Improving Primary Care and Saving Healthcare Dollars With Physician Extenders

Year: 
2016

There is clear evidence that availability of primary care has significant implications for British Columbia’s economy both in terms of overall population health and the impact of employee productivity and absences on business. Though our government has made expanding availability of primary care a key priority, British Columbia still suffers from a lack of primary care. In other jurisdictions, the shortage of primary care has been addressed successfully with the introduction of physician extenders. The British Columbia government should embrace the physician extender model so that our economy may reap the benefits of primary care and create new efficiencies in our healthcare system.

Background

At a macro level, research indicates that health (measured in terms of life expectancy) is positively correlated with economic growth (measured in terms of GDP growth rate)[1]. Statistics also show that two key drivers of employee absences[2]–absence due to illness and caregiving for family members[3]–are health related.

The costs of illness related impacts on business are immense, as demonstrated by just a few recent statistics:

  • According to the Conference Board of Canada, private sector organizations estimated their direct cost of employee absences to be 2.3 percent of gross annual payroll;[4]
  • A Statistics Canada report found that in 2011, total work time missed due to illness or disability was 3.1% of the average work week, which translates to 7.7 days per year;[5] and
  • The 2012 General Social Survey reported that 1.6 million employee caregivers took leave from work; nearly 600,000 reduced their work hours; 160,000 turned down paid employment; and 390,000 had quit their jobs to provide care.[6]

Against this backdrop, it is crucial to recognize the role of primary care in improving health outcomes and reducing the impact of employee illness on business:

  • It has long been accepted and confirmed that availability of primary care is strongly linked to better health outcomes.[7][8]  In addition, a larger supply of primary care physicians is associated with lower costs of health services[9][10][11], and higher quality[12]. Simply stated, a healthier population means fewer employees who must miss work because they are sick or must provide care to a sick family member or friend; and
  • When employee illness occurs, primary care is in most cases dramatically more efficient than the alternative, a visit to the emergency room. Whereas physician office visits can be booked in advance to minimize work interruption, the emergency room waiting times in British Columbia are now routinely measured in terms of hours.

It is now common knowledge that primary care is in short supply in British Columbia. In the central Okanagan alone, it has been estimated that as many as 40,000 people do not have access to a family doctor. Other regions in the province experience the same issue, including Vancouver and various smaller B.C. communities.

The implications of the British Columbia’s primary care shortage for business are not hard to grasp. Less primary care means lower productivity.

In February 2013, a joint initiative by the B.C. government and the BC Medical Association was launched to address growing concerns about lack of primary care. The initiative, aptly named “A General Practitioner (GP) for Me”, had as its ultimate objective securing a General Practitioner (the principal purveyor of primary care) for everyone who wants one by 2015.

Though A GP for Me has made progress, this progress has been incremental only, the shortage of primary care remains. Additional strategies to complement those used in A GP for Me are required to address this issue, not only just for the immediate future but for many more years to come.

Solution: Recognition of the “Physician Extender” in the Medical Services Plan billing scheme

A physician extender is a trained assistant who can perform several tasks that a family doctor normally performs.  The physician extenders are able to relieve doctors of the many less complicated cases, which frees the physicians to handle more patients in general. Crucially, the medical-legal responsibility for the physician extender rests with a supervising physician, which ensures that physician extenders are assigned cases that are within their scope of practice. Accordingly, under the physician extender model, a physician retains primary responsibility for patient care, which distinguishes the use of physician extenders from other non-physician affiliated primary care models (e.g., independent nurse practitioners).

The United States pioneered the use of physician extenders (often referred to as physician assistants) in the 1960s. Their use of physician extenders has led to dramatic improvements in efficiency and they are widely accepted part of the primary care system in the United States.[13]

In Canada, physician assistants were first introduced in the Canadian Forces to address a shortage of military physicians, and remain an integral part of our armed forces healthcare system. As well, other provinces in Canada, including Ontario, Manitoba, Alberta and New Brunswick have trialed and made provision for the use of physician extenders. Though results are early, indications are that physician assistants can improve health efficiencies in the Canadian health care setting.[14]

In British Columbia, there is an ample supply of professionals (such as nurse practitioners) with training and skills that are equivalent or superior to those who act as physician extenders in the United States and other Canadian jurisdictions. However, despite the availability of skilled workers who can fill these roles, the physician extender model is not used at all in British Columbia.

The reason for this is that in British Columbia, use of physician extenders is, for practical purposes, inhibited by limitations imposed by the “Guide to Fees”, which governs what services physicians may bill to the British Columbia Medical Services Plan. More specifically, the section on “Delegated Procedures”, section c. 20, on page 1-19 specifically provides that “visit” type services as examinations, assessments and consultations. Simply put, there is no practical way for physicians in British Columbia to financially integrate a physician extender into their practice.

The solution to this is simply to permit British Columbia doctors to use their Medical Service Plan billing numbers to bill for services provided by physician extenders. The advantages of this solution include the following:

  • Linking the physician extender billings to a supervising physician provides an unambiguous indication of the physician’s professional and legal responsibility for the physician extender’s practice;
  • Services provided by a physician extender can be billable at a lower rate that equivalent services performed by a physician, which creates the potential for efficiencies and greater return on healthcare dollars;
  • Enabling physicians to profit from physician extenders provides a financial incentive for enterprising medical school graduates to choose family practice over the traditionally more lucrative specialty practices, which will ultimately increase the supply of family physicians in British Columbia; and
  • A recent study has shown that physicians are motivated to hire physician assistants to help deal with long wait times and long hours, which suggests that the physician extender model may help ease the burdens on British Columbia’s primary care physicians.[15]

THE CHAMBER RECOMMENDS:

That the Provincial Government:

  1. Integrate the role of “physician extenders” as an additional solution to the primary care shortage in British Columbia;

  2. Provide British Columbia’s family physicians with the ability and incentives to financially integrate physician extenders into their practices; and

  3. Support necessary training and regulation of physician extenders to ensure that British Columbians received the best quality, most cost-efficient care.

Footnotes

[1] D. E. Bloom, D. Canning, and J. Sevilla, “The Effect of Health on Economic Growth: A Production Function Approach,” World Development 32, no. 1 (2004): 1-13.

[2] Employee absences cost the British Columbia economy more than a billion of dollars annually. Stewart, Nicole, “Missing in Action: Absenteeism Trends in Canadian Organizations,” The Conference Board of Canada, September 2013, http://www.conferenceboard.ca/e-library/abstract.aspx?did=5780

[3] Dabboussy, Maria and Sharanjit Uppal, “Work absences in 2011,” Statistics Canada, April 20 2012, http://www.statcan.gc.ca/pub/75-001-x/2012002/article/11650-eng.pdf.

[4] Stewart, Nicole, “Missing in Action: Absenteeism Trends in Canadian Organizations,” The Conference Board of Canada, September 2013, http://www.conferenceboard.ca/e-library/abstract.aspx?did=5780

[5] Dabboussy, Maria and Sharanjit Uppal, “Work absences in 2011,” Statistics Canada, April 20 2012, http://www.statcan.gc.ca/pub/75-001-x/2012002/article/11650-eng.pdf.

[6] Sinha, M. (2012). "Portrait of Caregivers, 2012." General Social Survey, Statistics Canada. http://www.statcan.gc.ca/pub/89-652-x/89-652-x2013001-eng.htm

[7] Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly. 2005;83(3):457-502. doi:10.1111/j.1468-0009.2005.00409. x.

[8] Pierard, E. (2009). The effect of physician supply on health status as measured in the NPHS. Retrieved February 25, 2012 from http://www.rdc-cdr.ca/effect-physician-supply-health-statusmeasured-nphs.

[9] Hollander, M.J., Kadlec, H., Hamdi, R. & Tessaro, A. (2009). Increasing value for money in the Canadian healthcare system: new findings on the contribution of primary care services. Healthcare Quarterly, 12(4), 32-44

[10] Mark, D.H., Gottlieb, M.S., Zellner, B.B., Chetty, V.K. & Midtling, J.E. (1996). Medicare costs in urban areas and the supply of primary care physicians. Journal of Family Practice, 43, 33-9.

[11] Baicker, K. & Chandra, A. (2004). Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs, (Suppl. web exclusive), W4-184−197).

[12] Baicker, K. & Chandra, A. (2004). Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs, (Suppl. web exclusive), W4-184−197).

[13] See B. Hague, The Utilization of Physician Assistants in Canada, An Environmental Scan, Health Canada, April 2005. Available online: https://capa-acam.ca/wp-content/uploads/2012/06/2005_The-Utlization-of-P...

[14] Decloe, McCready, Downey, Powis, Improving health care efficiency through the integration of a physician assistant into an infectious diseases consult service at a large urban community hospital. Can J Infect Dis Med Microbiol. 2015 May-Jun;26(3):130-2. Available online: http://www.ncbi.nlm.nih.gov/pmc/articles/pmid/26236353/

[15] M. Taylor, W. Taylor, K. Burrows, J. Cunnington, A. Lombardi, and M. Liou, Qualitative study of employment of physician assistants by physicians: benefits and barriers in the Ontario health care system, Can Fam Physician. 2013 Nov;59(11): e507-13. Available online: http://www.ncbi.nlm.nih.gov/pmc/articles/pmid/24235209/

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