Nova Scotia

Doctor says she could take more patients, but the system is in her way

A Halifax doctor says the health authority's rigid approach to collaborative medicine and challenges with the pay system could keep some physicians from buying in to new ways of working together.

Payment models, rigid setup options among criticisms, even as Nova Scotia pushes collaborative models

Dr. Ajantha Jayabarathan says the provincial health authority should be more flexible in what it permits for collaborative family medicine. (CBC)

Dr. Ajantha Jayabarathan says she could be treating more patients in a province where thousands are without a family physician, but feels she is dealing with a system that works against her.

The family doctor in Halifax has 1,400 patients in her solo practice, but since 2009 has shared her space a few times a week with mental health professionals, osteopaths and others in a type of collaborative service.

"Although I appear to be a solo practitioner, I've actually, quite innovatively, developed a collaborative network," she said.

Barriers to expanded care

Jayabarathan would like to collaborate more, but the system isn't designed to facilitate it, she said. It's frustrating because she sees people without doctors and knows that, with some help, she could take them on.

As the province starts rolling out collaborative family practices, Jayabarathan said a lack of flexibility and challenges with payment structures mean there are other collaborative opportunities being missed.

She estimates she could take on an additional 100 patients if she had access once a week to a family practice nurse who could be shared with other doctors. But the cost of the nurse would fall to her, she said, and it's not possible to see enough patients to cover the expense and meet needs when she's already working 12-hour days, six days a week.

"Frankly, that's a recipe for me to burn out in no time."

A spokeswoman for the Nova Scotia Health Authority said as it transitions to the new family practice model it is interested in "exploring future opportunities with family physicians who are interested in practicing collaboratively with other primary health-care providers, and the various ways that we can work together to support them in doing so."

Challenging pay model

Jayabarathan said one frustration is fee codes that either don't reflect what doctors do or aren't flexible enough to allow for collaborative work.

For instance, even if a family practice nurse were doing a simple task such as a blood pressure check, Jayabarathan would still have to check in in order to bill for the procedure.

Jayabarathan explored moving from fee for service to an alternative payment plan, similar to a salary, but said what was offered would not have helped the situation and was much lower than what new graduates make. She worries about that impacting the ability to convince existing doctors to move into collaborative practices.

Kevin Chapman, a director with Doctors Nova Scotia, said a blended fee structure, one that combines fee for service and compensation based on patient load, would address a lot of these challenges.

Fee code changes coming

In the meantime, Chapman said an updated framework for fee codes, which are based on what a patient presents with and what the doctor does, should be ready by November. It would be another year before they're fully rolled out, he said.

Chapman said the updates should better reflect the realities of a doctor's office today, including the complexity of some office visits. Right now, doctors can bill for a general office visit or a geriatric visit, but the update should be able to account for visits that take longer because a patient might be sicker or need more care.

As a private operator who has rent and staff costs to cover, Jayabarathan said changes need to consider how "somebody like me can continue to provide the care I provide and the fee code actually makes sure that I don't go under."

In just the last two years, she's seen her ability to see the same number of patients go down as complexity of cases increases, and that's affected her bottom line.

About the Author

Michael Gorman is a reporter in Nova Scotia whose coverage areas include Province House, rural communities, and health care. Contact him with story ideas at