The Society of Rural Physicians of Canada divides the country into 5 regions. The North/West Region includes the province of British Columbia and the territories. Some measure of the politics of the rural medical economics of the region are listed below. If you wish to become involved please contact the regional committee chair listed here.
British Columbia introduced the concept of restricted billing numbers to Canada in 1985 (Bill 50). Thrown out by the BC Supreme Court they tried again with Bill 41 which was also found to violate the Charter of Human Rights and Freedoms. Despite a mixed review of the effectiveness of the program by Barer in 1988, differential payments for new graduates were introduced in 1996. They too were eventually withdrawn in August 1997.
Rurality Based Incentives
Subsequent strategy is currently more dependent on carrots and has reduced the urban rural physician gap better than any other province (see numbers). The Northern and Isolation Allowance Committee of the BCMA and MSP has a fixed budget to draw upon to provide payment premiums to certain northern and isolated physicians. The physician is assessed according to the size of his/her community, distance to major referral centres, number of specialists and number of general practitioners. A minimum number of points on this scale is needed before a physician (or community) qualifies for NIA. Payment premiums used to range from 5 - 20 % on gross MSP billings, and as of April 1999 up to a 30% bonus. Those communities receiving NIA are also exempt from the daily volume limits imposed on all other physicians in the province for payment of office visits. In 2000 Prince Rupert pop 19,000 gets 17.5% bonus. Burns Lake pop 7,000 gets 21%. Williams Lake, pop 26,000 is not in the NIA.
This program has been criticized in that the incentive depends entirely on volume and does not apply to other less isolated places. Some accommodation has occurred in 2000 with the other northern and rural communities with "retention" payments that are not volume dependent but rather vary from town to town. By example Cranbrook would get $30,000 for GP retention, $37,000 for Specialist retention. Golden would get NIA at 13% of FFS and $15,000 for GP retention and $18,750 for specialist retention.
The Rural Subsidiary Agreement took effect January 2003 with the $45.4M Geographic Incentive Premium replacing the NIA. 65% of the money is as percentage premiums on FFS, 35% is a lump sum monthly payments to docs living in rural communities. The amounts are determined by a scheme that is a modified NIA program which ranks all affected communities and then divides up the pot. As this is a retention payment Locums are not eligible.
A Rural Locum Program (RLP) helps communities with up to 3 physicians with 1 to 4 week locums since 1995 and has been expanded in 2003 to communities up to 7 physicians. Current funding pays locum doctors a guaranteed daily rate of $750, plus a $600 honorarium to cover round trip travel >4h, plus 100% of WCB, ICBC, and ER, plus on-call pay ($25/h). The locum gets the rurality topup on FFS (varies by community but can be above 10%). The host MD provides accommodations and the car. The Host MD is guaranteed 40% of office billings to cover overhead. Regional specialist locum support for core specialties has been funded in 2003 for a guaranteed daily rate of $1,000 plus fee-for-service earnings over the guaranteed amount. Specialists will also get on-call payments and a $1,000 travel honorarium.
There are about 15 isolated places that have salaried physicians. Some of these are administered by native health boards and some by the United Church of Canada.
In 1998 a settlement on Northern on call payments had been recommended by the fact finder in the "Dobbin Report." This would involve benefits for communities with less than 10 doctors. The CME allotment would increase, and there would be more money for rural "seniority," a $20 per hour bonus on top of fee for service after hours, or a flat rate of $30/hr. A first in Canada, rural GP-surgery and GP-anaesthesia get a $5/hr bonus for being on call. The Dobbin report is available in the library as a review or in full text. In 1999 there appeared to be a bit of reluctance and inconsistency with application of funding to locums, with some being Dobbin funded and others (those on the Rural locum Program) not.
In 2000 a new rural deal was struck. In general it offers 5.5 million on top of the original 8 million obtained under Dobbin for on-call and top-up CME funding to make the rural package broader in scope. The smaller towns get $30/h plus FFS for ER, and the larger towns on NIA get $10/h. Weekday shifts for GP-anaesthesia or GP-Surgery get paid $70. Specialty surgeons in NIA areas get paid $140 per shift. Of course then they gave $10M to Prince George for an incentive plan just for that northern city which upset the apple cart somewhat.
In 2001 ER Call after hours topups are $30/h plus FFS (and $40/h on weekends) for 6 and under doc towns. 7-10 doc towns get $20/h topups for ER FFS and >10 doc towns get $10/h. GP Anaesthetists and GP Surgeons get $5/h plus FFS but can't double dip when they are on call for ER as well.
In mid 2002 it appeared that all on call would be paid at $25/h + FFS but here's the catch, the regional health authority decides which services to cover and while all rural ERs are covered this is not so for all rural ORs. This means that in designated centres the on call services will be worth about $2,000 for availability from Friday to Monday morning, but, by example in many centres GP-anaesthesia have no stand by fee at all. How many people are now going to carry a beeper for no pay when the next town pays big money? The only mitigating factor is that there will be a call back fee of $250 for the first call back that day.
The 2003 Rural education action plan provides $2.25 million towards training for rural doctors. Funding can be applied to education-related costs like income loss, overhead, tuition, travel expenses, accommodation and board. The program also funds undergraduate medical students gaining rural practice experience, focuses on rural doctors’ participation in medical school selection and curriculum development, and provides a first-year practice enhancement fund for new doctors and bursaries for residents willing to practice in a rural community after they graduate.
All doctors in BC get a $1,150 annual CME allowance. There is also an additional up to $5,200 in CME funding per rural doctor annually. The amount of eligibility increases with the number of years in the community and is maximal in the most remote communities ($5,200 is for over 4 years in a community with over 20 isolation points)
In BC an office visit is $26.53 based on 00100. The ER code is based on evening call-back codes 01200 + 13200 and is $68.61. A delivery is worth $406.04 Remote areas get a premium based on a point system as mentioned above.
I suppose a rural incentive program for the Yukon is a bit redundant terminology when you consider that the referral centre may be Vancouver. They used to consider the city overserviced and discounted new MD's 50% of the schedule. The Physician resource committee was disbanded aug 1999 thus there is no longer any limitation on billings by new practitioners. The MD:Patient ratio is about 1:700 in the Yukon so while rural and remote, the payment scheme has prevented any under service, at least in town. All long distance calls related to patient care can be billed to a central government number throughout the territory. On call remuneration is still being discussed for rural doctors but has yet to happen. Rural doctors get clinic space in the community nursing stations. The nurses take first call. A salary model is available of $150K + 6 wk. holiday + 2 week CME plus travel out of the territory once a year.
The office visit is $30 based on 0100. ER callback is $133.70 based on 1800h-2259h 0151(92.90)+ 0100
North West Territories/ Nunavut
Like the Yukon it has been traditionally reasonably successful in recruiting physicians with its pay scale, at least to Yellowknife which used to have 30 GP's. In late 2002 this was no longer the case, with a third of FP/GP positions vacant and and all communities depending on locums. A 20% differential on FFS billings in isolated areas exists, although most doctors are on contract. The contract which started at $140K in 1998 has been increased in 2003 to $163.8K to $234K + benefits (RRSP, insurance, CME, CMPA, etc) depending on years service and special skills. The work week is nominally 40 hours plus 16 on call. Additional on call is paid at 1.25 time. Vacation is between 26.5 to 31.5 days a year. Additional recruitment and retention pay varies by the isolation of the community. The recent increases and shorter hours are hoped to recruit a further 21 physicians to a total 40 positions.
NWT pays $29.62 for an office visit based on A2 1st visit. A3, follow-up visit is billed at $15. ER callback is $79.60. There is a current 4% claw back.