A Canadian Physician, PGY-11.

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I Just Want to See Patients

Recently, a study came out that declared that the GP incentive payments for complex care, as designed by the General Practice Services Committee (GPSC) here in BC, have failed to improve several markers of healthcare utilization and general health.

Dr. Shelley Ross, co-chair of the GPSC, was quoted in print media defending the GPSC incentive program, stating that two years of data was not nearly enough to draw conclusions:

"There is no doubt that having a family practitioner who knows you, who sees you proactively, who has a care plan for what they want to achieve in consultation with the patients, is absolutely improving care and the patients feel like they are getting better care as well."

What Dr. Ross mentions seems self-evident: having a Family Physician that sees you longitudinally, who has a care plan in place for you, will obviously improve your care (or at least not worsen it!). Unfortunately Dr. Ross has played a sleight of hand here: what she is discussing is proper Family Medicine as we'd like to see it done, but what the study was actually about is billing incentives, otherwise known as "pay for performance". These are not the same thing, and there are much better ways to achieve good, longitudinal Family Medicine. If we're going to spend several hundred million taxpayer dollars, I think we need some evidence behind our programs, and pay for performance has little or no good data to support its use to improve complex care.

What Dr. Ross also glosses over here is that, if BC Family Physicians were just paid appropriately to see a roster of family medicine patients, comprehensively, the same goal could be achieved, with significant administrative savings, while decreasing the real risk of burnout. The complexity and opacity of the billing schedule in BC serves as a serious disincentive to young physicians like myself, as it leads to both significant administrative overhead, as well as difficulty figuring out just how much I might get paid, as many of the payments are deferred (i.e. paid yearly). For example, below I've listed just one of the GPSC's many incentive billing codes (G14033):

The Complex Care Management Fee is advance payment for the complexity of caring for patients with two of the eligible conditions and is payable upon the completion and documentation of a Complex Care Plan for the management of the complex care patient until the complex care plan is reviewed and revised in the next calendar year. A Complex Care Plan requires documentation of the following elements in the patient’s chart that: 1. There has been a detailed review of the case/chart and of current therapies; 2. There has been a face-to-face visit with the patient, or the patient’s medical representative if appropriate, on the same calendar day that the Complex Care Management Fee is billed; 3. Specifies a clinical plan for the care of that patient’s chronic diseases covered by the complex care fee; 4. Incorporates the patient’s values and personal health goals in the care plan with respect to the chronic diseases covered by the complex care fee; 5. Outlines expected outcomes as a result of this plan, including end-of-life Issues (advance care planning) when clinically appropriate; 6. Outlines linkages with other health care professionals that would be involved in the care, their expected roles; 7. Identifies an appropriate time frame for re-evaluation of the plan; 8. Confirms that the care plan has been communicated verbally or in writing to the patient and/or the patient’s medical representative, and to other involved health professionals as indicated. The development of the care plan is done jointly with the patient &/or the patient representative as appropriate. The patient &/or their representative/family should leave the planning process knowing there is a plan for their care and what that plan is. Notes: The Complex Care Management Fee was developed to compensate GPs for the management of complex patients who have chronic conditions from a least 2 of the 8 categories listed below. Providing the Complex Care planning visit and billing for the development of a care plan allows access to 5 telephone/e-mail fees (G14079) during the following 18 months. These items are payable only to the General Practitioner who accepts the role of being Most Responsible for the longitudinal, coordinated care of that patient; by billing this fee the practitioner accepts that responsibility for the ensuing calendar year. The Most Responsible General Practitioner may bill this fee when providing care only to community patients; i.e. residing in their homes or in assisted living with two or more of the following chronic conditions: 1) Diabetes mellitus (type 1 and 2) 2) Chronic Kidney Disease 3) Congestive heart failure 4) Chronic respiratory Condition (asthma, emphysema, chronic bronchitis, bronchiectasis, Pulmonary Fibrosis, Fibrosing Alveolitis, Cystic Fibrosis etc.) 5) Cerebrovascular disease 6) Ischemic heart disease, excluding the acute phase of myocardial infarct 7) Chronic Neurodegenerative Diseases (Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Parkinson’s disease, Alzheimer’s disease, stroke or other brain injury with a permanent neurological deficit, paraplegia or quadriplegia etc.) 8) Chronic Liver Disease with evidence of hepatic dysfunction. If a patient has more than 2 of the qualifying conditions, when billing the Complex Care Management Fee the submitted diagnostic code from Table 1 should represent the two conditions creating the most complexity. Successful billing of the Complex Care Management Fee (G14033) allows access to 5 Telephone/E-mail follow- up fees (G14079) per calendar year over the following 18 months. In order to encourage non-face-to-face communication with patients covered by some of the GPSC incentives, the initial four separate telephone/e-mail follow up fees have been simplified into a single code that will still apply to the planning incentives (Complex Care G14033, Mental Health G14043, Palliative Care G14063 & COPD G14053 which requires a COPD Action Plan). Patients covered by one or more of these incentives are eligible for five telephone/e-mail services over the 18 months following the billing of the qualifying incentive(s). i) Payable once per calendar year. ii) Payable in addition to office visits or home visits same day. iii) Visit or CPx fee to indicate face-to-face interaction with patient same day must accompany billing. iv) G14016, Community Patient Conferencing Fee, payable on same day for same patient if all criteria met. v) G14015, Facility Patient Conferencing Fee, not payable on the same day for the same patient, as facility patients not eligible. vi) G14017, Acute Care Discharge Planning Conferencing Fee, not payable on the same day for the same patient, as facility patients not eligible. vii) CDM fees G14050/G14051/G14052/G14053 payable on same day for same patient, if all other criteria met. viii) Minimum required time 30 minutes in addition to visit time same day. ix) Maximum of 5 complex care fees (G14033 and/or G14075) and/or GP unattached complex/high needs patient attachment fees (G14074) per day per physician. x) G14075, GP Attachment Complex Care Management Fee, is not payable in the same calendar year for same patient as G14033, GP Annual Complex Care Management Fee. xi) G14079 – Telephone/e-mail follow up fee is not payable on the same day. xii) Not payable for patients seen in locations other than the office, home or assisted living residence where no professional staff on site. xiii) Not payable to physicians who are employed by or who are under contract to a facility and whose duties would otherwise include provision of this care; xiv) Not payable to physicians working under salary, service contract or sessional arrangements whose duties would otherwise include provision of this care.

Phew! Think of the time wasted here in self-audits and clinically unnecessary documentation, just to ensure you're billing appropriately. Billing codes are not (and should not be) the incentive to do proper complex care; our training is.

How would I like to see this fixed? BC could attract many young physicians like myself by offering a fair compensation package that does away with the dozens of complex billing codes, and pays me to look after a cohort of patients longitudinally. I want to do proper Family Medicine, but the fee schedule doesn't enable that currently. Preferably, I would like the government to say ""we'll pay you $X/month to look after Y patients, comprehensively." I can dream! Until then, BC will continue to hemorrhage younger physicians.