The actions that will be taken by BC physicians in the coming weeks are coordinated by the BCMA, and I will be going along with them for the moment. I am not a member of the BCMA due to major philosophical differences between myself and this organization which are not of relevence in this context.
Physicians in Canada have been increasingly frustrated with the medicare system over the last 10 years and many are chosing to leave for practice climates that are far more congenial to physicians than Canada. There is a shortage of physicians in Canada and only by physicians not taking holidays and working ridiculous hours has the system been kept afloat thus far. Physicians are also beset by increased paperwork demands most of which involves an expectation of a physician doing work for free. This situation is unsustainable and at some point the medicare system will implode. That point may have come about in BC in May 2002.
When I personally find myself wondering what I am doing in medicine and calculating how much I could be making if I were to utilize my other skills in non-medical settings, then it becomes necessary to decide whether I continue to practice in Vancouver, or move to a location where physicians are more valued.
Part of the problem involves medicare in which medicine is "free". While this may seem like a good idea to many, people tend to use "free" services less carefully than those they have to pay for. The hourly remuneration of physicians should reflect the 10-20 years of schooling post-high school that is necessary to practice as a physician, but the fee schedule for medical services has not kept up with the dramatic rise in remuneration for services of all types that has occurred in the last 20 years. Various studies that have been conducted of public perceptions of physician remuneration indicate that the amount recieved by a physician for a simple office visit is considered to be 4-5 times higher by the majority of the population than what physicians actually are paid. When one takes into account all of the free services that physicians provide, it is a wonder that there are any physicians still practicing in BC.
One of the distortions of the medicare system, as can be expected from any application of socialist principles, is that mediocrity is rewarded far more than excellence. Under the current system of remunerating physicians, a physician who sees 10 patients/hour and provides perfunctory medical services is rewarded far better financially than a physician who limits himself to 4 patients/hour. I consider that when one is dealing with patients with multiple medical problems that a 15 minute appointment is barely adequate to provide medical care which I consider to be appropriate. One of my options is to opt out of medicare and only see patients privately where I could set my own rates; depending on how the dispute between physicians and the BC government progresses, I may chose this option.
The primary reason that I am going along with the BCMA's protest is that several innovative and cost-saving suggestions of the mediator's report have been summarily rejected by the BC government. These were of particular relevence to my practice, and involved being paid for providing telephone advice to a patient, or patient representative, and remuneration for telephone prescription renewals.
What people don't seem to realize is that when a physician provides advice regarding a medical condition over the phone they are liable for any adverse consequences should their advice be incorrect. At this point, no mechanism exists for a physician to bill the medical services plan for telephone advice. What the arbitrators report proposed was the creation of a fee code which would be payable to a physician if they provided telephone advice to either the patient directly, or to a physician, or other person involved in care of the patient. Presumably this would apply to other electronic communications with patients such as email. I thought this was a very significant decision since it could result in major cost savings. The remuneration for this service was set at 1/2 the amount paid for a basic patient office visit, or ~$13.
At present, if a patient goes to see their doctor for a problem and has some tests performed, usually another physician visit is necessary afterwards. In most cases, the test which was done yields a negative result, and this is what the patient needs to hear. The vast majority of physicians offices do not call people about negative results since this would be completely impractical. Also, non-medical office staff are not qualified to discuss test results with the patient and thus are generally instructed not to do so. If a patient needs to find out their test results, they thus have to book another appointment. The new fee code gave an incentive for physicians to call patients who normally would have booked an appointment only to be told not to worry about their lab tests to communicate with the patient directly. In my case, I find email far more convenient than the telephone, but regardless of the means of communication, a means of reducing costs to the medical system was proposed and rejected by the BC government. The cost savings are greater than the ~$13/patient that they would appear to be as the patient is potentially saved the cost of losing several hours of work, parking and gasoline to find out something that could have been communicated without a face-face meeting with a physician; under the current MSP fee schedule, physicians cannot be paid for talking to a patient on the telephone, or communicating via email. Lawyers have had the privilege of charging their full feels for telephone advice since the invention of the telephone, and it is time that physicians had equal rights to utilize these revolutionary new technologies in the same fashion.
Telephone prescription renewals are a problem in every practice. They involve office staff recieving the initial message, communicating it to physician who has to look through patients chart and determine whether a telephone prescription is appropriate, and then office staff must call up pharmacy to communicate prescription renewal. Some physicians offices solve this problem by totally disallowing telephone prescription renewals. Despite having to spend time to review a patients chart to ascertain the appropriateness of a telephone prescription renewal, and office staff overhead, the current remuneration for this activity is $0. The arbitrators decision involved the creation of a fee item of 1/4 the cost of an office visit which would be payable for telephone prescription renewal, about $6.50.
There are many legitimate reasons to perform telephone prescription renewals; an individual may be unable to come into the office or it may be inconvenient. They may have forgotten to renew the prescription on a vist a few days previously, etc. Rather than having a procrustean policy that every patient comes to the office for any prescription, this new fee item seemed like a brilliant solution to a widespread problem. Again, the cost savings would likely be far larger than the 3/4 of an office visit fee item as people have to take time off work, drive to their doctors office, pay for parking, etc to do something which could have now been done much more simply. It should be noted that a physician who renews a prescription, despite recieving no remuneration, is considered to be just as liable as if they had written that prescription for the patient and billed for an office visit.
Dr. Kline and I have been in recent communication with MSP regarding these two fee items and have been informed that they are not currently billable. Accordingly, until such time that the dispute between BC physicians and the BC government is resolved, the following practice changes will be in effect.
(1) No communication of results by telephone will occur
(2) No telephone prescriptions will be allowed.
If individuals wish to communicate with me either by telephone or email, then there is no charge for contacting the office, but if a reply is expected, then a $15 charge will apply. This will be applied rigorously to telephone communications as these require additional time for documentation and are temporally non-deterministic. Email communications are self-documenting, and as I read very fast, usually I can respond to emails in a fraction of the time I can to telephone calls; thus email communication won't necessarily be billed at this time. As telephone communication with patients is not an MSP recognized service, then billing for such a service is legal under the Canada health act. As email was never in Tommy Douglas's weltanschaung, then billing for email communications similarly does not violate the sacrosanct principles of medicare, that almost uniquely Canadian system that has so far been duplicated only in Cuba and North Korea.
Telephone prescriptions will be available for a charge of $10. It is up to each patient to decide if they want to book an appointment to obtain a prescription at no monetary charge to themselves (but a $26 charge to MSP), or if they consider the cost of the convenience of not having to see a physician for the prescription renewal to be worth $10.
It may be that the BC government has deliberately provoked this action by physicians in order to bring public attention to the financial aspects of medicine which have thus far been largely ignored; from what I've seen thus far, the requisite intellectual capacity for such subtlety appears absent. Regardless of how the crisis in the BC medical system has come about, it should be used as an opportunity to make some much needed changes that will bring the medical system into closer alignment with physical reality rather than the delusional political ideologies that underlie medicare.
Last update 7/5/2002 T:=01:16