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As Nova Scotia’s political candidates tour the province making campaign promises, we’re hearing more and more about their various visions for improving health care. One topic that comes up frequently is collaborative care. The College of Family Physicians of Canada recommends collaborative practice; they call it “the patient’s medical home.” Many people and organizations – including Doctors Nova Scotia – view moving toward a collaborative practice model as one way to ensure that more people in the province are able to get the health care they need, when they need it, close to home.
But new practice models need new payment models. If Nova Scotia is going to make collaborative care a bigger part of its health-care system, it also needs to transition to a new payment model. This model has groups of health-care providers (including family physicians, nurse practitioners, family practice nurses and other professionals, such as nutritionists and physiotherapists) working together to provide care to their patients.
Currently, most family physicians are paid on a fee-for-service basis – that is, the physician receives a set fee for each service they provide. There are strict limits to what, when and how often a physician can bill. As Nova Scotia’s population ages – and contends with the effects of increasing rates of chronic disease – physicians often have to spend more time with patients than they are paid for, which is not sustainable.
Moving to a collaborative care model would mean that nurses and nurse practitioners could provide the clinical services that are within their practice scope, such as education and counselling, flu shots and Pap tests, freeing up physicians’ time to care for patients with more complex health issues. But in order to succeed, the payment system needs to reflect the changing nature of a physician’s practice, so that doctors are paid for spending the time they need with patients.
In a recent position paper, Doctors Nova Scotia recommended that the province develop a new, blended payment model to better support patient care, fair compensation and good stewardship of public funds.
Luckily, there are already several different blended payment models in use across Canada, so Nova Scotia can benefit from other provinces’ experiences. The most effective blended payment models seem to combine the fee-for-service model with two other payment mechanisms: capitation and negation.
Capitation: Capitation is a payment structure in which a physician is paid a fixed amount to provide care to a defined group of patients (a “patient roster”) under his or her care. In this case, physicians are paid per patient, not per service. Some patients require more attention than others, so capitation systems usually do not pay the same for every patient but take the patient’s health needs into account. Payments for rostering an individual can vary drastically depending on predetermined modifiers such as age and sex.
Fee-for-service: Capitation is usually combined with fee-for-service payments (at a discounted rate) to encourage productivity and ensure that data is being collected on the services being provided. In this case, capitation determines a physician’s base salary, while fee-for-service provides additional earnings. It’s not unlike a salesperson who earns a base-plus-commission salary, although physicians may be limited in how much they can bill for fee-for-service.
Negation: If a patient who is rostered to a certain physician visits a walk-in clinic rather than their family physician for their care, the fee paid to the walk-in clinic is recouped from the family physician’s next capitated payment. Negation is a way of ensuring that the health-care system isn’t being over-charged.
In a blended payment model, all three components – capitation, fee for service and negation – work together to encourage physicians’ productivity, help patients get the care they need, encourage a wellness approach to health care and ensure good stewardship of public funds. If Nova Scotia wants physicians to embrace collaborative care, it’s time to offer a blended payment funding model.
If you want to ensure that physicians are paid fairly for their work, talk to your local political candidates when they knock on your door, through social media or when you meet them at public debates. Or visit our website to email each political party and ask them to make health care a priority.