Surrey-North Delta Division of Family Practice

Physician Compensation 101

Physician Compensation in British Columbia

Written by Saira Abrar and Jody Friesen, 2019

Family physicians have long advocated for changes to the Fee-for-Service model of compensation in BC, arguing that it does not appropriately compensate family physicians providing longitudinal care for high volumes of complex patients, including patients with comorbidities as well as more vulnerable patients who often need more support from their family physician.

As family physicians in Surrey-North Delta consider the future of health care in our community and Primary Care Network development, at the forefront is the important discussion about which funding models may best compensate family physicians to provide longitudinal, comprehensive and coordinated care for all members of our community. Fair compensation will be foundational to successful implementation of more integrated primary and community care. To support this conversation, the division has gathered together brief descriptions of the different compensation models that are being considered as part of Primary Care Network development.

Please reach out to a division staff member if you would like to be included on our email list for members interested in compensation-related updates and continuing this conversation with colleagues in Surrey-North Delta.

Fee-for-Service (FFS)

FFS is the compensation model most commonly used in BC and accounted for $2.9 billion or 70% of physician compensation paid by the Ministry of Health in 2015/2016. Physicians are reimbursed for each client visit or service rendered to a patient based on standard reimbursement rates defined under the Physician Master Agreement (PMA), which was very recently updated and ratified.

Out of all the models outlined below, family physicians often see this model as the one with a greater opportunity to achieve a high income than any other model, solely by increasing the number of services rendered. Research confirms that physicians operating within the FFS model tend to provide more hours of direct patient care, have a higher number of patient visits and provide more services (including diagnostic tests and curative services) than in other models. These findings may indicate better patient access through the FFS model, but alternatively FFS may also facilitate an overuse of service, an overtreatment of patients, and a “one problem per visit” approach to health care. Other potential downsides to the FFS model are the limits of the fee schedule, which traditionally do not allow for complex case management, collaboration with other health care providers and non-face-to-face encounters. Research also indicates that there is a relationship between higher physician income and decreased professional satisfaction.

For upcoming billing learning events related to Fee-For-Service, please see the list of resources at the end of this article.

Alternate Payment Programs (APP)

The APP program is an alternative compensation model for physicians where sessional or salary payments are not linked to individual patient visits. Benefits of the APP include providing physicians with higher income security while providing more time-consuming services or providing care to patients who may be more vulnerable and have more chaotic lives, and while providing indirect care such as telephone visits, and client conferences with allied health or other team members. Research has found that this compensation model tends to result in longer patient consultations and increased preventative care compared to FFS, while also resulting in a lower use of tests and referrals when compared to FFS and capitation. Downsides to this model include that physicians often loose some autonomy entering into an APP arrangement, and the volumes of services physicians render in this model tend to be reduced, which may impact patient access to health care.

APP arrangements are commonly used for compensating family physicians providing services at Fraser Health primary and community clinics, such as the Surrey Youth Clinic. As part of Primary Care Network development, the Ministry of Health has announced that 200, 3-year salaried service contracts will be created for new-to-practice family physicians as well as 200, 3-year salaried service contracts for nurse practitioners. As part of Primary Care Network development, communities have the opportunity to apply to have some of these family physician and nurse practitioner service contracts dedicated to their specific community, assuming that community has determined that adding these family physicians and nurse practitioners will address a need in the community.

Blended Models

In response to the concerns by family physicians that the FFS model may not appropriately compensate physicians for providing more longitudinal, complex care, and that APP models decrease patient access to health care, blended models that combine funding per patient as per annum along with some payment for service are seen as an alternative compensation format that may be able to address these concerns and reward family physician groups who a provide high availability of quality health care to patients registered to their practice.

Blended models tend to encourage collaboration within health teams, a delivery of preventive care and health promotion services, and facilitate formal patient enrolment. This patient enrolment or registration is associated with increased continuity of care, patient satisfaction, and facilitating chronic disease management. The downsides of the blended model include that patients with certain health statuses may be favoured over others, and the funding model can potentially shift the responsibility for patient behaviour to physicians, rather than encouraging empowered patients.

Enhanced Fee-For-Service - FPSC Family Practice Incentive Program

The FPSC Family Practice Incentive Program provides additional compensation beyond the Medical Service Plan fee schedule to family physicians providing quality, longitudinal patient care in areas such as chronic disease management, maternity care, mental health, and care for the frail and elderly. Most recently, changes to these incentives allow physicians to delegate non-face-to-face planning tasks to College-certified allied care providers working within a family practice, simplify the requirements for physicians billing a personal health risk assessment, and clarify the documentation requirements for Mental Health Management.

​​​​​​​Population-Based Funding (PBF)

There are currently a nine family physician practices in BC which receive compensation through the PBF model, including a handful of group practices in Langley. Highlights of this model include:

  • Compensation is paid to the group family practice, and the practice has discretion to determine the appropriate services, how they are delivered (in person, telephone, etc.) and by which family practice team member.
  • The amount of funding the practice receives is based on the disease burden of its registered patients. The disease burden is calculated based on adjusted clinical groupings (ACG)s developed at Johns Hopkins University, which assign patients into categories based on age, gender and all diagnoses submitted through MSP.
  • ACG categories recognize that the workload for the family practice is higher when a patient is older, sicker and more complex. Therefore, a practice would receive more funding per annum for providing comprehensive care for these patients than for younger, healthier patients.
  • The per annum funding covers a defined set of ‘core’ primary care services for registered patients, but a practice would still receive FFS for services the practice provides outside this core set, as well as for services rendered to patients who are not registered with the practice.
  • When a registered patient receives core primary care services from another family physician within the catchment area, the practice would experience a payment deduction, also known as outflows.
  • Prof. Frayne Alister, a family physician at Fort Family Practice in Langley writes that the mechanisms of PBF are more complex than FFS, but overall system expenditures can be significantly reduced.

 

​​​​​​​Value-Based Compensation (VBC)

VBC is a prototype blended model currently being used at three sites in Fort St. John. While similar to PBF, the disease burden and therefore funding of the practice is calculated based on a unique complexity index derived from the EMR problem list and patient encounter information (Note: all the prototype VBC family practice sites use MOIS EMR). 

Note: PBF and VBC are considered capitation blended models as they combine FFS with a capitation compensation model (per annum funding per registered family practice patient). Another blended capitation funding model has been implemented in Ontario for group family practices who opted into the model. The per annum payment in the Ontario capitation model depends on the age and sex of the enrolled patients and is less nuanced than the PBF and VBC disease burden scoring used to calculate per annum compensation for family practices. It is worth noting that the implementation of a blended capitation model in Ontario did not decrease emergency room use, despite compensation incentives available to physicians whose patients had lower emergency room utilization rates.

Medical services provided to Canadian Armed Forces members – updated billing rates as of May 1, 2019

Starting May 1, 2019, medical services provided outside of military facilities to eligible Canadian Armed Forces (CAF) members are to be billed using the equivalent Medical Service Plan (MSP) fee codes and rates. Billing for medical services provided to CAF members continues to be directed to Medavie Blue Cross for processing. CAF members are not to be billed directly for services paid for by the CAF. For more information, please contact Medavie Blue Cross Inquiry at 1-888-261-4033.

Interim Federal Health Program (IFHP)

IFHP provides temporary health coverage for certain medical conditions for refugees coming to Canada for resettlement. IFHP compensates physicians registered with Medavie Blue Cross for services provided to refugees with IFHP coverage. To register with Medavie Blue Cross visit the Medavie website. More information about IFHP can also be found in this handbook.

Primary Care Networks and Physician Compensation Considerations

When it comes to physician compensation, a variety of different models exist and are being considered in Primary Care Network development to meet the needs of different patient populations. The Surrey-North Delta Division of Family Practice is working diligently to inform and support our member physicians in considering opportunities for maintaining or advocating changes to funding models.

The new PMH calls for the creation of an ad hoc joint committee of Doctors of BC and government members to help develop alternate compensation models for primary care. Find more information about the committee here: https://www.doctorsofbc.ca/news/special-call-opportunity-participate-compensation-model-consultation-committee

​​​​​​​Useful Resources for Learning More about Physician Compensation

The College of Family Physician of Canada (2016). Physician Remuneration in a Patient’s Medical Home

https://patientsmedicalhome.ca/files/uploads/BAG_Rem_ENG_WEB_rev.pdf

Medical Services Plan – Free Billing Webinars for New-To-Practice Family Physicians

FPSC and the Society of General Practitioners are providing free 90-minute webinars for new-to-practice family physicians. The next webinars are coming up on May 7 and June 11.

Insurance Corporation of British Columbia (ICBC) – New Regulations as of April 1, 2019

New ICBC regulations came into effect on April 1, 2019. More information on ICBC compensation for physicians can be found here.

WorkSafeBC (WSBC)

Find more information and WSBC physician compensation details in the agreement between Doctors of BC and WSBC.

Please reach out to a division staff if you would like to be included on our email list for members interested in compensation-related updates and continuing this conversation with colleagues in Surrey-North Delta

SND Division Contacts: