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Doctors for all in Ucluelet, but the only medical clinic could close at month’s end

Dr. Carrie Marshall did the clinic’s math in January and it revealed what she already knew: “The cost of running the clinic far outstripped what would be a reasonable sustainable business model.”
Dr. Carrie Marshall in her Ucluelet office. COURTESY DR. CARRIE MARSHALL

Anyone who wants a family doctor can have one in Ucluelet — an unusual situation amid B.C.’s doctor shortage that could change if the town’s only medical clinic isn’t saved by month’s end.

Dr. Carrie Marshall, the lease-holder and owner of Ucluelet Medical Clinic, which includes two other physicians, informed the town in January she’d lose money if she were to renew the clinic’s lease May 31.

“We are very fortunately one of the only places in the province that can say we all accept new patients,” said Marshall. “Everybody on the coast that wants to be attached is attached to a family physician.”

But Marshall did the clinic’s math in January and it revealed what she already knew long before the pandemic struck: “The cost of running the clinic far outstripped what would be a reasonable sustainable business model.”

During the pandemic, she felt it “inhumane” to raise the issues threatening the clinic’s closure. Now she feels she has no choice. Her colleagues are onside and they are making decisions as a group.

“We are all deeply committed to longitudinal family medicine,” Marshall said. “We’re just waving the white flag to say that in order to continue, we need changes in how these business models deliver health care.”

Marshall’s overhead in 2021 was about $120,000. And as is the case for some other physicians, the fee-for-service model that compensates her — about $31 per patient visit, not including possible incentive top ups, before overhead is paid — has become untenable.

Marshall is in talks with the mayor, Island Health and the province about a solution.

Ideas being explored include primary care networks sharing resources between clinics, municipal help in the ownership or lease for the clinic, the health authority taking over the building, alternate payment plans, and fee-for-service incentives.

“What we’re really looking for is trying to disrupt service to Ucluelet as little as possible,” Marshall said. “The advantage we have is none of the physicians are leaving the coast, no one’s moving away, we all live in Tofino because we need to be on call for the hospital.”

Other municipalities have also been grappling with potential clinic closures. Last month, the province announced it would spend $3.46 million to keep five south Island walk-in clinics open.

Marshall said thus far there’s been no mechanism, funding source, or policy nimble enough “to throw at this to keep doors open” without significant disadvantages.

She is, however, confident of a solution: “We will, hopefully, be able to stay in that space and provide at least some services in person,” she said.

Health providers acknowledge travel to Tofino, 45 minutes away by vehicle, would be a burden for people with mobility issues or who are frail or have medically complex issues. Marshall anticipates that the Ucluelet clinic will become a “leaner” operation with more services centralized out of Tonquin Medical Clinic in Tofino and a greater use of telehealth.

Years ago, the clinic was open five days a week but is now down to three days. “We’re hoping we can continue with that level of service, but it may be there is one physician [on] instead of two … at any one time,” she said.

Ucluelet’s Mayor Mayco Noel said losing the town’s only medical clinic is not an option.

“It’s like closing down the grocery store,” he said. He’s less confident of a solution other than the town taking over the lease or having a non-profit run the clinic, but he’s concerned about setting that precedent.

“We’ve tried to let the bureaucrats find solutions over the last 90 days, and they’ve done lots of meetings but there’s been no real decisions to deal with the problem and there’s a time crunch of who’s going to take over the lease,” Noel said.

The town has a viable clinic, doctors and access and it behooves the health authority and province to maintain that either by taking over the lease or providing a $15,000 a month subsidy, at least in the short term, until solutions are found, he said.

“It’s typical small town stuff … where we’re really a low priority,” he said. “I would love to work with the province to come up with some immediate solutions.”

As a long-time businessman, Noel admits all the bureaucracy “drives me nuts.”

”How many more conversations do we need to have regarding the fact we need to ensure the lease is maintained?” he said.

Marshall maintains there’s no “one-size-fits-all” panacea for a family doctor crisis, in which 900,000 people in the province are without a family physician.

Instead, a “smorgasbord” of service models and payment models are needed, she said. “Incentivizing physicians is going to depend on where they live geographically, where they are in their life, where they are in their career and what they want in terms of a work-life balance.”

On Thursday B.C. Green Party leader Sonia Furstenau outlined steps the province could take to address the crisis.

In the short term, Furstenau said, the province should provide financial support to existing family practices for rent, administration and supplies, for example, so that no more offices have to close their doors.

In the long term, she advocated for the province providing more infrastructure for team-based primary care and a further shift away from the fee-for-service payment model.

B.C. Health Minister Adrian Dix said last month that alternate payment plan arrangements with physicians have risen from $500 million in 2017-2018 to $758 million today. “We have been working in that direction, working with the Doctors of B.C., working with family practices to do so.” Some doctors prefer the fee-for-service model but others don’t want to run businesses or bill for every service.

Lindsay Hedden, assistant professor of learning health systemsat Simon Fraser University, said primary care clinics need to be supported to keep the doors open in the short term. In the longer term, those clinics need to be asked what they need, she said, warning low-barrier quick solutions don’t exist.

“What we really need at this point is a pretty big overhaul of the way the system is structured — and that isn’t going to be fun or easy for anyone,” she said.

Hedden said physicians more choice when it comes to payment, practice models, and team-based care models. They want to be able to take vacations or retire knowing they are not the sole provider, she said.

A growing number of physicians don’t want to be small-business owners “to keep the lights on” especially as that’s become more complicated, costly, and burdensome over the years, Hedden said.

In that instance, “what we need is infrastructure supports in the same way the province has built Urgent and Primary Care Centres,” she said.

Since 2017, the province has created 27 urgent and primary care centres, which provide access to same-day, urgent, non-emergency health care. The province has also created more community health centres — community-based, non-profit or public organizations that provide comprehensive primary care services, the model Hedden prefers.

“I don’t think we’ll ever get to the point where a government isn’t going to say, you know, we’re completely fundamentally overhauling primary care and all of these existing clinics are now going to be rolled into clinics that are owned and operated by health authorities,” said Hedden.

“That will never happen — but at least providing those options, I think, is the right next step.”

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