Questioning the costs and care of CCCs

The Nova Scotia Health Authority is advertising for health care professionals to join the collaborative care practices.

Is this a real request or a public relations move to mute some of the Auditor General’s criticisms about the NSHA’s secrecy, lack of transparency and poor communications?

If the NSHA needs to reach physicians, nurses and other professionals, it has only to reach out to their associations, regulatory boards and colleges. This ad, it would seem, is more about looking busy and active than being productive.

The other issue is whether these collaborative care practices are the panacea the NSHA would have us believe they are. Or are they just about a different type of bloated bureaucracy?

Four years ago I was invited to attend a medical information day by the Minister of Health. At that day we heard medical students say they wanted to collaborate in a family practice. What I heard said was this next generation of doctors wanted practice partners. They wanted someone to share the work with, to bounce ideas off, to help keep up with medical advances, and to cover for holidays and sick days. The impression was that new doctors wanted to work with two or three others. I did not hear anything along the line of the collaborative care centres/practices the NSHA is promoting. It could be that an aversion to commit to a solo practice – which students say is not presented as an option in medical school – has been misunderstood by the bureaucrats who embraced the idea of over-building a response. A doctor opening a solo practice doesn’t give the ribbon-cutting photo ops of a clinic opening.

Students didn’t say they wanted this and many of the experienced physicians, surgeons and specialists question this model of care delivery. The feeling is that CCCs are an expensive way to deliver care to fewer patients. Below are the detailed questions and concerns of long-time Yarmouth County family physician Dr. Peter Loveridge, MB, BS, DMRD, FRRMS, who lectures in family medicine at Dalhousie University.

This is a copy of a letter Dr. Loveridge wrote to the Doctors Nova Scotia newsletter in response to an article. He asked helphealthcare to share it. It has been lightly edited for clarity to a lay reader.

The Editor, Doctors NS magazine

I am not sure if DostorsNS is set up for comments, but I would like to comment on the article highlighting … collaborative practice. I am a rural doctor who has worked in Yarmouth County for more than 40 years. The article does not give a balanced view of this approach, and leaves many really major problems unaddressed. In replying to this I did take the trouble to go through the 29 pages of “strengthening the primary care system…”, a rather turgid read full of bureaucratese and jargon.

I write entirely as a remote rural doctor. I have nothing to say about urban practice, though it seems now that the inhabitants of HRM are now experiencing the same problems we have had to deal with for decades. I will use the HA example of serving a population of 10,000 people, though the geography of rural NS rarely leads itself to such neat packages.

In the bad old days of 20 years ago, such a population would have been served by a group practice of 4 doctors. (Five if you were lucky and 2 or 3 if you weren’t.) The docs paid for everything out of their (usually) FFS earnings. There would be 3 ancillary staff (+/- 1) and they did all the managing of the practice. Usually one of the senior physicians would have some management oversight. Didn’t much matter about the details, as no-one other than the physicians was responsible for payment of the overheads. The practice would receive about $250k per physician in fees, sometimes in a high volume practice a bit more; in a practice with a lot of elderly, multi-morbidity patients, a lot less. Hospital in-patient coverage, ER coverage, nursing homes, surgical assists, and obstetrics, often in collaboration with other practices, was almost universal. Works out to a cost to the taxpayer of about $100/year/patient.

Now, consider the NSHA’s obsession with collaborative care centres and supposed medical homes, each one serving about 10k patients. Sorry, the geography doesn’t work. My municipality, population just under 8k is 2/3rds the size of Luxembourg. The two population centres are a 45-minute drive apart, and it’s an hour-and-a-half from one end to the other on a good day. The unfortunate people in Weymouth (Digby County) are expected to get service in Digby, a 45-minute drive on the only unimproved section of highway 101. Westport, where previous governments managed to maintain a physician presence for at least 50 years and maybe longer, face an hour-and-a-half drive and two ferry crossings. Try doing this in February with a northwesterly gale and blowing snow – these times can be tripled. The people in Westport, a prosperous fishing community which contributes mightily to the GPP, are not amused. Administrators in the NSHA give every impression of having zero understanding of this problem and are not interested in getting enlightened.

So, consider the unaddressed problem with all this talk: the money. Here is at least a realistic yearly estimate of running the cost of such a place:
4-5 doctors – $1 million
2 NP’s – $260k
2 practices nurses – $160k
2 adaptive team members (the NSHA’s jargon, don’t really know what it means) – $160k
6-8 clerical staff – $250k
management – $100k

Then the rent or capital cost of a building holding a minimum of 17 health care professionals and its maintenance, utilities, supplies, insurance, etc. That’s a $2.5 million capital cost and $200k maintenance as a very conservative estimate. If the non-physician staff are unionised, you can add at least 30% to the costs.

This works out to about $2.6 million a year (building cost amortised over 20 years, but being it the government, in all probability it is higher than this), and an annual cost per patient of $260, more than double the cost of a traditional group practice.

If you, as a rural doctor really want the bile to raise in your gorge, you can read this last spring’s article in the Halifax paper about the DFM clinic in Spryfield. Here, 10 physicians, 14 residents and at least 12 other clinical staff manage to look after 4200 patients, and no, they can’t possibly manage any more. Patients are not guaranteed that they can see “their own” doctor, the concept is discouraged. Dalhousie family medicine is anything but transparent with disclosing finances, but a very conservative estimate of the costs works out to about $1400/patient/year. No mention is made of things like ER shifts, nursing homes, obstetrics, etc. I truly despair about what training the residents would get, it is not in the real world.

It is often stated that new doctors want to go into turnkey operation where they do not have to be small business owners. This may be true, but when these same people go into a CCC and find out they are subject to the whims of an (appointed) manager … this begins to pale rapidly. My kingdom is pretty humble, but at least I am the King, and if I need a new fax machine I just order it. I do not have to put in a requisition, wait for three quotes, and if the manager deems it important enough, wait two months for it to arrive. There may be some merit in joining a well run CCC, but joining a bad one, which outnumber the good one by two to one, is a nightmare, I’ve been there.

Of our first 10 residents graduating from our program, only one is in a CCC. 3 left the province, 2 to do ER, one to a rural community in BC, 3 to Shelburne (not a CCC) one to Yarmouth, one to Clare, one to Dartmouth, and one to Cape Breton. After 10 years of post secondary education most docs want to be their own master and actually don’t want to be employees in name only with none of the benefits. Though the CCC, which our one resident is in, is the best run one in our district, she is not happy. She wants to work half time as she has a baby, and the CCC is not flexible enough to charge her part time expenses. Another young doc (not a recent graduate) left the place as he worked mostly in ER’s and they couldn’t accommodate him either. I will refrain from commenting on the other places, though I did survive 6 weeks in one. …

Now, I will have a brief word about nurse practitioners. I don’t have a problem with the concept, in fact, when I was a resident, many decades ago and across an ocean, we had such creatures (we didn’t call then that), as we did when I first came to Pubnico 44 years ago. But community NP’s in western NS work from 9-4 Monday-Thursday. It is rare they see more than 10 patients a day and an average is 7. Most family physicians see at least 30 patients a day, 5 days of the week. I’m sure you have seen on the news the case of the young lady in Lockeport who couldn’t get a diagnostic mammogram.. The small print stated she had 5 NP’s in 4 years and the service had been withdrawn from their community, leaving her high and dry. The reality is that if a 4 person group practice, because of retirement, moving away or death, is replaced by a 3 doc + 1 NP practice, the remaining docs will have their workload increased by 30%. This may well make the practice unsustainable. If you think NP’s are going to do the extended hours, weekends, ER shifts, surgical assists, hospital inpatients and the like, you are dreaming. There also has to be consideration of the costs of an NP. NP’s earn about $110k/year, but their benefits raise this to about $130k/year. They have to have support staff and an office. This cannot be done for less than $50k/year, so the total annual cost is $180k. Given the limited number of patient encounters, the cost per encounter is close to $100. The corresponding cost for a family doctor is $32, or a bit less than $40 if the patient is over 65. This does not make economic sense, but any mention of this is considered to be hostile to nurses. It is time for realistic talk here.

The bottom line of all this is that the traditional solo or group practice is a very cost effective way of delivering care. Practices have always collaborated, it is just that government haven’t controlled it. Everything else costs at least twice as much, and there has not been a single credible plan as to how this is going to be funded.

Peter Loveridge



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4 Responses to Questioning the costs and care of CCCs

  1. Taxpayer says:

    It may be helpful to know the writers profession
    He is a doctor

  2. Doug Appt says:

    Who calls the shots re NPs if they are unionized and employees of the NSHA. An untenable situation for Docs in a clinic trying to manage the practice

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