How we pay doctors affects everything from patient care to filling those vacancies

This column is the opinionof Dr. Aruna Dhara,a co-director of the health humanities program at Dalhousie University anda practising family doctorin Nova Scotia.For more information aboutCBC's Opinion section, please see theFAQ.

When you go to the doctor, you likely present your MSI card at the office without ever thinking about paying for your visit.

But there are good reasons for patients to understand how doctors are paid for their work, because it's how the health-care system communicates to physicians what it values and it influences the type of care that you get as a patient.

Right now, Nova Scotia has two ways to pay family doctors: some get paid a salary, while others bill MSI for each service they perform.

With the Houston government asking for suggestions about how to revamp primary care, we have a real opportunity to promote the care we want from family doctors through changes in how we pay them.

Fee for service

Fee-for-service medicine seems like a straightforward payment model; in it, each service is coded and assigned a dollar value so physicians who do more per visit are ostensibly paid more as are physicians who see more patients.

The incentive is for efficient, high volume care that packs as much as possible into a single visit. The government's view seems to be that a standard office visit, with its accompanying office visitcode, could include taking someone's blood pressure, refilling a prescription, addressing the patient's back pain, counselling about contraception or all of the above.

Butit's often not possible to provide all of those services at once.

Doctors practising like this could theoretically take on more patientsand do more per visit. In a province with nearly 78,000 patients on a waitlist for a family doctor,this is definitely a win.

Except, of course, it's not that simple.

A lot of the work of keepingpatients healthydoesn't fit well into those MSI codes for example, much of the counselling doctors provide is actually ineligible for billingand, even when it is, patients are only allowed a couple of hours per year. And the critical time that physicians spend building relationshipsor co-ordinating care for complex medical issuesdoesn't fit neatly into those codes.

A cynical physician would argue that since the government doesn't think this work is valuable, there's no need to do it. In reality, most doctors just spend the time patients need in the office, and do many hours of paperwork and arranging care after their clinic closes for the day.

But chronic undervaluing of the work of primary care is a key factor in why family doctors burn out, which makes doctors less effective and harder to recruit.

Salaries

On the other end of the spectrum, physicians can get paid a salary. They simply book the time they'll need for a patient to get the care they need although they also have to submit what's known as shadow billing to the government. That means they code the visit as best as they can using the MSI codes, with the government understanding that those codes don't fully capture the scope of their work.

In this system, you could see your doctor for an hour for counselling if you needed itor combine counselling, a pap smear and an insurance form into a single visit. Any individual patient would be satisfied, but the downside is not many patients could get seen in the course of a day.

And in practice, most salaried doctors are expected to shadow bill some percentage of their salaries; often, bonuses are dependent on meeting a certain number of codes, even though the government knows these codes are inadequate.

From an incentives perspective, this pushes care back to being about seeing lots of patients and doing only the things that are coded for, which just isn't good care.

A future possibility

A newer, and more complicated model is capitation, which Ontario has been using for many years with mixed results and it's a model that Nova Scotia is considering, too.

Essentially, the province would underwrite patients, assigning each an estimate of what it should cost to be cared for by a family doctor over the course of the year, with the figure varying based on age and sex.

Unfortunately, this system works best for patients that need health services less often.

The best model

So which model is right for Nova Scotia? The answer is probably all of them, depending on who you are, where you live, and what kind of health care you need. For a government, trying to recruit family doctors, offering different models that considerthe preferences of the provider is also a consideration.

What's clear is that the coding system for services that we use as a reference right now does not capture the real work of caring for patients and keeping Nova Scotians healthy.

Ultimately, physicians work for their patients and government works for all of us, and we need some honest conversations to figure out what good care means to different communities.

Perhaps that is the critical first step to make sure the models we choose make sense for the people they're meant to serve.