Nova Scotia doctors battle government over pay model
A blended physician-pay model could provide financial security while still incentivizing doctors to see more patients.
The Department of Health and Wellness is arguing, however, that it will not change the agreement until March 2019, when the current contract ends. “Formal negotiations for the next master agreement is the appropriate time and process to consider proposed changes to payment models,” Tracy Barron, media relations advisor, said in an email statement. Barron added that 80% of doctors voted in favour of the agreement in 2016.
But Doctors Nova Scotia is suing the government for breach of contract. Among other complaints, the group claims the government has negotiated alternative payment plans (APPs) with some family physicians, instead of using the template agreed upon by Doctors Nova Scotia, the Nova Scotia Health Authority and the government. Most doctors in the province are paid via fee for service. Doctors Nova Scotia said the APPs are not ideal because they require doctors to provide care to patients in hospitals, and they don’t incentivize doctors to see additional patients.
There are almost 45,000 Nova Scotians on a wait list for a family doctor, and about 60 family physician positions are unfilled in the province. More than half of Nova Scotians’ doctors are over age 50, added Dr. Manoj Vohra, president of Doctors Nova Scotia. “The crisis is only going to get worse” if a new payment model isn’t created, he said.
Vohra said his group would like to see a payment model that blends capitation with fee for service. “Being paid a portion of the fee-for-service billings can incentivize doctors to work harder, and then you have the base salary that can ensure that when you’re unable to work harder, you don’t go into the red,” explained Vohra.
The call for a collaborative care model is partly inspired by policy changes implemented in New Brunswick last year. Under the Family Medicine New Brunswick program, doctors are paid a set fee for each patient on their rosters, and an additional 40% of the provincially negotiated fee for each service they provide. To join the program, doctors must agree to work with a group of physicians to provide after-hours care for patients. Andrew MacLean, director of Family Medicine New Brunswick, said the program is just beginning to roll out and they’re not ready to comment on how many doctors have signed up.
It is not surprising, however, that the Nova Scotia government is reluctant to adopt a blended model, according to Greg Marchildon, professor at the Institute of Health Policy, Management and Evaluation at the University of Toronto. “Perhaps the government wants to run the numbers very carefully to know exactly how fiscally at risk they are [under the proposed blended model], and this is partly because of the experiences in other parts of the country,” he said.
Blended models in Ontario “have been very expensive and there’s been mixed evidence in terms of their results,” he said. While systematic evaluations haven’t been performed, studies have shown that Ontario’s Family Health Teams outperform fee-for-service models in colorectal cancer screening and diabetes care, but that patient-reported outcomes regarding access and coordination didn’t improve under new models.
But unlike in Ontario, new fees for email and phone consults in New Brunswick will incentivize increased access to care, said MacLean. Plus, by providing a portion of the fee-for-service payments, in addition to paying per patient, doctors remain incentivized to see a higher volume of patients. “One of the benefits to being late to the party on funding collaborative-care models is we were able to look at what worked and didn’t work elsewhere,” said MacLean.
In Nova Scotia, however, the fractured relationship between Doctors Nova Scotia and the provincial government may make it difficult to build the trust necessary to negotiate a new payment system, suggested MacLean. “We worked for a long time with the government of New Brunswick to get them to where we are today,” he said. “If it weren’t for the positive relationship we have with them, we could not do this.”
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