UNLOCKING THE POTENTIAL OF NURSES TO INCREASE ACCESS TO PRIMARY HEALTHCARE (2021)

Canada needs to expand the number of players who can deliver (and collect payment) for Primary Healthcare. The decades-old model of family doctors as the primary gatekeepers to MSP billing, and therefore delivery of primary healthcare, needs to be adjusted to allow BC to catch up to the rest of the world in offering team-based care.

This will:

• Increase access to care for patients (by increasing the number of providers in Primary care);
• Increase quality of care (demonstrated by countless studies); and
• Decrease the overall cost of healthcare to taxpayers through by increasing access and quality of care, resulting in more preventative care and reducing the need for Primary care access, such as emergency room visits for non-emergencies.

Why should Chambers of Commerce be concerned about this model? Because family doctor’s offices and clinics are private corporations or sole proprietorships, with almost all of their funding coming from a single source: the Province.

Furthermore, access to a primary healthcare has an indirect impact on businesses through:

• Labour availability – the ability to access a family doctor’s office is influencing individual’s choice of where to live;
• In rural areas it can be used as a recruitment and retention benefit;
• Increased preventative care benefits workers and employers to reduce absenteeism; and
• Improved worker heath and reliability results in more productive workplaces and better employee retention/satisfaction.

All of these impacts will result in a reduction of costs to businesses and workers which results in an overall economic benefit to business and province.

Background

The MSP System in BC

In Canada, we think of the healthcare system as “free”, but in actual fact there is a system of payment which happens in the background, where doctors are paid by the government for services they have provided to patients.

This system is called public health insurance and in BC, it is known as the Medical Services Plan (MSP). It covers the cost of medically necessary insured doctor services. The most applicable example is a visit to a family doctor’s office. After the visit, the family doctor submits the appropriate “billing code” which relates to the services they performed, then the government pays the doctor through the MSP system for delivering those services.

Family doctor’s offices are actually private businesses (sole proprietorships or incorporations) within the MSP system and have (mainly) only one source of income: payments from the government. This system is also known as a “fee for service” system.

The MSP (or “fee for service”) system is the primary way in which Family Doctors are paid for delivering care to the general population. They collect this payment from the government for delivering services and use it to run their doctor’s office (cover operating expenses) and make an income.

The Family Doctor Crisis

Across Canada, 15.3% or about 4.7 million people do not have access to primary healthcare providers, including family doctors, according to 2017 Statistics Canada data. While BC’s 18.2% was higher than the

national average (and means about 900,000 in the province had no access to primary healthcare providers) it was not the highest. Quebec and Saskatchewan were at 22.3% and 19.4%, respectively¹.

The Family Doctor Crisis is not just an issue in your local region, it is a provincial and national problem that is a result of a larger systemic issue.

Nurses; An Underutilized Resource in Primary Care

Nurses are trained to perform a wide variety of healthcare related tasks and are regulated under the authority of provincial law by the College of Registered Nurses of BC (CRNBC) – the same as doctors with the College of Physicians and Surgeons of British Columbia.

Several studies have shown that the management of patients by nurses in primary care has a positive effect on overall patient satisfaction, experience of care, and care outcomes.

Many of the services regularly performed at a family doctor’s office are well with-in the technical scope of a registered nurse. For example, here is a brief (not exhaustive) list of some of these procedures: Vaccinations, taking blood pressure, preventative care and teaching, triaging and taking medical history, removing sutures, wound care and chronic disease management.

Nurse practitioners (NP) are registered nurses who hold a Master’s degree in nursing and are trained to practice autonomously within a collaborative healthcare system. Extensive evidence indicates that NPs provide high-quality, patient-centred care; as a result, the BC Ministry of Health introduced the NP role in 2005 to help the province meet a growing demand for primary care. While NPs worked in various settings, they are employees of the health authority, paid a salary (not billed as a pay for service through the MSP system) and, as a result there, is a limited number of positions in the Province and the overall cost for their services is artificially inflated by unnecessary overhead and bureaucracy.

Despite some targeted initiatives, Registered Nurses (RN) and Nurse practitioners (NP) continue to be underutilized in Primary Care. While a number of reasons have been identified, the absence of an appropriate funding mechanism was found to be the most significant barrier to RN and NP utilization in primary health care.

The Issue

The Payment System in Primary Healthcare is Directly Linked to Limited Access to Primary Healthcare

The underlying problem to access in Primary Healthcare is complex. It is not simply a shortage of qualified professionals. BC has increased its intake of medical students and residency spots over the last number of years, yet this has not translated to an increase in access to family doctors. This is a result of a number of factors including the ability for doctors to take positions as “hospitalists”, where they can collect a salary of $275,000 with less risk, responsibility and work compared to opening a family doctor’s office. In effect the current healthcare system is inadvertently financially incentivizing doctors to not enter primary care, a problem they are also trying to solve.

A major issue is the payment system used in Primary Healthcare. Currently doctors are effectively the only healthcare providers who can access and collect payment from the MSP (Fee for service) system².

Newly graduate doctors are not attracted to the idea of running a small business, which involves maintaining a physical office, managing staff, ordering supplies, and managing a clinic, where they are solely responsible for the income and expenses (and all of those associated risks). They are instead much more attracted to a “team based” model of care where business risk and effort is lower and rewards are higher.

Canada has been slow in making the shift to “interprofessional teams-based care” despite:

• Vast scientific evidence showing their success in other countries; and
• The BC Ministry of Health’s 2015 strategic policy framework for primary and community care highlighting a direction to transition primary care into a team-based environment.

What is “interprofessional teams-based care”? It is a model where the burden of delivering primary health care (family doctor’s offices) is shared by a team-based model with nurses, social workers, and other allied health workers under the same roof.

Why has Canada’s shift to “interprofessional teams-based care” been slow? Because if a family doctor decides to incorporate a nurse in their clinic, they must pay the nurse’s salaries out of their own earnings. Furthermore, the nurse is not able to collect payment from the MSP system for delivering healthcare – only doctors are able to collect payment from the government through the MSP system.

Despite this, the benefit of incorporating nurses into a family doctor’s office is so great (reduced workload for doctors, reduced burn-out, increased satisfaction, increased support and increased number of people who can access primary care) that some doctors choose to take from their own wages/income to pay for a nurse’s salary in their clinic.

Largely, only Doctors can collect payment through the MSP system³. Team-based care in primary health care (family doctor’s office) is virtually non-existent because there is no mechanism to pay other healthcare providers (such as nurses) through the MSP system.

The Solutions

Enabling Nurses to access the MSP System

Canada needs to expand the number of health care professionals that deliver (and collect payment) for Primary Healthcare. The decades-old model of family doctors as the primary gatekeepers to healthcare needs to be adjusted to allow Canada to catch up to the rest of the world in offering Team-based care.

This will:

• Reduce the burden on physicians;
• Increase access to care for patients (by increasing the number of providers in primary care);
• Increase quality of care (demonstrated by countless studies); and
• Decrease the cost of healthcare overall for taxpayers through both increased access and quality of care, resulting in more preventative care while reducing the burden on stop-gap measure for holes in Primary care access, such as emergency room visits for non-emergencies.

The infrastructure to make this happen already exists. We have an existing MSP billing code system and we also have existing electronic medical record infrastructure, which nurses (along with other healthcare providers) are already familiar with.

In BC Nurses can already access the MSP billing code system. For example, all licensed NPs in British Columbia are required to enroll with the Medical Services Plan and obtain a practitioner number. The practitioner number permits the NP to submit encounter records for insured services provided to patients who are registered under the Plan; however, these practitioner numbers are not used for compensation purposes, but rather to capture nurse practitioner practice activities⁴.

Furthermore, in BC the recognized scope of Nurses (Registered) and Nurse Practitioners was amended July 26, 2016 to include the prescribing of controlled drugs and substances. This was further expanded upon by Dr. Bonnie Henry in 2020 to help with the opioid overdose crisis. These standards for NP CDS prescribing were developed in close collaboration with both the College of Physicians and Surgeons of BC and the College of Pharmacists of BC.

We may have a shortage of family doctors in Canada, but we do not have a shortage of nurses (RN’s and NP’s). Our current system severely limits the ability for nurses to deliver care in Primary Healthcare as there is no mechanism for them to be paid for their services.

Oversite, Structure and Accountability

One very valid argument against the movement to allow nurses to access the MSP billing system revolves around accountability and structure. What most individuals do not realize is that similar to Doctors who have the College of Physicians and Surgeons of BC, there is also a body of oversight for nurses: the College of Registered Nurses of BC.

Looking at the earlier example of the expanded scope of nurses around prescriptions: an accountability framework, including rigorous oversight was developed program for NP CDS prescribing by drawing on the experience of the College of Physicians and Surgeons of BC in collaboration with the Ministry of Health. This success story proves that the argument of a lack of oversight or the inability to develop an accountability framework is simply not true.

Furthermore, the Ministry of Health has created a stream known as Registered Nurses with Certified Practice (RN(C)). These nurses are authorized to independently refer patients for select, medically- necessary, laboratory tests approved as within scope by the College of Registered Nurses of BC (CRNBC).

The goal behind the RN(C) referral program was to improve patient care in British Columbia and facilitates registered nurses with certified practice to work to their full scope of practice. This program is of particular benefit to patients in communities who do not have an attendant physician or nurse practitioner, but who do have access to nursing care provided by an RN(C). It should be noted that RN(C) can access an MSP practitioner number (access the MSP billing system), allowing laboratories performing these services to submit claims to MSP for remittance (payment).

All of this being said; an RN and a NP have a reduced scope when compared to a physician and it must be recognized that the ultimate responsibility of care needs to rest with a physician who does have the full understanding of the healthcare scope. This policy recognizes this fact and wants to make clear that patients should be ultimately attached to a doctor. Nurse services would be akin to a visit to a walk-in clinic or emergency room for qualifying services and where the results would be sent back to the family doctor for ultimate oversight for the patient’s overall longitudinal care. There should also be allowances (perhaps a new billing code) developed to allow for doctors to bill for time spent “reviewing” the services completed by RN’s and NP’s – recognizing this ultimate oversight responsibility.

This structure would also offer the benefit of naturally incentivizing the development of “team-based” care – which ultimately will increase access to primary healthcare and quality of healthcare.

With these recommendations, BC can use the existing robust MSP payment system to increase primary healthcare capacity almost immediately, without largescale additional cost and substantial reduction in primary care costs with a concomitant increase in access to medical assistance.

Furthermore, access to a primary healthcare has an indirect impact on businesses through labor availability and improved worker heath and reliability. This results in more productive workplaces, better employee retention/satisfaction and reduced overall costs to businesses and workers which results in an overall economic benefit to the Province.

These changes would also enable a giant step forward for Canada to catch up to the rest of the world with the proven long-term benefits of Team-based care.

THE CHAMBER RECOMMENDS

That the Provincial Government:

1. Expand the existing MSP billing code available to RNs and NPs to reflect services with-in their provincially-regulated scope of practice (in addition to the existing limited Health Authority salaried positions);
2. Expand membership in the General Practice Services Committee (GPSC) to include RNs and NPs to help further identify ways to reduce barriers and support implementation of Team-based care in Primary Healthcare; and
3. Develop a new billing code to recognize the time required by doctors to review and oversee services completed by nurses through this expanded billing code access – to accurately reflect the overall patient care responsibility of Doctors.

¹ The Capital Daily: The Vancouver Island doctor shortage, explained; Oct 23, 2020.

² There are some very limited billing codes that NP’s and RN’s can currently access in BC – this policy looks to expand on these precedents.

³ There are some very limited billing codes that NP’s and RN’s can currently access in BC – this policy looks to expand on these precedents.

⁴ The Canadian Nurse Protective Society: Ask a Lawyer: Nurse Practitioner Billing, May 2016