In late June 2006, hospitalists in British Columbia (B.C.) were on the verge of walking out of their regions’ hospitals in protest over payment and workload. The strike was narrowly averted (see “Tough Negotiations Avert B.C. Hospitalist Walkout,” August 2006, p. 1), and chief negotiators for the B.C. hospitalists signed an interim agreement that left the door open for future pay hikes and an examination of workload among other issues.
Two years later, some progress in providing pay increases and adjusting workloads has happened, according to some B.C. hospitalists. David Wilton, MD, is one of the directors of the Vancouver Hospitalist Society, a nonprofit organization that contracts with Vancouver General Hospital and the University of British Columbia Hospital (both overseen by the Vancouver Coastal Health Authority). Although Dr. Wilton reports “things have been working at a snail’s pace,” he and his colleagues have made important inroads in developing more collegial relations with the British Columbia Medical Association (BCMA) and the Canadian College of Family Physicians (CCFP). By taking guidance from SHM, Canadian hospitalists are strengthening their own association by increasing awareness of the value of hospital medicine in Canada.
Where the Trouble Began
BC is divided into six regional health authorities—five of which have active hospitalist programs. Hospitals are administered by the health authorities, whose administrators have come to appreciate hospitalists’ value in increasing patient flow and thus reducing emergency room crowding. However, the health authority administrators do not determine hospitalists’ salaries. All B.C. physicians’ compensation is established through periodic negotiations between the BCMA and the province’s Ministry of Health (MOH).
A Letter of Agreement signed by the two sides in April 2006 revealed serious problems for the hospitalists. The association, dominated by establishment physicians, had (for purposes of the Letter of Agreement) placed hospitalists lower on the pay scale grid than community-based family physicians. Even though hospitalists in Canada predominantly are from a family practice background (the opposite of the United States, where the majority of hospitalists come from internal medicine backgrounds) the BCMA’s under-appreciation of hospitalists’ workloads led to a low base rate for calculating salary increases.
Subsequently, the B.C. hospitalists realized they needed to be proactive about their own interests and hired an attorney to attend meetings with the ministry. Although the ministry never agreed this second, public round of talks were negotiations, an agreement to re-examine contracts was reached.
—Wayne DeMott, MD, hospitalist at Royal Jubilee Hospital in Victoria, B.C.
The contract (signed in June 2006) stipulated timelines for a wind-down provision if there were no satisfactory outcomes with the alternate payments committee or the newly established tripartite Hospitalist Workload Model Working Group, comprised of MOH, local health authority, and hospitalist representatives. An interim contract was signed in September 2007 (retroactive to March 2007) and is again up for renewal since it is now past the April 1, 2008 deadline. The strategy for the near-term is to renew the compensation contract for shorter time periods and wait until the BCMA re-opens negotiations with the MOH in 2010 for an updated Letter of Agreement.
Repairing the Divide
In the meantime, B.C. hospitalists have delved into multiple initiatives they believe eventually will bear fruit. Chief among these is establishment of a hospitalist section within the BCMA. In 2006, the situation was “somewhat antagonistic” between hospitalists and the BCMA, says Geoff Appleton, MD, the current BCMA president.
“There has been friction between GPs and hospitalists because GPs have felt themselves pushed out of the hospital sector,” he says, “and they felt that hospitalists were getting paid more for hospital work than they were.”
Hospitalists, on the other hand, contend GPs were abandoning hospital-based practice, which created a new opportunity for those specializing in inpatient service delivery.
“Hospitalists did not feel they were represented as well as they should have been with the last round of [MOH] negotiations,” Dr. Appleton says. “They feel that they have been undervalued from a BCMA point of view, we don’t like to see that kind of conflict. I think once hospitalists help their colleagues understand the services that they are providing, then some of that resistance can go away. I’m hoping that they’re happier with what we’ve been doing and that their sectional status has improved things for them.”
Others in British Columbia agree with Dr. Appleton’s prognosis. “I think we’ve got optimism,” says Wayne DeMott, MD, a hospitalist at Royal Jubilee Hospital in Victoria, B.C. and chief negotiator for the BCMA’s Section of Hospitalist Medicine. “I think we’re trying to seek a much better representation of our issues from our parent organization that has struggled with figuring out what the heck to do with hospitalists. I do sense that they are trying to accommodate us a bit better and that they’re going to look at how they will represent us in the future.”
Understandably, though, Dr. DeMott also expresses wariness: “We had to go on a pretty tough journey in 2006 and we still haven’t forgotten how we were treated two years ago. We’re definitely going to continue to advocate strongly for ourselves.”
U.S.-Canadian Similarities, Differences
As U.S. hospitalists observe the growing pains of hospitalists in the Canadian healthcare system, it might look like deja vu all over again.
“In many ways, Canadian hospitalists are following a similar arc [as our U.S. HM colleagues] in carving out their niche,” says Dr. Wilton. The void created when family practice physicians abandoned hospital care in the late 1980s and early ’90s has turned into an opportunity for hospitalists. In turn, family practice physicians who at first were resistant have become accepting as they begin to appreciate the service hospitalists provide.
Even though U.S. and Canadian healthcare delivery and reimbursement systems differ, hospitalists “have a similar scope of practice” in the two countries, says Echo- Marie Enns, MD, CCFP, a hospitalist in Calgary, Alberta, and the first president of the Canadian chapter of SHM. John Nelson, MD, medical director of the Hospitalist Practice at Overlake Hospital in Bellevue, WA, a consultant for hospitalist practices with Nelson/Flores Associates, and co-founder and past president of SHM, agrees. “Eighty to ninety percent of the issues with hospitalists would apply to both settings,” he says. “There are ways in which they differ, but in broad strokes, they’re almost identical.”
Hospitalists’ situations and reimbursement agreements do vary from province to province, Dr. Enns notes. She was the lead hospitalist when the Calgary program started in 1998. She also worked in B.C. for a time and noticed that the MOH can be adversarial toward physicians at times. On the other hand, hospitalists in Alberta say they are “very well treated,” and have reported high satisfaction levels overall.
“The hospitalists here admit greater than fifty percent of the patients to medical beds in the region. So, we are the admitting force for the hospital,” she says. “We have a very cooperative relationship with the administration and have been able to initiate a lot of excellent initiatives to improve patient flow in moving patients to the most appropriate bed at the right time. As a result, we’re also getting to be more well known amongst the public.”
Currently, the Hospitalist Workload Model Working Group awaits money to hire an external consultant to study hospitalists’ workloads across the province. B.C. hospitalists also are forging a new partnership with the Canadian College of Family Physicians (CCFP). Family practice physicians formerly were wedded to the “mantra of the full-service family physician who did everything—patients, obstetrics, pediatrics—and now they are recognizing that practice patterns are changing,” explains Dr. Wilton. “In order to remain relevant, they need to acknowledge hospital medicine, embrace it and regulate it, to make sure that it is done well.”
The CCFP is now partnering with hospitalists to establish a hospital medicine certification process. Another positive step: the University of Toronto is beginning a new one-year hospital medicine fellowship program. (www.sunnybrook.ca/education/Hospitalist).
Hospitalists across Canada are “in the middle stages” of forming their HM society, reports Dr. Wilton, who has led efforts to build a national database and to launch a survey of Canadian hospitalists. Dr. Enns, who initiated the first Canadian SHM chapter in 2000, thinks opportunities abound for increased collaborations across the border. For instance, she says, having Canadian hospitals involved in multicenter trials of DVT prophylaxis or diabetes initiatives could prove fruitful.
Dr. Nelson also agrees SHM and Canadian hospitalists should continue to consult and work with each other. “There are a number of Canadians who are active in SHM and I think that should continue,” he says. “We have a lot to learn from one another because for most of the issues we face the solutions are going to be the same.”
Drs. Wilton and DeMott invite their U.S. colleagues to attend the 6th annual Canadian Hospitalist Conference from Sept. 27-28, at the Morris J. Wosk Centre for Dialogue in Vancouver, BC. SHM CEO Larry Wellikson, MD, will be the keynote speaker. To register visit www.cpdkt.ubc.ca.
Dr. Wilton notes that despite the slow rate of change for hospitalists, there are positive aspects to their work. “We all know—fundamentally—that we are essential to the functioning of the hospitals,” he says. “We know we’re needed and valued on the frontlines. The [government] bureaucracy and the medical establishment are slow to change, but they eventually will.”
Dr. DeMott considers the future of BCMA hopeful. “We’re going to have a bigger role at the BCMA. They’re going to come to completely appreciate us, and things will hopefully be less acrimonious in the future.”
Both physicians agree the crisis of June 2006 served to heighten awareness of hospitalists’ value.
“It was the hospitalists’ time to make people recognize what we do and that we need to be adequately compensated for it,” Dr. Wilton says. TH
Gretchen Henkel is a medical writer based in California.