Family medicine in the era of endemic COVID-19

When we are no longer able to change a situation … we are challenged to change ourselves.

Viktor E. Frankl, Man’s Search for Meaning¹

Over the past year and a half, the coronavirus disease 2019 (COVID-19) pandemic has rapidly, radically, and probably permanently changed the way that family physicians practise medicine.² An unprecedented shift to virtual care in the first few weeks of the pandemic allowed many of us to provide good-enough care for most of our patients, but as a fourth wave sweeps the country, new challenges and uncertainties await.

What will it be like to practise in a brave new world of blended virtual and in-person face-to-face care? In the near term, what will be the fallout of delays in accessing preventive care or for those with chronic conditions who have put off seeking care owing to fears of getting COVID-19 before they could be vaccinated? How will we deal with the growing burden of mental health issues among our patients because of the many and various impacts of COVID-19?

Many experts believe that COVID-19, unlike SARS, will become endemic in the population, much like seasonal influenza, although there is still uncertainty about that.³ In the longer term, how will we grapple with this new, and likely newly endemic, disease, the implications of which could include more seasonal visits for clinical assessment and testing, and the increased work of providing annual vaccinations over and above the ones we already provide to both children and adults?

Finally, in the era of endemic COVID-19, how will we find the appropriate balance between providing direct clinical care, whether virtually or in person, with the myriad and time-consuming clerical, communication, and administrative tasks that have been uploaded to family physicians over the past decade because of poorly designed electronic medical records, which have also radically changed the way we practise?⁴

How will we fare with so much and such rapid change? Where there is so much change, instability, and uncertainty, there is also an unprecedented opportunity and need for research.⁵

One of the biggest changes to be wrought by COVID-19 could be the way that family physicians are paid. In the earliest days of the pandemic, many family physicians working in traditional fee-for-service (FFS) models of care were hardest hit, with financial implications for them and potential health implications for their patients.

In this issue of Canadian Family Physician, we feature original research by Dr Philip Jacobs and his colleagues in Edmonton who examined the financial impacts of COVID-19 on family physicians in Alberta (page e306).⁶ Using financial modeling and reasonable assumptions as outlined in the study, they assessed family physician FFS billings before, during, and after the pandemic. They found that changes in family medicine practice patterns owing to COVID-19 and the rapid introduction of telemedicine visits resulted in potential reductions in average annual physician income (billings after overhead) by as much as 70% to 80%.⁶ As a result, they conclude that reduced income from existing structures, at current fee levels, could make FFS office-based family medicine practice unsustainable for some family physicians. They also make the case that after COVID-19, since family medicine practice changes that result in a combination of office-based visits and telemedicine will probably become permanent, changes in fees or alternative payment approaches will be required to maintain many community-based family medicine practices.

In an accompanying commentary (page 805),⁷ Dr Goldis Mitra and her colleagues from the University of British Columbia in Vancouver provide a concise history of physician payment models in Canada and make the case that it is time for the more widespread adoption of alternatives to FFS payment models. One of the most interesting elements of their argument is that there is evidence that younger physicians increasingly prefer to practise in settings with alternative payment plans and that those who are forced into FFS payment models are less likely to practise comprehensive family medicine.

The COVID-19 pandemic has provided a massive stress test to Canadian family medicine, revealing, among many things, the vulnerabilities of FFS payment models.