Is the state of family practice (particularly in British Columbia) as dire as social media and traditional media is painting it currently?

[ubcstudent]

I’ve seen comparisons showing BC family practice doctors having take home pay that is slightly more than NPs while seeing double to triple the patients. Is it true that overhead in urban  and mid-size centres was already 30% before the pandemic and is easily in the 40’s now? I feel like some of this information has got to be sensationalized or cherry-picked. To me, it almost seems too bad to be true. Interested in hearing thoughts from more senior members (and I understand a lot of this applies to other provinces too so I welcome perspectives from all over Canada).

[Bluberblubo]

neither a GP nor in BC, but I think it's true. There is a physician's financial page of canada with docs across the country and there are several discussions about the state of family docs in bc and how it's increasingly frustrating to work there without good compensation when less demanding work can mark the same amount of money or more.  I think you need to be invited from someone in the group to join

[Supervenience]

Not in BC, but I will echo the above poster at least regarding Ontario. Anecdotally I have heard and read of practising FPs being dissatisfied with their work and, more alarmingly imo, having trouble finding locums and practice takeovers (even for FHO's, which only a few years ago were going for bidding wars). It seems that many newer grads are opting towards non family practice jobs at the moment

[shikimate]

I know for certain that some FM in downtown Toronto were trying to give away their practice but nobody would take it because who wants to pay ridiculous rent when your billing codes are the same?

Aside from that, 35$ a visit might make sense without overhead if you rent in rural Nova Scotia, but not when gotta rent an office in Vancouver lol. 

I did a quick search and to get a men's haircut in Vancouver is like 40 bucks lol.

[zoxy]

39 minutes ago, shikimate said:

I did a quick search and to get a men's haircut in Vancouver is like 40 bucks lol.

Probably less overhead for the haircut than a GP. You don't need a receptionist/assistant like a GP does and you need less square footage for a hair stylist than a doctor.

Anyway, BC is angling for more IMGs as GPs as the solution to their problem. They're trying to do this via a Practice Ready Assessment or PRA as they're calling it. They're not even expanding the number of IMG FM residency spots. Improving working conditions and pay is not something that governments consider.

https://vancouversun.com/news/local-news/foreign-trained-doctors-in-b-c-stuck-sitting-on-a-shelf-instead-of-closing-shortage-of-family-physicians

[medisforme]

I am a BC based longitudinal family physician and I can verify that the reports are not sensationalized.  In victoria in particular, the number of GP's leaving longitudinal family practice is staggering.  With high overhead and relatively stale fee codes, it really doesn't make sense for people to go into this line of work in BC.  I certainly would never recommend a new grad go onto longitudinal family practice in BC.  In the city I practice in, they are basically dependent on recruiting IMGs.    I think we have attracted 3 non IMG new family practice grads in the past 5 years (and none in the past 3 years) which nowhere near makes up for the docs leaving/retiring.

Unfortunately, our provincial government and health minister in particular are out of touch with reality when it comes to dealing with the current family physician crisis.  Adrian Dix has met several times with GP advocacy groups but no one is holding their breath.  the NDP can not stop their enthusiastic push for UPCC's (Urgent Care and Primary Care clinics), which are essentially glorified walk in clinics that cost 3-4x more to run than a typical family practice.  On top of that, they can't even find physicians to work at these clinics.  The UPCC in Abbotsford and another in Surrey are completely dependent on NP's to see patients because physicians won't sign on.  A fast NP will see 3 patients/hr, most see less than that.  Far less efficient than family physicians most of whom see 5-6 patients/hr.

I am playing it by ear over the next 1-2 years, if this trend continues I plan to pursue more niche areas of family practice that I already have my foot in which have almost no overhead (addictions/OAT, LTC).

[NewClerk]

The new to practice contracts don't seem too bad (295k in first year for 800 patient panel, minimum like 33hours per week in office) with some debt forgiveness. However, there seems to be apprehension toward them. Maybe someone can clarify if these are in fact good or bad contracts, because on paper they don't seem too bad? 

[Supervenience]

7 hours ago, shikimate said:

I know for certain that some FM in downtown Toronto were trying to give away their practice but nobody would take it because who wants to pay ridiculous rent when your billing codes are the same?

Aside from that, 35$ a visit might make sense without overhead if you rent in rural Nova Scotia, but not when gotta rent an office in Vancouver lol. 

I did a quick search and to get a men's haircut in Vancouver is like 40 bucks lol.

Not to mention currently you would likely make more money doing rural locums while living in Toronto thanks to CTSLPE and other rural bonuses while dealing with less overhead, administrative/paperwork headache, etc...

[The Bunny]

The short answer to the title of this thread is yes. It’s an absolute mess. The latest government plan to give new grads $25,000 if they practice family med has had no takers. It’s that bad. 

[shikimate]

https://www.cbc.ca/news/canada/ottawa/fewer-medical-students-are-pursuing-family-practices-and-these-doctors-are-worried-1.6516261

To think about "overhead" you also have to include time to prepare for the work and clean up after work. Just like if you run a restaurant, you have to do purchasing and inventory before the restaurant opens and do book keeping and maintenance after the patrons leave for the night. I think that's why a lot of people left the food service industry because it's grueling work.

I think that's the part that becomes more and more daunting for FM on FFS. Managing reports, results and what not should be part of the workload/remuneration calculation, just like a lab test has a technical component reimbursement and a professional component reimbursement. Either they do that for FM visits, or just do the salary model and cover the admin/cost for family docs. 

[frenchpress]

On 7/10/2022 at 4:30 PM, NewClerk said:

The new to practice contracts don't seem too bad (295k in first year for 800 patient panel, minimum like 33hours per week in office) with some debt forgiveness. However, there seems to be apprehension toward them. Maybe someone can clarify if these are in fact good or bad contracts, because on paper they don't seem too bad? 

These contracts don’t solve anything long term. They are for a maximum of two years. And then what? You’re dealing with the same stagnant fee codes, ballooning overhead, and burn-out inducing practice conditions of not-new-to-practice GPs that includes mountains of unpaid administrative work and being required to provide 24/7 coverage for patients, and you’re tied to a practice and you can’t find a locum to get any time off - I.e. you’re in the exact situation driving current GPs to quit.

To quote papa Fang, “They’re taking us for fools…” https://www.abbynews.com/news/b-c-reconsidering-signing-incentives-for-new-family-doctors-following-push-back/

 

[medisforme]

The 295k doesn't include overhead (so subtract 20-40% from that) and the signing bonus works out to $120 and change/week (no where near worth the grief you will encounter).  The amount is actually insulting given the amount of unpaid work family doctors engage in.  Also, the government basically has not addressed the issue of overhead costs in any way.  That is the main issue preventing new grads and old grads from practicing community family medicine.

Furthermore, family medicine fee codes have been stagnant for 20+ years.  Check out the graph below to see how the basic visit fee (ages 2-49) code lags further and further behind inflation.  Actual data used to form the graph is from Doctors of BC. .  It is a joke how little family docs in BC earn compared to the amount of work they do.  I honestly feel it is likely the only medical specialty where the workload increases after residency as you are sheltered from a lot of the paperwork, documentation and business side of it in residency.

[NewClerk]

3 hours ago, frenchpress said:

These contracts don’t solve anything long term. They are for a maximum of two years. And then what? You’re dealing with the same stagnant fee codes, ballooning overhead, and burn-out inducing practice conditions of not-new-to-practice GPs that includes mountains of unpaid administrative work and being required to provide 24/7 coverage for patients, and you’re tied to a practice and you can’t find a locum to get any time off - I.e. you’re in the exact situation driving current GPs to quit.

To quote papa Fang, “They’re taking us for fools…” https://www.abbynews.com/news/b-c-reconsidering-signing-incentives-for-new-family-doctors-following-push-back/

 

It also doesn't include money you can make on the side from hospitalist and emerg or obs? But damn, I guess I assumed you'd be able to continue the contract after two years. That does suck big time..

[shikimate]

Great graph above, and you have to remember CPI inflation is a "cooked" number because they don't consider commercial rent (which to start is much higher than residential per squarefoot). Commercial properties are charged higher fee for utilities and property tax. Often commercial property taxes are around 2-2.5% whereas residential is about 1-1.5%. Another point is that unlike a church, charity or hospital, a medical clinic cannot claim "non profit" reduction in property tax.

All in all the CPI inflation # by itself is an underestimation of the "true" inflation, not to mention it is used for residential cost of living, not commercial operations. Therefore the graph above is likely being "euphemistic" regarding the fee gap.

And we haven't even got to the bashing of doctors by the likes of Toronto Skunk newspaper back around 2011-2015. If you go back to that time around the OMA negotiations and read what Theresa Boyle wrote, you'll get an idea as to why doctors staged a coup at the OMA later. All that has downstream effects on morale of medical students. The portrait they were trying to paint was that all high billers are engaged in some kind of fraud, even though some high billers probably work a ton to get to that billing amount or bill for a group etc.

Why be like boomers and work 75 hr a week and make a ton of money but get bashed as greedy? Might as well take an easy salaried job make 250K but see 3 patients an hour and have time to go play sports after work.  There was an article in the Vancouver Sun this week by some boomer who reminisces the "good old days" when their doctor always worked on Saturdays. Guess what, it's not worth doing that anymore in 2022.

[Findanus]

There's lots of talk in the news and in 'thinkpieces' about alternate practice models, midlevel expansion, salaries, increasing foreign doctor recruitment etc.

 

But you rarely ever see a discussion about the only effective solution.

 

The only thing, the one simple thing that will solve the issue, increasing the fees, is never discussed. That's because it costs the most money and doesn't allow the government to gain control over the provision of primary care.

 

 

[indefatigable]

55 minutes ago, shikimate said:

Why be like boomers and work 75 hr a week and make a ton of money but get bashed as greedy?

The other issue is that the work is now more time-consuming and harder - even working the same hours the patients are now more complex and have more administrative burden compared to 30-40 years ago.  Unlike say ophtho where cataract surgery has become easier and faster due in part to technological advancement, "routine" visits from a much more chronically ill population take more time both to assess and to manage with appropriate testing, charting, follow-up, referrals..   EHRs haven't made work faster.  So working the same hours with an outdated fee code and a more complex population is less high yield financially than it was several decades ago.

[shikimate]

Exactly, that's why a lot of FM docs now enjoy doing ER or walk in clinic. Basically write a script for symptomatic relief, do the bare investigations, maybe do up a referral, and see you later alligator. To do a thorough review for an elderly person with multiple issues really is like an IM consult and should be paid at least 150$+. Working at student health center seems popular these days, mostly healthy young people and low overhead/admin work, lots of supportive services for mental health stuff.

[ArchEnemy]

Can confirm that the situation in BC is truly as dire as the news make it out to be.

To make matters worse, the province doesn't value MDs, and rather hire NPs instead to save costs at the expense of British Columbians' health.

GPs are starting to charge private fees to enroll in their practice (ranging from $500-1000/annum), thereby creating another two-tiered system between the haves and have nots.

Edited July 12, 2022 by ArchEnemy

[zoxy]

7 hours ago, ArchEnemy said:

GPs are starting to charge private fees to enroll in their practice (ranging from $500-1000/annum), thereby creating another two-tiered system between the haves and have nots.

Is this legal under the Canada Health Act? My understanding was that as long as you're accepting provincial government Medicare, you can only charge for services that aren't covered by the provincial government, making such fees untenable as long as you intended to operate within the public sphere.

Edit:

It's apparently legal in every province but Quebec and is supposed to cover services that government insurance does not cover. And it's only legal if patients are given the option of paying per diem for the additional services that the annual fee is supposed to go towards. If patients are paying ahead, how are they to know if they will be requiring uninsured service for the year? Would they then get a refund if they don't require the uninsured service that they've already paid for? Something tells me GPs wouldn't be refunding patients in this case.

Not sure how I feel about this. If this becomes more prevalent, Dix and the rest will have a field day portraying doctors as greedy and the public will lap it up. I feel that it will be self-defeating in the long run, even from a purely financial perspective without even taking morals and ethics into consideration.

https://www.cmaj.ca/content/183/7/781

 

[frenchpress]

1 hour ago, zoxy said:

Is this legal under the Canada Health Act? My understanding was that as long as you're accepting provincial government Medicare, you can only charge for services that aren't covered by the provincial government, making such fees untenable as long as you intended to operate within the public sphere.

Edit:

It's apparently legal in every province but Quebec and is supposed to cover services that government insurance does not cover. And it's only legal if patients are given the option of paying per diem for the additional services that the annual fee is supposed to go towards. If patients are paying ahead , how are they to know if they will be requiring uninsured service for the year? Would they then get a refund if they don't require the uninsured service that they've already paid for? Something tells me GPs wouldn't be refunding patients in this case.

Not sure how I feel about this. If this becomes more prevalent, Dix and the rest will have a field day portraying doctors as greedy and the public will lap it up. I feel that it will be self-defeating in the long run, even from a purely financial perspective without even taking morals and ethics into consideration.

https://www.cmaj.ca/content/183/7/781

 

NPs are already billing privately, and can charge whatever they want for things that would be considered ‘insured services’ like interpreting labs results and writing prescriptions. Except unlike doctors, they don’t have to opt out of MSP to bill privately, because they can’t actually bill MSP with their scope to start with. But with the current crisis, people will pay. The government actively allows and seems to encourage this two tiered system, as long as physicians don’t participate. 

For example https://dakova.janeapp.com/?fbclid=IwAR3Vt3rlLO8iEDogYnk6jSrBN54lQG2QW69NODWtxWHBy1g2d8xt-b7fv1Q#/discipline/6/treatment/20

$80 for a 20 minute follow up appointment. Makes me livid. 

[NewClerk]

1 hour ago, frenchpress said:

NPs are already billing privately, and can charge whatever they want for things that would be considered ‘insured services’ like interpreting labs results and writing prescriptions. Except unlike doctors, they don’t have to opt out of MSP to bill privately, because they can’t actually bill MSP with their scope to start with. But with the current crisis, people will pay. The government actively allows and seems to encourage this two tiered system, as long as physicians don’t participate. 

For example https://dakova.janeapp.com/?fbclid=IwAR3Vt3rlLO8iEDogYnk6jSrBN54lQG2QW69NODWtxWHBy1g2d8xt-b7fv1Q#/discipline/6/treatment/20

$80 for a 20 minute follow up appointment. Makes me livid. 

Wow. Just wow.. and there are people that are for sure paying that. That doesn't sit well with me 

[medisforme]

https://fraservalleytoday.ca/2022/07/12/chilliwack-primary-care-centre-to-lose-all-its-dedicated-family-doctors-by-mid-september/

 

Another update for those so inclined.  Chilliwack UPCC losing literally all its docs, will have none remaining by mid-september.  MOH apparently tried to back out of a pre-negotiated contract with some of the physicians and they had had enough.  Patently obvious, there is no respect for family doctors by our current provincial government.

Its incredibly frustrating seeing Horgan on TV trying to pressure Federal government to increase transfer payments as if this is the solution to get health care back on track, when his government has literally burned hundreds of millions of health care dollars on UPCC's.  If the money for UPCC's had been given to support GP overhead or increase GP fee codes, that in itself would have been a large boost to our primary care system and likely resulted in increased retention and even recruitment of family physicians.

[shikimate]

Reminds of that grand hotel built by Kim Jung Un in north Korea but never had any guests in it lol.

[Findanus]

2 hours ago, medisforme said:

https://fraservalleytoday.ca/2022/07/12/chilliwack-primary-care-centre-to-lose-all-its-dedicated-family-doctors-by-mid-september/

 

Another update for those so inclined.  Chilliwack UPCC losing literally all its docs, will have none remaining by mid-september.  MOH apparently tried to back out of a pre-negotiated contract with some of the physicians and they had had enough.  Patently obvious, there is no respect for family doctors by our current provincial government.

Its incredibly frustrating seeing Horgan on TV trying to pressure Federal government to increase transfer payments as if this is the solution to get health care back on track, when his government has literally burned hundreds of millions of health care dollars on UPCC's.  If the money for UPCC's had been given to support GP overhead or increase GP fee codes, that in itself would have been a large boost to our primary care system and likely resulted in increased retention and even recruitment of family physicians.

It's about control. It's not about the quality of care or access to it.

[Vya]

@FindanusCan you give me a TLDR about why the government is pouring money into the UPCCs? I dont really understand the difference between these and regular walk-in clinics. Is it because they staff them mostly with NPs, so the province thinks it can save money?