Primary Care Physician Compensation Reform: A Path for Implementation

The 2019 MacKinnon report, commissioned by the Alberta government, recommended ending fee-for-service (FFS) as the model for paying primary care physicians because of its significant and inherent inefficiencies. Since then, the COVID-19 pandemic has also demonstrated the value of moving Alberta’s family physicians to an alternative payment (APP) model. While the MacKinnon report was in favour of enacting legislation to change the compensation model, this paper instead recommends offering physicians a choice of alternative payment programs as an incentive to move on voluntarily from an FFS system. Other provinces have attempted to reform physicians’ pay using a quadruple aim model for health-care improvement, which identifies the major points policy- makers must examine in instituting a replacement for FFS. The quadruple aim model is four-pronged and encompasses patient experience, population health, care team wellbeing and cost reductions. Alberta Health Services already uses the quadruple aim model to improve patient care and quality outcomes, although the MacKinnon report focused primarily on reducing costs. However, reforming doctors’ compensation is not just about the amount they should be paid; it must also consider that the method of compensation has a profound impact on both cost and quality of care received. Meanwhile, the self-isolation and social distancing measures for both doctors and patients, established with the arrival of the COVID-19 pandemic, have put Alberta’s doctors on a policy roller-coaster. Applying the FFS compensation model during the pandemic has resulted in the use of virtual care codes such as telehealth billing and in-person limited assessment codes. However, these codes were immediately problematic because they do not adequately account for complex patient care that requires longer visits, after-hours premiums and the Rural Remote Northern Program. During a pandemic is not the right time to embark on physician compensation reform. This gives the government time to reconsider the controversial approach taken prior to the COVID-19 pandemic. The need for compensation reform in Alberta is driven by the reality that Alberta has the highest proportion of physicians on FFS along with some of the highest FFS payments per physician in Canada. Meanwhile, family physicians in other provinces are now more likely to be covered by an APP rather than the former FFS system. The problem with FFS is that it tends to encourage physicians to create volume in number of patients seen per day, in order to increase compensation. Thus, it also encourages more diagnostic testing, which increases costs to the health-care system. In general, physicians compensated under FFS have much less incentive to consider costs when treating patients. The argument for legislating pay reform is poorly justified. No other province has legislated physicians out of the FFS system, and that is not a route Alberta should take, either. Nova Scotia has brought in a one-size-fits-all APP, while Ontario implemented a menu of higher paying APPs that produced greater downstream cost savings, making APPs an increasingly attractive payment option to family physicians. Ontario’s approach would be better for Alberta because it improves patients’ overall experience with primary care, their care outcomes and the wellbeing of those who care for the patients. Alberta should offer a menu of APP models tailored to primary care so that the family doctors themselves can choose the best model for their own practices. As this paper has demonstrated in its comparison of the experiences of other provinces, and as the COVID-19 affirms, the menu approach is the model most strongly aligned with the goals of quadruple aim.