I work fee-for-service. I do this out of distrust of the government. It's the last shred of my tattered independence. As time passes, more and more physicians are exchanging their independence for bags of money dispensed by the government. The price: joining multi-acronymic entities like FHTs and FHNs, which ostensibly provide 24-hour coverage for their patient base. Participation in this regime is lucrative, an offer hard to refuse: Why deny yourself as much as a 30% increase in income? Thus aggregates of family doctors, nurses and nurse practitioners form into conglomerate blobs that achieve the inverse function of what the government intended: instead of family doctors being responsible for their patients after hours, family doctors are responsible for their own patients —and those of a dozen other doctors — one night a month. It's a sweet deal.
I've been invited to join one of the larger family health teams in town. It's so big it's a brigade. I would join 25 other doctors, their tens of thousands of patients and their just-under-once-a-month call schedule for oodles of money and an occasional sleepless night.
I declined. I think these things were conceived for small groups of family doctors — ten, say — who out of good conscience made an alliance for the health of their patients and in consideration of our overrun emergency departments. In my community, these groups are becoming immense. When you're on call, you're responsible for half the town. With a smaller group, you become familiar with your colleagues' patients and practice styles. You are, for lack of a better term, connected with your practice. A one-in-twenty call schedule amounts to disconnection, a hectic patchwork of coverage where no one knows anyone else.
So why the push for these teams? Are they really in the patient's best interest? Or is this a long-term strategy for governments to control costs? A fee-for-service doctor can essentially earn as much money as he or she cares to work for, whereas a doctor enrolled in one kind of call scheme gets paid for the number of patients on the roster plus a pittance for every patient seen each day. It is not hard to grasp that the government has more control over the latter method.
I acknowledge the weaknesses of the fee-for-service system, including abusers who bill for every cent they can and see patients as briefly as possible. Yet it seems even more wasteful to throw money at inflated call-scheduleateers who cash in because they're on call once a month. Maybe I'm just jealous. But a large part of me resents the government trying to control what I do, and I can't see the benefit of letting call groups mushroom into call syndicates.
So I work in my clinic day after day and watch other doctors get gobbled up by “teams” that are little more than glorified call schedules. I continue to earn my money fee-for-service. I feel obliged to admit here that I am not formally on call for my patients, a fact that reduces my moral authority on this topic, I suppose (even though I am considering banding together with a few other doctors to form a small call group). But what's worse? No call schedule, or a critically anemic call schedule? A charade of a call schedule that is in existence only to satisfy the government's bean counters?
— Dr. Ursus