ER closures due to uneven fee schedules

News articles about ER closures always place the cause of the disruption as “a doctor shortage”.

In January 26, 2017, Cumberland News Now quoted Dr. Bill Lowe, head of family medicine for the Nova Scotia Health Authority’s northern zone that the ER closures at All Saints was due to “an inability to find sufficient locum physicians to fill all the shifts.”

March 30, MBS Radio reported, “The South Cumberland ER in Parrsboro will be closed Saturday from 8:30am-8:30pm. It’s due to a doctor shortage.”

On April 20, MBS reported, “The South Cumberland ER in Parrsboro will have several day closures next week and weekend. It’ll be closed Monday, Wednesday, Thursday, Friday, Saturday and Sunday from 8:30am-8:30pm due to a doctor shortage.”

Cumberland News Now reported on April 26 that the Pugwash ER would be closed for four hours “because there is no physician to provide the necessary medical coverage.”

On May 17, CKDH radio reported another ER closure for Pugwash “due to a doctor shortage.”

In total Cumberland County ERs had 65 closures in 71 days.

What is left out of the announcements about these doctor shortages is that there are no doctors available to work for the fee schedule offered. The fees paid to rural ER doctors are so low that it doesn’t make economic sense for physicians to leave their offices to staff ERs. To do so is an act of fiscal charity.

Left unsaid is that our universal health care system has a tiered, geography-based fee schedule. The Nova Scotia Health Authority, like its predecessor authorities, believes that rural health can be provided for less money than urban health. So the fees paid to doctors working in rural ERs is less than that paid to doctors working in city ERs.

I’ve written about this before (

In setting the fee schedules there is a lop-sided valuation of responsibilities. Health executives, whose pay is not based on geographic determinants, have decided that rural ERs are less challenging situations, so those doctors are paid $75 an hour less than a doctor in a Halifax-based ER.

It’s a curious distinction. It implies an official policy that says city people are sicker than rural residents. The subtext is that rural lives don’t matter (as much).

How is it that we believe a uniform rate of pay for teachers is necessary to achieve a universal level of education for all students in the province, but we use geography to devalue a physician’s contribution to patient health? MLAs, Cabinet Ministers, civil servants, health executives have one pay scale, regardless if they represent and/or work in a rural or urban riding or setting. There is no distinction made based on geography. So why is it okay to play with health care dollars in this manner?

We can hire all kinds of recruiters to try to attract doctors to the province, but if we don’t pay them competitively, we will continue to have ER closures. Of course, those closures don’t happen in the city because of the pay rate provided to ER doctors. As I previously wrote a county warden felt it unfair to place rural doctors at the bottom of the pay pile because they (the rural doctor) had the greater responsibility for the patient.

In a city ER, the doctor has a wider array of support services and specialists to call on. A city ER can “process” a patient more quickly. In a rural setting, the ER doctor has fewer on-site resources, so is more involved in stabilizing the patient then determining if that patient can return home, must stay on-site for treatment or should be transferred to the city.

I also suggest that rural doctors are often dealing with a bloodier type of medicine given rural occupations in farming, fishing and forestry. Not as many city residents are working with heavy equipment, large animals or sharp instruments in all types of weather.

The growth in ER closures is the canary in the mineshaft for the problems in health care. In the past, physicians spoke about problems with the system and management. Now their complaints are management and money.

When it comes to management physicians feel undervalued, stressed and abused. The NSHA speaks of “consultations”, but that is, to quote many physicians, “corporate bullshit”. There are meetings, but the conversation is one sided. Management isn’t listening. The acrimony is so great I’ve heard of physicians telling NSHA executives to “shut up” so they – the physicians – could speak. It doesn’t happen. But the NSHA, coddled by an out-of-touch board, pretends to have dialogue and “consultations” with doctors. And nurses.

On the topic of money, family physicians are stressed. The current fee schedule doesn’t cover basic services like renewing prescriptions, so doctors have to add a billable service to an office visit. Another ridiculous situation is that for a face-to-face appointment a doctor is paid half of what the Province pays for a call to the 8-1-1 service, which is not answered by a doctor.

A doctor’s appointment used to be for whatever medical issues a patient had. Now, patients are actively discouraged from arriving with a list of ailments. Most doctor’s office walls and websites contain notices to confine yourself to one or two issues. A basic patient appointment generates a billable fee of less than $31.

So, to cover their costs, doctors are forced into a type of production-line-like appointment schedule. Where once doctors saw patients for all their medical concerns, time management has become an economic necessity. Doctors were scheduling appointments in 15-minute increments. Recently, I have seen appointments scheduled in 12-minute increments. That allows a doctor to see an additional 8 patients per eight-hour day, so 40 patients a day instead of 32.

Given the costs of operating a practice – rent, utilities, supplies, office staff, technology, equipment, etc. – doctors have to think as much about the economics of a practice as the medicine. The public has the impression that doctors roll in money. The dirty little secret in Nova Scotia is that the family practice income is shit. I recently heard of a family physician whose taxable income was $60,000! A lot of family physicians are earning in the $98-to-$144,000 range. That can seem like a comfortable income when compared to what others earn in Nova Scotia, but doctors deal in life and death. They spent years studying to achieve their qualifications to practice. We pay others comparable amounts – or more – for duties and services with substantially less stress and responsibility.

If we want to solve the doctor shortages – whether in ERs or private practice – we need to pay physicians better. We also have to lighten up on this death-grip idea that a collaborative care practice is the super solution to health care delivery. It is viewed as a questionable option. More on that next week.





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