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Nurse practitioners shocked by Higgs government decision to charge for medical tests
Nurse practitioners say new rule that charges 'private' providers will hurt orphan patients the most
Chantal Richard, president-elect of Nurse Practitioners of New Brunswick, said the move to charge for any medically required tests ordered for patients is another blow to those without a primary care provider. (Submitted by Chantal Ricard)
A new rule introduced by the Blaine Higgs government is raising concern among nurse practitioners, who believe it will introduce yet another barrier for the more than 44,000 New Brunswickers who do not have a primary care provider.
Under the policy, which came into effect April 1, any medical practitioner who is operating outside of the public system and charging patients directly, will be billed by the regional health authority for any diagnostic or laboratory tests ordered.
Chantal Ricard, president-elect of Nurse Practitioners of New Brunswick, said the decision is "impeding access to care."
"We believe that these tests should be insured because they're medically necessary and ordered for patients with valid Medicare cards and ordered by licensed health professionals."
Nurse practitioners can diagnose illnesses and injuries, order and interpret tests, and prescribe medications. They are also able to refer patients to a specialist or transfer care to a physician if required.
No explanation for policy
CBC News requested an interview with Health Minister Dorothy Shephard but she was not available to explain the rationale for the decision.
"We've met with them on a few occasions," nurse practitioner and association president Raelyn Lagace said when asked if she knew why health officials made the change, "But we haven't come to any conclusion as to what they're trying to accomplish."
Health Minister Dorothy Shephard was not available for an interview. A government spokesperson says her department does not keep track of the number of doctors or nurse practitioners seeing patients outside of the public system. (Ed Hunter/CBC)
In a letter obtained by CBC News dated June 19, 2020, and addressed to the Vitalité and Horizon Health board chairs, then-health minister Ted Flemming writes that the change is meant to establish "consistent policies and bylaws related to the granting and use of privileges for ordering tests and diagnostic services."
He said government has been made aware "in recent months" of instances where nurse practitioners and doctors are "utilizing publicly funded resources such as laboratory tests and diagnostic services, while charging patients fees."
Lagace said about 150 nurse practitioners are working in New Brunswick. Many are salaried employees with the health authorities, and others work independently, charging patients directly for their visits.
'I'm not quite sure what's going on'
Nurse practitioners who billed patients for a consultation in the past could then order medically necessary tests, which would be covered by Medicare. Lagace said nurse practitioners wouldn't charge anything for tests, only for the consultation.
"If you are a citizen in New Brunswick and require medically necessary tests, you already are paying taxes and should have access to these publicly funded systems that your tax dollars pay for."
Health policy expert Gregory Marchildon agreed. The Ontario research chair in health policy and system design said the move by government strikes him as "a bit of a shift."
In New Brunswick, an increasing number of patients have been forced to seek care outside the public system because they can't get access to a family doctor, or to specialists with long wait lists.
"The fact that these residents are charged for their medically necessary, primary care services only because they can't get access to a physician or nurse practitioner with a Medicare billing number seems contrary to the whole purpose of Medicare," Marchildon said.
Gregory Marchildon, Ontario research chair in health policy and system design, said all residents with a health card are entitled to 'every medically necessary hospital, diagnostic and physician service.' (Submitted by Gregory Marchildon)
"I'm not quite sure what's going on here in New Brunswick, but the rule is that every Canadian should have access … to every medically necessary hospital, diagnostic and physician service. And it seems to me that there is no loophole for that."
Marchildon said if a test isn't medically required — for instance, if someone just wants an MRI "to see if there's possibly anything wrong"— the hospital shouldn't charge for that test. Rather, "they should be just simply refusing to do it."
"The way in which this is being dealt with doesn't sound helpful or constructive," he said. "And it could be very much contrary to the Canada Health Act."
The Department of Health said it does not track how many physicians are working outside the public system in New Brunswick.
Policy impedes access
A March 2021 memo to Horizon Health physicians and nurse practitioners, from two Horizon vice-presidents outlines a range of examples of when physicians or nurse practitioners would "receive a bill directly from Horizon Finance Department."
The list includes services that would be considered medically necessary such as "a patient who requires investigation for anemia," and those that wouldn't, such as "a patient who requires a chest X-ray for a scuba diving licence."
While the new policy charges the medical practitioner who orders the tests, Ricard and Lagace said the costs would ultimately be passed on to the patient.
Lagace said nurse practitioners charge between $29 and $49 for a consultation with a patient, and it's not feasible for them to then pay between $128 and $600 for diagnostic tests.
Raelyn Lagace, president of Nurse Practitioners of New Brunswick, said her members want more flexible options to provide care and ultimately would like to have Medicare billing numbers, similar to doctors. (Submitted by Raelyn Lagace)
"We don't want to pass that bill on to the patient," said Ricard. "We've been working with government for the last two years trying to make changes that would improve access for patients and remove barriers for care, but government chose to take this direction.
"In essence it ties our hands. It shuts us down."
Government goes ahead, despite 'gaps' in care
At the end of the day, Lagace said, the Higgs government is hurting those without access to primary health care the most.
That's something Flemming recognized in his letter from June 2020.
"Please note, Government is also aware of gaps in access to primary health care that would occur should [nurse practitioners] no longer be able to see their existing patients as part of a private practice," Flemming wrote. "This is evidenced in our commitment to fund the establishment of [nurse practitioner] staffed clinics in the province."
Former health minister Ted Flemming said in June 2020 letter that changes to the policy for diagnostic tests and laboratory tests were being made to 'ensure publicly funded health resources are both utilized appropriately and applied equitably.' (Jacques Poitras/CBC)
Lagace said new clinics, staffed by nurse practitioners, are set to open in Moncton, Saint John and Fredericton. Each nurse practitioner will eventually be able to take between 800 and 1,000 patients and will operate within the Medicare system.
While that is good news, she still questioned the direction the government is heading and pointed out the new policy doesn't fit with other goals.
"We want to increase the population of New Brunswick." she said. "But if we can't provide health care, then that's not an option. People are not going to stay if they cannot get access to care.
"People in New Brunswick in the Fredericton region have been on these wait lists for five, seven, 10 years and are not able to get access to care."
Call to revise policy
Ricard and Lagace are calling on the government to change the new policy, arguing New Brunswick citizens are entitled to these tests through the Hospital Services Act.
"There's a need and there's room for all of us and I think that all available health care providers should be on deck," Ricard said.
"We don't understand why government would choose to take away this only option for many patients before having something better to offer them."
Marchildon said New Brunswick should immediately contract with whatever health providers it can, including independent nurse practitioners, to offer care to everyone, "rather than penalizing New Brunswick residents for something they have no control over."
Information Morning - Moncton0:00Health practitioners working outside the public system to be charged for lab testsABOUT THE AUTHOR
In my view, if Higgs is unwilling to fix the core problem of not enough family doctors, then he should be thankful for the private practitioners who are trying to fill that void and he should pay for any legitimate tests
Meanwhile, over a year and a half ago, "the problem" was identified, by the then Minister of Health, good old Teddy Flemming.
https://www.cbc.ca/news/canada/new-brunswick/billing-numbers-eliminated-family-doctors-1.5303180
But, I'm guessing, good old Higgs and company, can't grind a few bucks out of that, so we'll just sweep it under the rug, and forget about it.
https://www.cbc.ca/news/canada/new-brunswick/province-phase-out-physician-billing-system-1.5301606
Province to eliminate physician billing number system
New Brunswick Medical Society working on alternative
"The physician billing number system no longer works for the province," Health Minister Ted Flemming said in a media release Saturday.
"It is flawed because it restricts the number of physicians practising, restricts the mobility of physicians and impedes recruitment."
Flemming made the announcement during the New Brunswick Medical Society's annual general meeting in Moncton.
During the throne speech in November, Premier Blaine Higgs said one of his major commitments while in government was to eliminate the physician billing number system.
The billing number system was introduced in 1992 and controls where and how many physicians can practise in the province.
Doctors are assigned a billing number as a way to maintain an even distribution of doctors throughout the province, specifically in rural areas.
"After 30 years, we've come to understand that it's a failed experiment," said Dr. Serge Melanson, the president of the New Brunswick Medical Society, in an interview.
"By removing it, we're essentially streamlining the process such so we can recruit physicians to the province faster and actually give more flexibility and options to physicians who are looking to set up practice in the province."
Melanson said he hopes this change will provide New Brunswickers with more access to doctors.
Dr. Serge Melanson, president of the New Brunswick Medical Society, said he hopes the elimination of the billing number system will improve access to health care. (CBC News)
"We're hoping this will increase recruitment which will, in turn, improve access to health care to our patients," he said.
The system is expected to be phased out by mid-December.
The New Brunswick Medical Society is working with the regional health authorities and the Department of Health to develop an alternative to the billing number system that works on rural recruitment and access to primary care.
"We're empowering the regional health authorities, Vitalité and Horizon, which already have mandates and abilities to hire physicians," Melanson said. "We're actually providing them with more tools to do so in an effective manner."
Scrapping billing numbers could ease urban family doctor shortage, minister says
Northern leaders fear move could cost smaller, rural communities their doctors
The challenge of finding family doctors for smaller communities and rural areas will be relatively easy to solve by paying them more money to practise there, Ted Flemming said Monday.
"The shortage, the wait list, in rural New Brunswick is very, very low compared to urban New Brunswick. The rural issue is just not serious in the sense of numbers."
Of the 32,000 New Brunswickers on waiting lists for doctors, 27,500 are in urban centres.
Fewer than 1,000 people are on waiting lists for family doctors in some northern zones, while the lists in the largest cities have passed the five-figure mark, Flemming said.
Health Minister Ted Flemming announced on the weekend that the government will abandon the billing-number system. (Jacques Poitras/CBC)
Flemming announced on the weekend that the government will abandon the billing-number system, a mechanism created in 1992 to rein in soaring health-care costs.
He made the announcement at a meeting of the New Brunswick Medical Society, which endorsed the move. The Progressive Conservative government promised the change in its throne speech last fall.
Each doctor practising in the province gets a billing number they use to invoice Medicare for the services they provide. But the individual billing number is linked to where the doctor practises, restricting their movements.
If no billing number is available in a community, a new doctor can't set up a practise there.
Bigger the place, longer the wait
Anthony Knight, the CEO of the New Brunswick Medical Society, said billing numbers in urban centres have not grown at the same pace as their populations, or their family-doctor wait lists.
"That number should align with patient needs and patient expectations in terms of their health status, the size of their communities, and the demographic changes we see in our province with the shift of people in certain communities moving to more urban centres," he said.
By eliminating the billing numbers, it will be easier to get more doctors into cities where the longest wait lists exist, Flemming said.
As an illustration, the minister pointed out that in the Bathurst-Acadian Peninsula zone of the Vitalité health authority, 932 people are on the waiting list for a family doctor — fewer than the normal patient load of one physician. In the Campbellton zone, 412 are on the waiting list.
But in the Moncton area, the wait list is 10,272 people, and in Fredericton it's 11,874, Flemming said.
"Finding coverage for 412 people is an easier task than 10,300," he said.
"The demand for primary health care is in the cities. It's not in rural areas. That doesn't mean we don't need to find that [northern] position. That's not insurmountable. That's one nurse practitioner."
Concern over effect on rural communities
Some leaders in northern New Brunswick are already expressing concern about the loss of the billing numbers.
"Those numbers in my mind guaranteed positions in the regions," said Denis Savoie, the mayor of Eel River Crossing and the chair of the Regional Service Commission in the Restigouche area.
"In the current system, it was one of the tools we had to make sure doctors came to the area."
Flemming said the regional health authorities and the medical society will work toward a new system, including financial incentives, to fill the gaps in northern and rural communities.
"If you want someone to locate in certain areas, you have to give particular incentives," he said.
Knight said that without billing numbers restricting mobility, doctors based in urban centres could rotate into rural communities for short periods, perhaps for extra pay.
"We know that certain incentives do work," he said. "They help to encourage physicians to work in communities, maybe not permanently but for periods of time. They could shift in and out with a team of doctors."
Anthony Knight, CEO of the New Brunswick Medical Society, says that incentives can help attract doctors to rural communities. (Michael Gorman/CBC)
That would be better than leaving a billing number vacant because a new doctor is unwilling to permanently establish themselves in that rural or northern community, he said.
New doctors are looking for work-life balance and many of them prefer an urban setting, yet billing numbers are often not available in cities, Knight said. And persuading them to practise elsewhere can be "a hard sell."
Another flaw with billing numbers is they distort the calculation of how many patients are being seen.
One doctor may have 2,000 patients while another easing toward retirement may be seeing far fewer. "I'm not saying the work is not valuable," Flemming said. "What I'm saying is a billing number does not represent the same delivery of medical service."
Into 'the deep end'
The province is aiming to have a new system in place by Dec. 15.
Knight said the new regime "may not be fully ready but there should be, I'll call it, a landing pad for anyone that's interested in establishing a practice on that date."
Flemming said he leapt into "the deep end" without a clear replacement because it's been clear for years the billing-number system was flawed and he didn't want to delay changes any longer.
"You can study and you can do this and this and this," he said. "This is something that had to be done. I had no appetite for another study and another review. It's the right decision."
With files from Information Morning Fredericton
http://davidraymondamos3.blogspot.com/2020/02/inaction-on-health-care-crisis-hurts.html
Saturday, 22 February 2020
Inaction on health-care crisis hurts everyone, economist says
https://twitter.com/DavidRayAmos/with_replies
David Raymond Amos @DavidRayAmos
Replying to @DavidRayAmos @alllibertynews and 49 others
FYI I still have no Health Care Card but I just PAID another big bill for emergency room services and STILL Higgy and the economist Richard Saillant don't care N'esy Pas?
http://davidraymondamos3.blogspot.com/2018/08/cbc-and-their-economist-buddy-richard.html
https://www.cbc.ca/news/canada/new-brunswick/higgs-health-reforms-cancellation-analysis-1.5466815
https://ihpme.utoronto.ca/faculty/gregory-marchildon/