Dr Carrie Marshall did the clinic’s math in January and it revealed what she already knew: “The cost of running the clinic far exceeded what would be a reasonable and sustainable business model.”
Anyone who wants a family doctor can get one in Ucluelet — an unusual situation amid BC’s doctor shortage that could change if the town’s only medical clinic isn’t saved by the end of the month .
Dr. Carrie Marshall, leaseholder and owner of the Ucluelet Medical Clinic, which has two other doctors, told the city in January that she would lose money if she renewed the clinic’s lease on May 31.
“We are very fortunately one of the only places in the province that can say that we are all accepting new patients,” Marshall said. “Everyone on the coast who wants to be attached is attached to a family doctor.”
But Marshall did the clinic’s math in January and it revealed what she already knew long before the pandemic hit: “The cost of running the clinic far exceeded what would be a reasonably sustainable business model.”
During the pandemic, she deemed it “inhumane” to raise the issues threatening the clinic’s closure. Now she feels she has no choice. His colleagues are on board and they make decisions as a group.
“We are all deeply committed to longitudinal family medicine,” Marshall said. “We’re just waving the white flag that to continue we need changes to how these business models deliver healthcare.”
Marshall’s overhead in 2021 was around $120,000. And as is the case with some other physicians, the fee-for-service model that pays her – about $31 per patient visit, not including any incentive surcharges, before overhead is paid – has become untenable.
Marshall is in talks with the mayor, Island Health and the province to find a solution.
Ideas explored include primary care networks sharing resources between clinics, municipal assistance in owning or renting the clinic, building ownership by the health authority, alternative payment plans, and fee-for-service incentives.
“What we’re really looking for is to try to disrupt service in Ucluelet as little as possible,” Marshall said. “The advantage we have is that none of the doctors leave the coast, nobody moves, we all live in Tofino because we have to be on call for the hospital.”
Other municipalities are also grappling with potential clinic closures. Last month, the province announced it would spend $3.46 million to keep five South Island walk-in clinics open.
Marshall said so far that there is no mechanism, funding source or policy nimble enough “to launch this to keep the doors open” without significant downsides.
She is confident of a solution, however: “We can hopefully stay in this space and provide at least some in-person services,” she said.
Health care providers recognize that traveling to Tofino, a 45-minute drive away, would be a burden for people with mobility issues or who are frail or have complex medical conditions. Marshall envisions the Ucluelet clinic becoming a “lean” operation with more centralized services out of the Tonquin Medical Clinic in Tofino and greater use of telehealth.
Years ago, the clinic was open five days a week, but now it’s down to three days. “We hope we can continue with this level of service, but there may be a doctor [on] instead of two… anytime,” she said.
Ucluelet Mayor Mayco Noel said losing the town’s only medical clinic was not an option.
“It’s like closing the grocery store,” he says. He’s less sure of a solution other than the city taking over the lease or having the clinic run by a nonprofit, but he fears setting that precedent.
“We have tried to let the bureaucrats find solutions over the last 90 days, and they have had a lot of meetings, but there have been no real decisions to fix the problem and there is a lack of time to find out who’s going to take over the lease,” Noël said.
The city has a viable clinic, doctors and access and it is the responsibility of the health authority and the province to maintain this either by taking over the lease or by providing a subsidy of $15,000 per month, at least in the short term , until solutions are found, he said.
“It’s typical small town stuff…where we’re really low priority,” he said. “I would like to work with the province to find immediate solutions.”
As a lifelong businessman, Noel admits that all the bureaucracy “drives me nuts.”
“How many more conversations do we need to have about making sure the lease is maintained? ” he said.
Marshall argues that there is no “one size fits all” panacea for a family doctor crisis, in which 900,000 people in the province are left without a family doctor.
Instead, a “mix” of service models and payment models is needed, she said. “The incentive for doctors is going to depend on where they live geographically, where they are in their lives, where they are in their careers, and what they want in terms of work-life balance.”
On Thursday, B.C. Green Party Leader Sonia Furstenau outlined steps the province could take to deal with the crisis.
In the short term, Furstenau said, the province should provide financial support to existing family practices for rent, administration and supplies, for example, so that no more offices have to close.
In the long term, she advocated for the province to provide more infrastructure for team-based primary care and move further away from the fee-for-service model.
British Columbia Health Minister Adrian Dix said last month that alternative payment plan agreements with doctors have grown from $500 million in 2017-18 to $758 million today. “We’ve been working in that direction, working with doctors in BC, working with family practices to do that.” Some doctors prefer the fee-for-service model, but others don’t want to run a business or charge for every service.
Lindsay Hedden, assistant professor of health systems learning at Simon Fraser University, said primary care clinics need support to keep doors open in the short term. Longer term, these clinics need to be asked what they need, she said, warning that there are no low-barrier quick fixes.
“What we really need at this point is a pretty big overhaul of how the system is structured – and that’s not going to be fun or easy for anyone,” she said.
Hedden said doctors have more choices when it comes to payment, practice models and team-based care models. They want to be able to take a vacation or retire knowing they’re not the only provider, she said.
A growing number of doctors don’t want to own small businesses “to keep the lights on,” especially since it’s become more complicated, expensive and time-consuming over the years, Hedden said.
In this case, “what we need is supportive infrastructure in the same way the province has built emergency and primary care centers,” she said.
Since 2017, the province has established 27 primary and emergency care centers, which provide same-day access to urgent and non-emergency health care. The province has also created more community health centers — community-based, non-profit or public organizations that provide comprehensive primary care services, the model Hedden favors.
“I don’t think we’ll ever get to the point where a government won’t say, you know, we’re completely overhauling primary care and all of these existing clinics are now going to be integrated into clinics that are owned and operated by the health authorities,” Hedden said.
“That’s never going to happen – but at least offering those options I think is the right next step.”