March 25,2013 Victoria Power Director, Primary Health Care Chronic Disease Management and Rural Health Services

Dear Ms. Power and Dr. Biglow: Thank you for your letter March 21, and for your responses to our concerns. There were several matters about which I am now more confused. You state that "the fee for service system has undergone significant change to make care of complex patients more attractive". Your letter provides no indication that this was accompanied by further training of doctors. Is it your claim that no additional training was required and that all that was required was an increase in fees? Did you have any plan or method to evaluate that high quality care was provided in response to this initiative? If so, I would very much like to know of it and its outcomes. While I am aware that the doctors who looked after us at Health Point probably had no special training in caring for complex care senior patients at the outset of their service, it became clear to me that they had acquired it over time. No doubt the fact that they had time with each patient to evaluate and research their needs contributed to the high quality of care that I observed. This did not apply to family physicians responding to higher fees by seeing more patients. Later in your letter, you state, "The changes made provide the opportunity to offer even better for each patient." Please explain to me how this change equates to better care. Also please explain how you will monitor that "better care" is being provided. Thank you for helping me resolve my additional concerns. Yours very truly, Dr. Clair Biglow Medical Director Urban Family Practice

Dr. Edwin E. Daniel Professor Emeritus University of Alberta #601 2910 Cook Street Victoria, B.C., V8T 387 7784333535 edaniel@ualberta.ca

Virginia Posey Daniel, M.Ed.

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March 21,2013

Dr. Edwin E. Daniel Professor Emeritus, University of Alberta #601 - 2910 Cook Street Victoria, BC V8T 3S7

Dear Dr. Daniel and Mrs. Daniel: Thank you for your letter of March 13, 2013 expressing support for the continuation of the Health Point Care Centre model of care, and your concerns about the physicians who have decided to leave the practice. The clinic exists to support the needs of people like yourself, and patients like you are the reason Vancouver Island Health Authority (VIHA) has and will continue to significantly subsidize the cost of the clinic. When Health Point was founded, fee for service payment for Family Physicians (FPs) to look after complex patients, including seniors, was insufficient to support the time commitment required. Because such patients often had difficulty accessing the care they needed as a result, the clinic was a heavily subsidized operation from the outset. The physicians were paid on a contract, rather than fee for service, and significant resources were put in place to support them (registered nurses, medical office administrative support, a manager), because it was recognized that care of this kind needed such extra support. Since that time, the fee for service system for family physicians in BC has undergone significant change to make care of complex patients more attractive. More and more doctors offices are seeing increasing numbers of patients with high needs, whether chronic disease or simply the frailty that accompanies advancing age, and new fees have been introduced that better accommodate this shifting reality. Many Victoria family practices now see patients very much like you and other patients seen in Health Point while carrying much larger patient populations than Health Point has been able to achieve. This has contributed to wait lists at Health Point. Two years ago, to access the new provincial incentives for physicians providing care to complex patients, Health Point physicians transitioned to fee for service, as the fee improvements were unavailable to physicians on contract. We believed this transition would enable the clinic to increase the number of patients and address the wait times. . . ./2

Primary Health Care, Chronic Disease Management and Rural Health Services Royal Jubilee Hospital 1952 Bay Street, Victoria, BC V8R 1J8 Phone: 250-519-1539 Fax: 250-370-8694

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-2 Fees under the fee for service model are set to accommodate the overhead costs associated with operating a doctor's office (to pay for staff, lights and power, rent, etc.). The cost of the overhead at Health Point is set deliberately lower than physicians generally pay in Victoria; however, in keeping with the commitment to continue to subsidize the care of the high needs patients. After two years, the wait times remain, the number of patients hasn't changed much (remaining at about half that of similar practices elsewhere), and the overhead payments received from the physicians did not meet even the lowered expectations for overhead. Efforts to remedy the situation have been unsuccessful, and the physicians have therefore given notice. VIHA remains committed to providing exemplary care through Health Point, care which is enhanced, senior-friendly, and appropriately resourced. The changes made provide the opportunity to offer even better care for our seniors. We are confident that we will be able to recruit physicians to Health Point Care Centre who will continue the dedicated care you expect from the clinic. In the meantime, we are working with the departing physicians to ensure a seamless transition as possible. Thank you for expressing your interest and concern; we hope the explanation provided reassures you of VIHA's commitment to you and your wife and to the model of care at Health Point, and gives you confidence that the good care you receive will continue. Sincerely, Sincerely,

Victoria Power Director Primary Health Care, Chronic Disease Management and Rural Health Services cc: Cal Tant

Dr. Clair Biglow Medical Director Urban Family Practice