N.B. doctors want pandemic-forced virtual care to be permanent, but with better pay

The New Brunswick Medical Society has revealed its vision to improve the province's health-care system.

The group's 57 recommendations are contained in a 45-page report released Wednesday morning and include building on technological gains forced by the COVID-19 pandemic. 

Doctors want the province to permanently adopt virtual care, which was relied on heavily during the pandemic.

At a news conference Wednesday, the society's president said the pandemic proved health care can be more efficient with better use of technology.

Dr. Jeff Steeves said virtual care can play a critical role for years to come, allowing for "efficiencies and convenience that can change the health system." 

The society sees an opportunity to capitalize on the momentum the pandemic created for virtual care, but doctors want  to be paid the same for virtual care as with in-person care.

Patients are also receptive to virtual care, the society said. A poll in May 2020 suggested 40 per cent of patients had a virtual care appointment, and 92 per cent were satisfied with their experience. More than three-quarters wanted to see virtual care continue after the pandemic. 

New Brunswickers have never been unhealthier.- New Brunswick Medical Society report

The medical society put together the report after receiving input from New Brunswick doctors — 530 physician responses from all corners of the province responded to the group's survey. Virtual meetings were also held with more than 190 physicians.

"New Brunswickers have never been unhealthier, there is a shortage of health-care professionals and available hospital beds, and wait times for surgeries and emergency care among the highest in Canada," the report says. "Our province also has the largest proportion of seniors in Canada." 

The status quo is unsustainable, the medical society says

To improve the system, additional funding will be necessary, but the medical society doesn't put dollar values on any of the recommendations. 

"A significant investment in our health-care system must be made immediately; the system cannot innovate under current budget constraints," says the report's introduction. 

Steeves said the report was given to government in April as part of the health-care consultation process, but so far, he's had no response. He said he's not worried about that — yet.

"We would be if we don't hear from them soon," said Steeves.   

In a statement issued Wednesday afternoon, the Department of Health thanked the medical society for its recommendations and said many of the concerns in the report are not new. 

"The provincial government knows the health system needs improvements, and that's why it went out earlier this year to hear what people had to say about the system," wrote spokesperson Gail Harding. 

"The recommendations from the medical society, along with the many submissions from other health-care providers and citizens, are being reviewed in order to build a five-year provincial health plan."

The doctors' report calls for improvements in several areas, including technology, virtual care, wait times, and seniors' care.

Steeves said the accessibility is likely the top priority.

In the short term, that means getting those without a family doctor access to health care, which would include virtual care and access to walk-in clinics. In the medium term, it would look at how to create efficiencies in the system, using more technology and teams of integrated health-care providers. 

In the long-term, Steeves said, recruitment and retention of doctors is the priority. 

"None of this is possible without increasing the number of physicians in the province," he said. "That has to be done. Everything else is stopgap to get people care now."

Improve health and well-being

"Income plays a large role in health outcomes," says the report. 

"Wages are directly related to health determinants: low-income citizens are more than twice as likely as those with moderate or high incomes to have lower quality of health."

Income "shapes overall living conditions" and influences health-related choices, including quality nutrition, physical activity, tobacco use, and excessive alcohol use. 

"Statistics Canada figures indicate that New Brunswick households are earning less than anywhere else in the country. New Brunswick is also struggling with some of the highest rates of children living in low income households, specifically in Saint John and Moncton. Half of New Brunswick families have an income of $54,200 or less, with 13.8 per cent of our population living in poverty."

The medical society says the government should "target deep poverty" by improving education and literacy, and improving access to education and skills training programs. The government should also increase the supply of affordable housing and rent supplements, and provide more income support and childcare subsidies. 

More money for patient-centred care

The group says New Brunswick doesn't spend enough on patient-centred care. 

"Overall health spending in New Brunswick is low," according to the report. New Brunswick has the lowest per capita health expenditures in the Atlantic provinces." 

Doctors say the system needs more money immediately. 

"The NBMS is encouraged given the recent announcement of a 5.1 per cent budget increase this year, however, to continue innovation and progress, the NBMS strongly recommends an increase in the health care budget of six per cent per year over the next five years to ensure initiatives have a strong foundation and can be well-established to operate in the future."

Review primary care payment models 

The report says most physicians in New Brunswick are paid on a fee-for-service basis, which doesn't encourage "prolonged patient encounters, or interdisciplinary, team-based care, particularly when compensated for chronic disease management, mental health care, and senior care."

The medical society would like to see a review of payment models, "to preserve the valuable elements associated with the fee-for-service model that encourages physician productivity while improving patient-centred care."

Increase access to primary care

Although about 90 per cent of New Brunswickers over the age of 12 years have a regular health-care provider, "challenges remain with respect to accessing primary care services when they are needed most," states the report. 

It says only 25 per cent of New Brunswickers believe they can get an appointment with their family physician within 48 hours; 56 per cent believe they can get an appointment within five days; and 17 per cent say it would take more than two weeks. 

 "Improving access to primary care may require incentivizing after-hours work" among other things, the doctors say.

Currently, only 16 per cent of New Brunswickers say their family physician has extended office hours — meaning weekends or past 5 p.m. on weekdays — and only 18 per cent indicate that their physician has alternate arrangements for after-hours care.

Reduce wait times

One of the reasons wait times are an issue is because of non-urgent patients seeking treatment in emergency departments, according to the report. 

The report calls for more effective and efficient triaging of patients. 

It cited a model piloted at the Moncton Hospital, which resulted in "increased throughput of patients leading to elevated patient satisfaction."

The report states that Atlantic Canadians have the longest wait times for specialist care in the country. The average Canadian waits 22.6 weeks for a specialist consultation, while patients in New Brunswick wait 41.3 weeks. 

Part of the problem is New Brunswick's current paper-based referral system, says the report. The medical society suggests an electronic referral system would be more efficient. 

Reduce the need for sick notes 

"The burden of paperwork on a physician's office has grown exponentially in recent years and is now considered a significant contributing factor to physician burnout across Canada," according to the report.

A large contributor to this is employers requiring "sick notes" from physicians.

The report said that requirement is "inappropriate for many reasons … it forces sick patients into small waiting areas where they risk spreading their illness to others; it limits access to medical appointments for others who may require more urgent care; and in many cases, physicians are asked to verify that a patient was sick, days after an illness has passed."

Doctors want government to change policies requiring sick notes in order to free up physicians' time.

Addiction and mental health

"Addiction and mental health resources in New Brunswick are lacking, and patients are suffering as a result," states the report.

It says the total cost from mental health illnesses to the Canadian economy is estimated to be at least $50 billion per year.

"Over the next 30 years, the total cost to the economy will be more than $2.5 trillion. In any given year, one in five Canadians experiences a mental health problem or illness. More than 6.7 million Canadians are living with a mental illness today. By comparison, 2.2 million people in Canada have Type 2 diabetes."

The medical society said New Brunswickers need faster access to the right services, including professionals specifically trained to deal with mental health issues. The group also stressed the importance of early detection and intervention. 

The opioid crisis

"Over prescribing has played a role in the current opioid crisis," the report states. 

"Canada is the second highest consumer of opioids worldwide and must take a comprehensive approach to halt widespread prescribing."

The medical society would like to see "a prescriber profile: a personalized data set for each prescriber in New Brunswick that outlines their opioid prescription rate, assesses its appropriateness, and compares the provider to their colleagues and peers."

Such a system, the group suggests, would hold prescribers accountable.

Reducing unnecessary treatment

The medical society supports the use of Choosing Wisely Canada recommendations as a way to cut down on unnecessary tests and treatments. The movement, which works to dispel the false belief that "more care is better care," began in the United States in 2012 and now includes 20 countries across five continents, according to the report.

The program uses a series of published toolkits for each specialty and provides how-to guides for reducing overuse, waste, and harm in different clinical settings.

The current areas of focus for Choosing Wisely in New Brunswick are:

• imaging for lower back pain
• antibiotics for viral respiratory infections
• preoperative tests for low-risk procedures
• antipsychotics in long-term care
• benzodiazepines in long-term care
• Using Blood Wisely, campaign to decrease inappropriate red blood cell transfusion practices in Canada.

Seniors' care

According to the report, New Brunswick has the highest concentration of seniors as a percentage of its total population in the country, which is causing a "significant strain on the health-care system." 

The medical society said the government should try to keep seniors living independently in their homes for as long as possible to avoid " costly institutionalization for as long as feasible." That includes an adequate income, suitable housing and an "age-friendly built environment" that allows seniors to live independently, including access to public transportation in areas where there's a high concentration of seniors. 

Other recommendations

• Review reproductive services with the goal of improving access
• Conduct a post-COVID-19 review of its response to the pandemic to prepare for potential future crises
• Improve 2SLGBTQ+ health inequities
• Address Indigenous health inequities
• Improve rural health care
• Ensure equitable access to services in the Francophone system
• Improve health care for new Canadians 
• Augment after-hours care and walk-in clinics
• Give patients access to their own personal health information through patients portals
• Increase the use of electronic medical records to allow better communication between members of a patient's care team
• Improve compassionate end-of-life care and provide standardized medical assistance in dying treatment across the province
• Enhance operating room capacity
• Address workplace violence in health-care settings
• Expand and support patient advocacy initiatives