Capitation – An Answer for our GP Shortage?

Commentary, Healthcare & Welfare, Rebecca Walberg

If re-elected, Manitoba’s NDP Leader, Gary Doer, is promising to hire 100 more doctors, while so far Tory Hugh McFayden is relatively silent on our shortage of physicians. As part of a Patients’ Bill of Rights, Liberal Jon Gerrard is pledging access to a doctor on the same day a medical problem arises, and to increase funding to attract more doctors to family practice. It’s an important problem, one begging for an innovative solution.

We should consider a structural reform, paying family physicians with a system called “capitation.” Under capitation, doctors receive a flat fee for each patient admitted to their practice. That encourages doctors to accommodate as many patients as they reasonably can. Capitation also makes family practices, traditionally less prestigious and lucrative than specialties, more profitable for doctors.

What is the downside? Using it as the only basis for compensation is problematic. It creates incentives for doctors to accept more patients than they have time to treat. It also encourages doctors to select healthy patients over the elderly and those with chronic conditions. Combined with the fee-for-service model and patient guarantees, though, capitation can serve as a corrective to our current situation, where too many Manitobans lack a family doctor, and too few of those with one get timely care for non-emergencies.

That method of payment also fits well with Gerrard’s desire that GPs be required to see patients on a same-day basis during the work week and to provide at least a phone consultation after hours. Both mandates would put family doctors back on the front lines of health care, and it’s certainly not as radical as it sounds. Until quite recently, this was the norm for general practitioners. When doctors weren’t available to deal with urgent problems, they arranged back-up coverage from colleagues.

A capitation fee for family doctors will cost the system more than a fee-for-service regime. But it will save just as much, or more, by reducing the burden on emergency rooms and, by shrinking their waiting times, make spending in them more effective.

The major beneficiaries of such a change are patients. Migraines, sprains and minor infections are examples of problems that cause very little danger but much pain and discomfort. Far too many people with minor but pressing ailments must choose between waiting several days to see their own doctors, or going to an Emergency Department and waiting a turn there. The former suffer unnecessarily, while the latter’s trips to the hospital are time-consuming, unpleasant and, for the taxpayer, very expensive.

Treating patients is the main raison d’être of our healthcare system. Putting their needs first should be the top priority for any reforms, including the important one of improved access to doctors. Family doctors are the core of primary care. As a patient’s first contact with the medical system, they provide the key elements in effective health care, prevention and early detection. They also stand at the centre of the gatekeeper role, in directing patients to specialists.

Our shortage of GPs, especially in rural areas, is a serious problem. Those who are only sporadically available to their patients help make simple and preventable problems become complex and stubborn. The challenge is two-fold: we need more family doctors, and they must provide truly comprehensive care.

For the two party leaders offering to increase the supply, a cautionary note: It’s easier said than done. The University of Manitoba’s medical school recently increased its number of spaces, but this won’t yield more clinicians for years. Another piece of the puzzle is to make Manitoba a more desirable place to live with a thriving economy. But this, too, takes time.

In the shorter term, Canada can seek out immigrants with medical training. We can also speed up their accreditation for work here, a smart position offered first by Jon Gerrard, who correctly mocks the fact that trained specialists are driving taxis, and echoed by McFayden. More immediately, Manitoba needs to do more to retain the doctors already living and graduating in this province, and ensure meaningful access to them. Given his profession, it’s no surprise that the Liberal leader has the most to say about doctor shortages.

Gary Doer’s blithe pledge to add 100 doctors to the system is as credible as his broken 1999 promise to end hallway medicine. How? Capitation fees might be the answer. They put the relationship between the family doctor and the patient back at the centre of health care. That’s an easy step in the right direction.