The Walk-In Clinic Crunch

With a chronic shortage of family doctors and overcrowded emergency rooms, walk-in clinics have taken up much of the overflow. Now these frontline clinics are anxious to know how changes to B.C.'s primary-care system will impact them.

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It’s a pain getting sick. But it’s an even bigger pain trying to get into a walk-in clinic these days.

And with a severe family doctor shortage and growing population in British Columbia, that’s what an increasing number of people are trying to do.

It’s fairly easy to find a walk-in clinic — they’re all over the place and business is brisk. In fact, lineups and waiting lists keep getting longer due to the demands on our health-care system.

Just ask Dr. Ian Bridger, who runs four clinics on the South Island.

“It can be challenging,” says Bridger, who owns Burnside Family Medical Clinic, Tillicum Medical Clinic, Uptown Medical Clinic in Walmart and St. Anthony’s Treatment Centre in Langford. “Our focus is on anyone who comes to our door that day — we will do our best to see them.”

Driving these lineups and walk-in wait-lists is a chronic shortage of family doctors and overburdened hospital emergency rooms that have forced many people to turn to walk-in clinics for their primary medical care.

“There is no competition for patients,” Bridger says. “What we are competing for is doctors.”

In fact, Dr. Bridger’s LinkedIn profile states in capital letters WE ARE CURRENTLY RECRUITING PHYSICIANS.

According to the College of Physicians and Surgeons of British Columbia, there are currently no general practitioners in Greater Victoria accepting new patients.

But there may be relief afoot for those seeking doctors, although where walk-in clinics are concerned, it’s not yet clear how a new provincial government strategy will play out.

Health-Care Reform

In response to the health-care crisis, in the spring of 2018, the British Columbia government announced the hiring of up to 200 new general practitioners, 200 nurse practitioners and 50 clinical pharmacists as a part of its plans to reform primary health care.

“At the heart of the strategy is a new focus on team-based care that will see government fund and recruit more doctors, nurse practitioners and other health professionals, to put patients back at the centre of health-care delivery,” according to a B.C. government news release on May 24.

The strategy includes setting up primary care networks (PCNs), the first of which will be created in Surrey. It will also include 10 urgent primary care clinics (UPCC), with the inaugural location in Richmond. Asked when Vancouver Island can expect PCNs or UPCCs, there was no information from the government at press time.

“Our new primary health-care strategy will help reduce wait times and make it easier for people to find a family doctor,”says Adrian Dix, B.C.’s Minister of Health.

And to get there, Dix is planning to pay some doctors a salary, while maintaining the fee-for-service model for others. And his sights are set on medical graduates, attempting to attract them into family medicine, a field that many young doctors are reluctant to go into under the current fee structure and demanding work schedule.

“We’re making sure new doctors are supported to focus on diagnostic medicine and developing strong relationships with their patients, and receive a good salary while they are also paying down their student debt,” says Dix.

“This kind of support,” he adds, “can encourage more residents educated and trained in B.C. to stay and serve in the province’s primary-care system.”

A Solution, But Will it Help Walk-ins?

“It is a start in the right direction,” says Mike McLoughlin, founding director of the Walk-in Clinics of BC Association, a lobby group advocating on behalf of walk-in clinics in B.C. and gathering information from users to petition the government.

However, he adds, “if you are going take 200 GPs out of the fee-for-service and put them on salary, then what are you replacing those GPs with in the fee-for-service system?”

McLoughlin is concerned that filling the new salaried positions will not only come from new graduates but also from existing family doctors.

“We will not limit this opportunity to only new graduates,” says Laura Heinze, media relations manager with the B.C. government.

So if existing physicians or nurse practitioners (NPs) with more experience and who currently do not have primary-care practices may be interested, there is also opportunity for them.

“How are they going to distinguish between those who are and those are who are not in that practice? There is nothing to stop doctors from quitting a family practice and then taking a government salary job,”says McLoughlin, who sees difficulties ahead for walk-in clinics. “t is going to make it more difficult for walk-in clinics to recruit new grad GPs because they cannot offer the same level of [job] security.”

And that opinion is shared by Dr. Bridger.

“We have not had a new payment system brought out for a long time,” he says. “If they introduce a new payment system for some doctors and it is very successful, they would need to expand that to all family practices and all walk-in clinics. The $30 we get for seeing a patient needs to be revisited.”

But for Bridger and other owners of walk-in clinics, the B.C. government has so far unveiled the “what” but it has not yet revealed the “how.”

That’s still to come, according to the B.C. government.

“Walk-in clinics are encouraged to work with their local division of family practice and health authority partners to define their role and to become part of the primary care network,” says Heinze, adding that that “walk-in clinics are well-positioned to evolve their service model in order to become urgent primary care clinics as part of the primary care network, if so desired.”

Bridger agrees that walk-in clinics are in a good position to offer urgent primary care; in fact, he argues that walk-in clinics have been delivering urgent primary care for years. And in his case, that’s been nearly a quarter of a century.

Bridger’s Clinics 

Photograph by Belle White.

Bridger, 59, is a family doctor who has been practicing medicine in the Capital Region for 24 years. In 2005, he was looking for a new office with more services nearby for his family practice. He bought a clinic on Burnside Road that also had a walk-in clinic, which was not in his original plan.

“Having purchased a building with a walk-in clinic, I set my mind to making it successful,” says Bridger. “So I had to learn the business of walk-in clinics and I was absolutely fascinated by it.”

Since then he has purchased Tillicum Medical Clinic, Uptown Medical Clinic in Walmart and, in 2016, St. Anthony’s Treatment Centre in Langford. Bridger’s clinics are four of 320 walk-in clinics in the province.

While Bridger won’t talk specifically about his walk-in clinics’ finances, he is willing to talk generally about how the money breaks down.

He says of the $30 per patient that doctors receive from BC Health, doctors get about 60 per cent, 30 per cent goes to overhead and the clinic makes about 10 per cent in profits. He adds that in the current climate of supply and demand, some doctors can command more than 60 per cent.

“Because there is a shortage of doctors,” he notes, “available doctors have demanded a greater percentage of the fee for themselves.” He describes this market force as one of the principal causes of clinics failing.

As the medical director of his four busy clinics, Bridger is well-versed in market forces and how to respond. He says his business model starts with autonomy: the ability to make business decisions without the need to seek approval from other owners for things such as spending money on technology.

“The first thing I did in my business model is I took all of my clinics to the same electronic records level so that all of our doctors could instantly learn how to use and find information,” he says.

Another key to his business model is not to start up walk-in clinics from scratch, but rather take over existing ones with existing patients.

“When you first start, you are not seeing enough patients per hour to keep the doctors happy or pay the staff, and doctors get upset and leave,” he says.

He admits that the exception to this rule was the opening of a new clinic in Walmart at Uptown Shopping Centre. But the location came with plenty of foot traffic, allowing the clinic to quickly see enough patients to break even.

“The interesting story,” says McLoughlin, “is how retail stores are supplying primary care — and this partnership between retail and walk-in clinics and family practices is providing the growth [of walk-in clinics] in British Columbia.”

And it’s that retail piece that has been the driving force behind successful walk-in clinics, enabling them to secure subsidies, often in the form of lower rents or landlord improvements or changes to make the space suitable for a clinic. The retail-clinic strategy works for retailers because it means there is a clinic located near their store pharmacy. That’s not only convenient for patients, it also attracts more foot traffic to the stores in general.

Another key to whether a walk-in clinic survives, thrives or dies is its proximity to other medical services, such as pharmacies, X-ray facilities and medical labs. Bridger argues that this proximity helps clinics attract doctors and generate enough profit to grow the business.

The History of Walk-In Clinics in B.C.

The history of walk-in clinics in this province can be traced back to the late 1980s. These clinics were able to dispense basic pharmaceuticals and prescriptions and treat everything from head colds to broken bones. As intended, walk-ins took some of the pressure off increasingly busy emergency rooms.

Despite that, over the years many family physicians have been critical of doctors working in walk-in clinics. They believed that walk-in clinics got the easy, less time-consuming patient care, while family doctors were left with the more complex and chronic care that required more time with the patient, resulting in less money earned than walk-in clinic physicians.

To level the playing field, the provincial government of the day brought in a fee structure for all family doctors, whether in a traditional family practice or in a walk-in clinic. Traditional family doctors also received additional money for specific specialized care for people with chronic or complex needs.

There was relative calm until about a decade ago when the province began to experience a family doctor shortage. More and more patients were unable to see a doctor in a timely manner — and so more and more people began turning to walk-in clinics.

Wait times increased and the pressure meant that the walk-in aspect of many walk-in clinics was no longer as convenient or timely.

“What is holding us back at the moment is that we do not have enough family doctors,” says McLoughlin. “Doctors choose to go where the money is better.”

While the B.C. government’s latest health-care reforms are being welcomed by many in the medical system, concerns will continue until more is known about how the reforms will be rolled out.

“Generally, I’m optimistic because the minister made a commitment to primary care [and] that is a very good sign that the government is taking access to care seriously,” says McLoughlin. “But it will not benefit walk-in clinics directly, only indirectly.”

While the new approach may stabilize young grads coming into family practice, McLoughlin says, “If those young grads who are working at the walk-in clinics decided it is better to work under an alternative payment arrangement and walk-in clinics cannot cover those shifts, it just means less capacity at clinics and longer line- ups.”

There is, however, one thing that most health-care providers agree on: it is unacceptable that more than 780,000 British Columbians are currently without a family doctor.

The Daily Cap System

Dr. Bridger argues there are two remedies that would quickly address the family doctor shortage. The first is to pay doctors a premium to work off hours to keep walk-in clinics open longer. The other would be to allow doctors to see more than 50 patients a day at full pay.

Currently, B.C. doctors have a 50-patient per day cap. After 50 patients, they get paid 50 per cent of their payment fee until they reach 65 patients, after which they receive no payment at all.

“We have physicians willing to work 10 or more hours a day,” he says, “but they reach their maximum number that the system will pay them for in eight hours. Now, if those patients go to the emergency room as their only recourse, it costs the system in the region $600 to see that patient in a hospital emergency room.”

McLoughlin’s association is calling for more flexibility in the cap system. It wants the provincial government to spread the cap over a longer period of time, say a week or a month. The argument goes that doctors can work more hours when more patients come to the clinic, and less hours on days when fewer patients walk though the door.

“By taking away that daily cap, clinics could stay open and see more people and we would not have the frustration the public has currently.”

However, Dr. Rita McCracken, a family doctor in Vancouver and a clinical assistant professor at the University of British Columbia, says she would be worried if the cap were removed and doctors could see more patients in a day.

“Episodic visits by different providers is not the high standard of care that people in B.C. need,” she says, “and doctors being able to see more patients in a day is not the answer to our health-care needs.”

McCracken believes the new reforms are heading in the right direction, with an emphasis on team-based care that is patient-focused.

“Walk-in clinics currently play a role in our stressed medical system, but to continue to be relevant, they need to be a place where patients can access team-based care, including nurses, medical assistants, social workers, counsellors, etc.,” says McCracken.

Bridger says he also favours a team approach in his clinics, but “the money would have to come from another purse,” he says. “The current fee model of $30 per patient would not sustain a team model.”

He also says the way patients’ electronic medical records are treated presents an issue. “A patient’s medical record cannot be shared between clinics due to privacy concerns, which means if [patients] cannot get into their walk-in clinic on any given day, they will have to wait another day or go to another clinic, which would not have their medical records.”

This Is At a Critical Stage

There’s no doubt the system of delivering primary care is at a critical stage. As the provincial population increases and ages, and as more family doctors retire, the demand for primary health care will only intensify. According to the most recent Statistics Canada census figures, the number of Canadians who are 65 or older grew by 20 per cent between 2011 and 2016. It’s the biggest increase for that age group in seven decades. In B.C., by 2031, almost one in four people will be over the age of 65.

Dr. Bridger himself is heading toward retirement. He has sold his family practice to a young doctor from the United Kingdom and his immediate plan is to continue to manage his business and work part-time in his clinics, looking forward to the day he can finally pull down his shingle.

“My driving force throughout my medical life has not been to make lots of money and run a business,” he says. “It is to look after the health care of my community.”

And here’s the irony: it’s not easy looking after the health care of a community when the health-care system itself is in urgent need of care.

UPDATE: On July 17, Mike McLoughlin of the Walk-In Clinics of BC Association told Douglas that the BC Ministry of Health has now invited walk-in clinics to the table to discuss ways for them to participate in the ministry’s primary-care initiatives.


Family Doctors: By the Numbers

780,000

Number of British Columbians who don’t have access to a family doctor

36%

Percentage of British Columbians who can get in to see the doctor on the same or next day.

56%

British Columbians who say their last visit to the ER was for something that could have been treated by their regular doctor, had they been available.

Source: B.C. Government, 2017

This article is from the August/September 2018 issue of Douglas.