Walk-in Clinics and Physician Billings (Part 2)

[Guest Ian Wong]

Here's part 2 of a series of articles published by the Vancouver Sun. This article is particularly informative in giving some details regarding the number of patients seen by a doctor in an average day, and the salaries and incomes that can be realised working as a family doctor in a walk-in clinic.

 

www.canada.com/vancouver/news/story.asp?id={0552A15E-F8B5-4DD7-9F44-49F7119ABF16}

 

<!--EZCODE BOLD START--> The walk-in health clinic trend: Care for the fast-food generation. What happens with long-term problems, family doctors ask.<!--EZCODE BOLD END-->

 

Larry Pynn

 

Vancouver Sun

 

Friday, May 31, 2002

 

More than 100,000 British Columbians are without a full-time family physician, a number that is expected to grow dramatically in coming years as more doctors retire and others switch to walk-in clinics offering better pay and more time off.

 

"The walk-in trend is growing," Dr. David Attwell, Victoria-based president of the B.C. Medical Association's Society of General Practitioners, lamented in an interview with The Vancouver Sun. "These patients have no other place to turn."

 

He expressed concern that continuity of care suffers in walk-in clinics that do not offer long-term treatment for complicated ailments. "You're not getting the same doctors taking care of the patients' same problems," he said. "That's the critical thing when you deal with patients with chronic, ongoing conditions."

 

Attwell singled out Consolidated Care Point Medical Centres Ltd., which opened five new clinics in Greater Vancouver last year, for creaming off the easy visits and leaving the tougher, more time-consuming problems to full-time family practices.

 

Unless the provincial billing system accounts for this discrepancy, he argued, more and more family physicians will switch from traditional practices to walk-in clinics.

 

"Care Point is different," Attwell said in an interview. "They basically see the very easy stuff. They essentially skim on the fee schedule, in the sense that an easy appointment at Care Point pays the same as a much more difficult appointment in a family physician's office.

 

"They [patients] are accepted for that one visit. But they're not accepted for continuing care. They don't open a permanent chart so the patient has someone to come back to on a regular basis, and that's the tragedy of it."

 

Care Point general manager Jim Roy countered that the company's walk-in clinics are misunderstood by the greater medical community and do, in fact, accept patients on a continuing basis if that's what they choose.

 

A file is kept on every visit, and made available to the regular family doctor as requested. But some patients don't want their family doctor notified, he said, perhaps because of embarrassment over having gone to another clinic or because of the nature of their condition, such as a sexually transmitted disease.

 

He added Care Point doctors give proper treatment to everyone who walks through the door, not just the easy cases. "We're not into stealing patients or taking only the quick patients."

 

Care Point reports that about 40 per cent of patients visit its clinics because they have no family doctor, 30 per cent because their family physicians are not available, and 30 per cent because the clinic is their family physician, he said.

 

The percentage of first-time patients varies between about 10 per cent in established clinics to 40 per cent in newer clinics in transient areas such as Davie Street.

 

Care Point expects to handle more than 250,000 patient visits in the Lower Mainland this year. About five per cent of those visits will be for a growing list of specialists signing on with the company in areas such as dermatology, urology, general surgery, and pediatrics.

 

"There is a change happening," Roy said of patients' demands to be treated when they need a doctor. "And the one constant in change is resistance."

 

Attwell agreed that traditional 9-to-5 offices no long serve the needs of a big segment of society. "We live in the fast-food generation," he said. "The same things goes for patients. They expect to get care when they need it."

 

Walk-in clinics have grown steadily since the mid-1980s. Today, most operate as adjuncts to full-service family practices, offering after-hours service to patients. Some, such as Care Point, operate only as walk-in clinics. Appointments are only accepted for specialists.

 

Walk-in clinics indirectly act as a safety valve for emergency wards, theoretically saving the medical system money. A general practitioner bills $26.53 for a basic visit, whereas an emergency ward visit can cost the system more than four times that.

 

Dr. Bill Cavers, a Victoria family doctor, said the province must provide greater support and financial reward for his colleagues to arrest the current trend and to prevent an increasing number of British Columbians going through life without a family doctor.

 

Cavers said he shares his practice with three other doctors but is also part of a "call group" of 16 doctors who provide support for each other, including both a weekend and night walk-in clinic.

 

He confirmed that walk-in visits tend to be shorter and less complicated than visits to his general practice. "Walk-in care is generally more lucrative and not as clinically taxing . . . ." he said.

 

Cavers said that for financial reasons, medical students are spurning general practice for specialist positions. According to a Canadian Medical Association report in May 2002, a record 53 of 1,260 available family practice residency positions went unfilled across Canada. As well, more than three times that number of GP positions were filled by medical graduates only because they could not get the specialist positions they wanted.

 

"The first choice is obviously going very quickly away from family practice," said Cavers, a former president of the Society of General Practitioners. "Only as a second and reluctant choice do they go into it."

 

Walk-in doctors tend to treat one problem, Attwell added, whereas a patient may list off several ailments to their family doctor in the same visit -- all of which equals one billing.

 

Family doctors also tend to be asked for free telephone advice and prescription renewals, as well as help filling out of forms.

 

Attwell argued that while walk-in clinics give solid medical treatment, they fail to address long-term continuing care needs.

 

Predicting that the number of "orphan" patients in B.C. -- now estimated at 100,000 -- will grow, he said it's all a reflection of inadequate compensation for work performed.

 

"A lot of family physicians are quitting general practice and going to work in walk-in clinics because there are a lot less hassles. You're not dealing with tonnes of paper work and phone calls and the pay is pretty darn good."

 

Roy said Care Point started in Vancouver in 1986 based on a prediction of future trends -- the desire for younger doctors to have a life outside medicine, and the desire for the public to get treatment when they need it.

 

"Patients want a timely answer to their medical problem. They want help now."

 

By leaving the administrative duties to Care Point -- in exchange for taking an average 40-per-cent cut of billings -- doctors focus on practising medicine and go home at the end of the day without the lingering headaches associated with a private practice.

 

"Physicians are not trained to do advertising, hire staff, supervise people, keep records, change light bulbs and everything else," Roy said. "Their job is to help people get well."

 

Rather than seeking to open new clinics, he explained, the company responds to invitations from doctors who are burned out and seek to move their practice in the clinic.

 

Care Point -- the working name for Consolidated Care Point Medical Centres Ltd., a publicly traded company -- employs 117 physicians, with about 40 working on any given day. They work flexible shifts -- perhaps two or three days a week, or eights month on and four months off -- but they are expected to stick to a set schedule. That way the company can operate effectively, and patients know when a certain doctor is on shift.

 

A Care Point physician typically sees 25 to 35 patients in a six-hour shift, Roy said. At the basic billing rate, that would represent $663.25 to $928.55 per shift. Subtract the 40-per-cent share to the company, and the doctor gets $397.95 to $557.13.

 

That works out to four to six patients per hour, without the after-hours office duties associated with a private practice.

 

In comparison, Cavers said, a family practitioner would typically see four patients per hour. Locum doctors filling for general practitioners on holidays might see substantially fewer since many patients tend to put off treatment until their regular doctor returns.

 

He added that the 40-per-cent cut to Care Point compares with a typical overhead cost to family practitioners of 45 per cent -- higher in urban areas.

 

Care Point operates daily 9 am. to 9 pm., except for Christmas.

 

WHAT CARE POINT IS

 

- Care Point launched its first Vancouver walk-in clinic on Commercial Drive in 1986. Today, the publicly traded company is the Lower Mainland's largest operator of walk-in clinics with a total of nine. It opened five new clinics last year. It expects to log more than 250,000 patient visits this year.

 

- Care Point's co-founder and major shareholder is Peter Briant, a chartered accountant and retired economics professor from McGill University in Montreal. Care Point physicians billed $4.3 million in the fiscal year ending Sept. 30, 2001, of which $1.7 million went to the company. That's up from $2.9 million in billings and $1.1 million in profits in 2000.

 

- Shortly after Care Point's arrival in Vancouver 16 years ago, it became increasingly common for general practitioners to expand their office hours to include walk-in patients on evenings and weekends -- a reflection of society's changing demands for flexible hours.

 

- The Society of General Practitioners estimates about 500 of the 3,000 full-service general practitioners in B.C. have walk-in clinics attached to their practices. About 250 others work almost exclusively in walk-in clinics or as locums replacing doctors on holidays.

 

- Doctors bill a basic $26.53 per visit in walk-in and traditional general practice offices.