The Big Idea: Pay family doctors differently

When I started medical school, I planned to be an obstetrician. But as I completed my training, I realized that what I really enjoyed was family medicine—the opportunity to build a long-term relationship with a patient over 20, 30, maybe even 40 years. I was inspired by colleagues who had attended a birth early in their career and then were later present at the birth of that person’s child. 

As I began practising, I soon became concerned with how family doctors in B.C. and across the country were struggling to provide patients with care. Around one in five people in B.C. and 6.5 million Canadians across the country don’t have a family doctor. I’ve had patients come in with concerns about bleeding who haven’t been able to access a pap test or cervical cancer screening because they didn’t have a family physician. By the time I’d seen them, they already had cervical cancer, an illness that is entirely preventable or detectible with early monitoring. 

The province struggled to attract and retain family doctors because the financial incentives to take on this complex and demanding work were scarce. Under the most common family medicine payment model in Canada— the fee-for-service payment model—family doctors only get paid for each patient they see, which is around $30 per visit in B.C. But caring for a patient is not confined to a 10- to 15-minute appointment. Behind the scenes, I also review lab tests, consult colleagues, follow up with case managers and think through a patient’s condition, but I don’t get paid for any of this work. This low payment forces doctors to continually calculate whether they are seeing enough patients to keep their clinics open, which creates distress for both physicians and patients. I’ve had people book appointments with me to renew prescriptions, but what they really wanted to talk about was family difficulty or intimate partner violence. Sometimes, I was forced to consider: if I spent 20 more minutes with this patient and didn’t see others, would I be able to cover my clinic bills for today, this week, this month? Family doctors can’t continue doing this kind of work after finishing medical school with $200,000 worth of debt.

SIGN UP TO READ THE BEST OF MACLEAN’S:
Get our top stories sent directly to your inbox twice a week

I wanted to change this system, so I joined BC Family Doctors as its executive director in 2018 and watched as these issues got worse during the pandemic. In May of 2022, physician organizations and patient groups protested on the steps of the B.C. Legislature in Victoria to call for better access to family doctors. Within that week, BC Family Doctors and Doctors of BC sat down with the B.C. government to work on a brand new way to pay physicians: the Longitudinal Family Physician, or LFP, payment model.

It blends three pre-existing models for paying doctors: hourly, fee-for-service and panel pay. This means if I had an eight-hour workday today, I would bill the province for eight hours of time, which might be spent reviewing labs and doing referrals in addition to seeing patients. On top of that, I would bill the province for each patient visit on the day. Finally, I’d receive a payment every quarter for every person I’ve identified as part of my panel of patients, accounting for the long-term care family physicians provide. Under this model, family doctors can earn around $385,000 a year before expenses like staff compensation and office bills—up from roughly $250,000 under the fee-for-service plan. The province agreed that investing more money into primary care reduces costs down the line by delivering care to patients at the right time, which is at the start, when they’re still at home, and not when they’re in the hospital. In February of 2023, the province introduced the LFP payment model. 

Today, over 4,000 family physicians are billing under the new LFP payment model. Of those, more than 700 are newly practising family doctors in the province. This is remarkable at a time of declining interest among medical school graduates in Canada to pursue family medicine. Around 400 longitudinal family physicians are left on the fee-for-service model and a couple hundred remain on other fee models. Physicians now tell us that they can, in good conscience, take the time that their patients need, and they can structure their workdays and appointments around the needs of their patients, not the bills. If, say, an 83-year-old patient comes into my office and has five medical conditions, I can sit down with her for 45 minutes and go through the range of her issues. Before, whether I took 10 or 45 minutes with her, I would have received the same payment, which made it harder to cover the bills in the clinic. But the LFP payment model recognizes that taking care of a highly complex 85-year-old is very different in many circumstances than a less complex 22-year-old and allows for more person-centric conversations.

READ: A doctor’s dilemma

One physician told us that she was able to take on new patients who have brain injuries. She can now take the time to review their health history, speak with the other doctors involved in their care and provide longer appointments. Another doctor saw a patient who needed both a gynecological exam and counselling for depression. The doctor spent 30 minutes with the patient, making sure that she felt heard and all her care needs were met in a single appointment.

The LFP payment model borrows from many high-performing health-care systems around the world: the Nuka system of care in Alaska, Intermountain Health in Utah, Kaiser Permanente in California, as well as systems in northern Europe. Next, we plan to take what we’ve learned from the launch of this payment model and share it throughout Canada.

The federal government estimates that we need 48,900 more family doctors by 2031 to keep up with demand and provide the care that Canadians need and deserve. We need to reorient health care to the everyday needs of patients, which in most circumstances is about primary care, integrated with hospital-based and specialized care. This is just the start.

 —As told to Xavier Richer Vis