Walk-in clinic patient characteristics and utilization patterns in Ontario, Canada: a cross-sectional study

Lauren Lapointe-Shaw; Tara Kiran; Christine Salahub; Peter C. Austin; Simon Berthelot; Laura Desveaux; Aisha Lofters; Malcolm Maclure; Danielle Martin; Kerry A. McBrien; Rita K. McCracken; Bahram Rahman; Susan E. Schultz; Jennifer Shuldiner; Mina Tadrous; Cherryl Bird; J. Michael Paterson; R. Sacha Bhatia; Niels A. Thakkar; Yingbo Na; Noah M. Ivers

doi:10.9778/cmajo.20220095

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RE: Conclusion unnecessarily targets the source of problem
Lauren Lapointe-Shaw [MD PhD]

Posted on: 04 May 2023
Conclusion unnecessarily targets the source of problem
Michael Verbora [MBA, MD]

Posted on: 02 May 2023

Posted on: (4 May 2023)
Page navigation anchor for RE: Conclusion unnecessarily targets the source of problem
RE: Conclusion unnecessarily targets the source of problem
Lauren Lapointe-Shaw [MD PhD], Clinician Scientist, University Health Network
I think we can agree that walk-in clinics are an essential access point for patients who are otherwise unattached to primary care, and that they also do provide access to primary care for attached patients who are unable to see their enrolling physician. We wrote: “A complementary policy would be to discount physicians working in walk-in clinics’ fees for encounters with patients enrolled to another practice, relative to the fees paid for seeing a patient who is not enrolled with a physician.” We highlighted this policy idea because it would mirror the current accountability mechanism (access bonus claw-back) for enrolling physicians.

The reason for the word "relative" is to emphasize that this solution could in fact include a fee increase (a carrot) for unattached patients (thus attached patients would be discounted in relative, but not absolute, value to payment for unattached patients).

These are complex issues, and as yet we do not know what is the most effective way to increase access.

How might increasing fee-for-service pay for walk-in clinic physicians affect physicians’ career decision-making? How could overall access to comprehensive primary care be affected if physicians who might otherwise have worked in a comprehensive practice choose instead to work in a walk-in clinic?
Competing Interests: None declared.
References
. 2023;:-.
Posted on: (2 May 2023)
Page navigation anchor for Conclusion unnecessarily targets the source of problem
Conclusion unnecessarily targets the source of problem
Michael Verbora [MBA, MD], Family Physician, McMaster University, Department of Family Medicine
"In 2020, only 41% of Canadians reported the ability to get a same- or next-day appointment with their family physician."

Therein lies the problem. While convenience drives visits to FFS Walk-in clinics, the reality is also that a majority of patients cannot be seen timely by a very busy family doctor. The responsibility for this "problem" lies between the family physician and the patient; not the FFS walk-in physician. Comprehensive care physicians are financially incentivized to minimize patient encounters. Shadow billing is minimal compared to capitated fees for patients. The conclusion "A complementary policy would be to discount physicians working in walk-in-clinics' fees for encounters with patients enrolled to another practice, relative to fees paid for seeing a patient who is not enrolled with a physician" would exacerbate access and longitudinal care you claim to care about. A discount in physician fees is a discount in the care provided, period.

Given FFS walk-in clinics are seeing higher acuity, have less context to patient health status, are available in evenings and weekend, more than comprehensive care family physicians, the conclusion should be to increase fees for FFS walk-in clinics who are providing this care which is more complex than comprehensive family medicine physicians.

If we did attempt to implement a system that financially penalized FFS walk-in clinics seeing rostered family physician pat...
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"In 2020, only 41% of Canadians reported the ability to get a same- or next-day appointment with their family physician."

Therein lies the problem. While convenience drives visits to FFS Walk-in clinics, the reality is also that a majority of patients cannot be seen timely by a very busy family doctor. The responsibility for this "problem" lies between the family physician and the patient; not the FFS walk-in physician. Comprehensive care physicians are financially incentivized to minimize patient encounters. Shadow billing is minimal compared to capitated fees for patients. The conclusion "A complementary policy would be to discount physicians working in walk-in-clinics' fees for encounters with patients enrolled to another practice, relative to fees paid for seeing a patient who is not enrolled with a physician" would exacerbate access and longitudinal care you claim to care about. A discount in physician fees is a discount in the care provided, period.

Given FFS walk-in clinics are seeing higher acuity, have less context to patient health status, are available in evenings and weekend, more than comprehensive care family physicians, the conclusion should be to increase fees for FFS walk-in clinics who are providing this care which is more complex than comprehensive family medicine physicians.

If we did attempt to implement a system that financially penalized FFS walk-in clinics seeing rostered family physician patients we would exacerbate the access problem we see today. Many clinics would close with a reduction in fees. Access to afterhours, weekends and acute care would worsen. ER visits would also increase leading to more expensive care for lower acuity issues. Furthermore, FFS physicians are the lowest paid physician group in Ontario. This policy would also exacerbate the wage gap between comprehensive care family physicians and FFS physicians, worsening relativity issues.

Instead of using a stick on physicians trying to improve access for patients, perhaps try a carrot. I am unaware of a single cut to physician income that led to improved patient care, access, or outcomes.
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Competing Interests: Dr. Verbora practices 90% clinical work in comprehensive care models and focused practice care (pain medicine). 10% of hours work provided by Dr. Verbora is in walk-in clinic FFS care.
References
. 2023;:-.