be found at www.gpsc.bc.ca.

This week, the Centre for Health Services and Policy Research published a paper that is critical of these reforms. The article below is our response to that paper.

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Primary care in BC – providing better patient care and building a better health care system

Have patients in BC benefited from recent investments in primary care through family doctors offices in the province? A paper done by the Centre for Health Services and Policy Research has suggested that they have not. But the authors used simplistic administrative billing data and did not provide evidence about patient outcomes or cost-effectiveness in making their claims.

Independent evaluations and national data, overlooked by the authors, show a much more positive and nuanced picture of primary care reform in BC over the last few years.Patients are indeed benefitting, as are doctors and the BC health system as a whole.

The authors rightly note that primary care is the backbone of the Canadian health care system. A decade ago, family practice was in crisis across the country, a trend that had begun a decade earlier. In BC, this reached a nadir in 2003 when only 23% of new graduates chose family practice, and of those, less than half were planning on becoming a full service family doctor.

In BC, we took an unique approach to meeting these challenges, deciding in a consensus between doctors and government to hold back a portion of the negotiated funds for doctor's compensation out of the Physician Master Agreement and use that to support targeted care for the most vulnerable patients. Note: this was not new investment of taxpayer money, but rather a repurposing of money that was already earmarked for doctors' incomes. In essence, it was doctors agreeing to invest their own negotiated money to support positive change.

A joint committee of government and doctors, called the General Practice Services Committee (GPSC), was formed to oversee this investment. Past rancour between the two sides was overcome by focusing on the question: What is best for patient care? This new cooperative culture focused on patient care has now existed for close to a decade, and has fostered many more initiatives.

Incentive payments were created to support doctors to provide evidence-based care that focussed on avoiding crises and hospitalizations. Incentives were also given for new ways of seeing patients such as group visits or telephone calls. In addition, the money was used to create the Practice Support Program, which develops modules for training for doctors and their office staff and includes everything from how to run more efficient offices to how to better manage various chronic diseases or provide better care for difficult issues like end of life care or youth mental health care.

The points raised by Lavergne and McGrail in their article show a lack of understanding of the BC approach, the provision of medical care, and fee for service fee items. Independent evaluations, not cited by the authors, have found that BC patients who received incentive based care had lower costs, and fewer hospital admissions, re-admissions, and lengths of stay, compared to those who did not receive incentive based care. In addition, GPs reported that the system of incentive payments has increased their ability to take better care of their patients and provide enhanced continuity of care, among other positive findings.

Moreover, according to 2013 national data collected by the Canadian Institute for Health Information (CIHI), BC has the best results of any province for a number of key health indicators that assess health care system performance. For example, BC, in 2013, had the lowest hospitalizations rates for "Ambulatory Care Sensitive Conditions" in Canada. This is a measure that improved primary care outside the hospital for conditions like diabetes, heart failure or congestive obstructive pulmonary disease is leading to the fewest hospitalizations.

And here’s another important result. Ten years ago, medical students showed very little interest in pursuing a career as a family doctor. Today, fewer GPs in BC are leaving the profession and more newly graduated doctors are choosing family practice, up to 39.7 per cent in 2014. With the positive changes taking place, young doctors are taking up family practice again, and that’s a renaissance of which we should all be proud. Moreover, the BC Health system has been able to bring down annual spending on health care to 2.6% growth per year.

Health care policy in BC, as in the rest of Canada, will always need robust, comprehensive evaluations to ensure we are spending money wisely and getting the best patient care for our dollars. However, accurate meaningful evaluation must include not just a simplistic measure of fee-for-service billing data, but the whole picture – including the measurement of physician engagement, physician education - and most importantly patient outcomes, such as better management of chronic diseases, and fewer hospital days and deaths

Doctors look forward to continuing to work with all our partners, especially our patients, to continue to improve our primary system so as to deliver the best quality care.

Dr. William Cavers MD

President of Doctors of BC (formerly BCMA)
Former Co-Chair of the General Practice Services Committee.