Fee-for-service needs an overhaul by Dr. Ali Damji

Fee-for-service is long overdue for an overhaul to bring it to the 21st century realities of medicine. Our current fee-for-service prioritizes volume of care, which can improve access, but may come at the expense of providing comprehensive care that is patient centred. These days, with our aging population, the incredible advances that have been made in medicine, and the advent of electronic record systems that puts years of data at our finger tips, a visit is almost never a “single issue, single code” visit. Yet this is what our fee-for-service system assumes. And this is highly problematic and frustrating both for patients who want to see a doctor that looks at the entire problem, and physicians whose payment models don’t incentivize them to practice medicine the way they want to or are trained to.

Conversely, salaried/blended models offer the ability to spend the time that is needed with each patient without as much of a pressure to see volume (but this is still an important consideration because you need to ensure your patients are still able to access you). If I need 30 minutes with an elderly patient who has three problems to discuss, I can address their concerns and not worry about the bottom line.

The second advantage is that the fee-for-service system does not capture a large portion of the care that is provided by patients. Without a code, physicians are often not paid at all for this work which can drive burnout and frustration and reduce willingness to provide this care e.g. telephone calls/virtual care prior to COVID-19 which could replace in person visits and be more convenient for patients, documentation, forms.

As someone who works with both models (blended capitation in my primary care practice, and fee-for-service for addiction medicine), I see the strengths and drawbacks of both. I personally feel that there may still be a role for fee-for-service in certain focused “single issue” areas of medicine that are very technical and focused, but that the vast majority of us should embrace novel models of compensation that incentivize still seeing volume by providing blended incentives, but will not penalize a physician financially for providing holistic comprehensive care that looks at the entire patient, without suffering financially. When we look at the patients who are often left behind like vulnerable populations, complex chronic disease, or the elderly, our payment model may hold part of the blame.

Dr. Ali Damiji is a family doctor in Mississauga, ON.

This piece originally appeared on the Medical Post’s website and newsletter. Reprinted with permission.

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