The last article discussed the changes in the practices of community family
practitioners. There are not enough to supply the demand so the government has been
interested in developing alternative primary care practitioners in the form of nurse
practitioners and physician assistants. For reasons of economic efficiency and lifestyle,
many GPs have dropped obstetrics and no longer apply for privileges to visit or manage
patients once they have been admitted to hospital. In response the government has
introduced midwives to do deliveries and hospitalists to look after patients who have no
family doctor or whose doctor does not look after in-patients.
This column is meant to examine only the financial arrangements of these other primary
care professionals, not their quality, relative clinical knowledge, etc.
First, let's take the GP's situation. The average GP is strictly fee-for-service. The average GP bills the Government $247,000 per year, by any standard a princely sum. However, the doctor's overhead, primarily the cost of his office and reception/business staff, is about 40 per cent. This leaves a before tax income of $150,000, without any medical, dental, or pension plan.
Let's now look at midwives. For multiple visits during the pregnancy, delivery, care in
hospital after birth, and a follow-up baby check in six weeks, the GP receives from the
Government $1,072. The midwife is paid $2,750 for the same package. Both pay roughly the same overhead and insurance by percentage. Why does the midwife not earn more than a GP then? Because the government cleverly limited the maximum annual income of a midwife to $110,300 by not allowing a midwife to do more than 40 deliveries a year (3.3 a month). To put this in perspective a very busy now retired colleague told me that he delivered 106 babies in his last year of active obstetrics in addition to having a full family practice.
What about nurse practitioners? To become an NP, one must do a bachelor's degree in
nursing followed by at least two years of practical experience, then two more years of
schooling to attain a master's degree level. A nurse practitioner is theoretically an
independent professional who may establish a practice, evaluate patients, order tests, refer patients, and prescribe most medications except addictive ones. However, the model has two fatal flaws.
First, the NP may not bill the medical services plan directly fee-for-service as a
physician would and therefore has to be paid the salary of $100,000 plus benefits by
somebody - there is no mechanism to operate as an independent office/small business. Only large clinics and institutions such as hospitals, health authorities, etc., who tend to operate on global budgets can afford to hire NPs.
The other problem is inherent to all salaried positions - productivity. Most of my career was totally fee-for-service but for the last three years, I and all the other physicians at a specific hospital were paid completely by salary. The differences were striking. The Chase experiment is another example. Physicians on salary there spent as long as they wanted with individuals in keeping with a holistic approach but the total number seen per day did not justify the amount the government had to pay the doctors. There is no reason to expect that the experience with nurse practitioners will be any different.
Physician assistants are different again. A PA will have a basic college degree and then
two years of special training. The PA is truly an assistant under the direct supervision of a doctor to do certain tasks such as assist in the OR, do preliminary histories on patients, etc.
PAs are employed by hospitals mostly and paid by salary, at a slightly lower rate than NPs in keeping with their shorter training and less independent responsibility.
The last category is the hospitalist. This is a GP who works only in the hospital, caring for in-patients who don't have a GP covering them. The hospitalist becomes the primary care giver for the patient. He/she co-ordinates the admission, tests, results, specialist
consultations and discharge in the most efficient and satisfactory way for both the patient and the hospital. The hospitalist too is paid by salary, at a rate about the same as his community colleague seeing six patients per hour. Only fairly large hospitals with a
"significant orphan hospital patient population" will make a hospitalist model cost
Overall, the government has spent a good deal of money to establish training programs
for persons other than doctors to provide primary health care to the population while
supposedly trying to save money. As explained above, midwifery has been an economic
The government sees the GP as costing $247,000 and the nurse practitioner $160,000
(salary plus benefits plus overhead assistance, per Lynn Guengerich president of the BCNP Association). The doctor sees it as $150,000 net for an MD working
fee-for-service and $130,000 for an NP on salary.
The need is for grassroots primary care but the design of the models for nurse
practitioners and physician assistants has ensured that they cannot function at that level in B.C.
Government does not yet seem to have grasped that pure salary without any incentives
most often equals lower productivity and higher unit costs.