Inequities in Fee-for-Service Remuneration Affecting Rheumatologists and Patient-Centered Care Across Canada: An Environmental Scan

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Objectives System structure (macro-level) health policy and payment methods directly impact provider (meso-level) and patient levels of the healthcare system. Identifying variations in funding remuneration of services can identify potential inequities in care. We compared fee-for-service reimbursement rates (and regulations/stipulations) that are available to rheumatologists across Canadian provinces. Methods We reviewed publicly available Physician Payment Schedules across provinces to derive key information on fee-for-service payment information for common rheumatology services (as of July 2024). Information extracted included several sections encompassing: consultations, office visits, special premiums for complexity/diagnoses, hospital services, multidisciplinary care, virtual care, procedures (including injections/arthrocentesis, point-of-care ultrasonography) and additional services (e.g. laboratory monitoring). We descriptively summarized data in a table and text. We assessed whether reimbursement structures support person-centeredness (access to care dimension). Results Compensation for consultations ranged widely, from $153.51 to $239.57 (Table). This was also apparent in follow-up visit payments ranging from $65.55 to $131.52 and are overall consistently reimbursed at a lower rate than initial consultations. Saskatchewan, Manitoba and Ontario offer additional reimbursement (premiums) for certain complex rheumatic conditions, whereas Saskatchewan, Quebec, New Brunswick and Newfoundland and Labrador offer age-based premiums. Overall, inpatient consultation reimbursement rates are similar to in-office consultations. Virtual care is inconsistently funded across Canada with variations in stipulations and is often reimbursed at a lower rate than in-person care. Funding to support multidisciplinary/interdisciplinary care models is sparse, with only British Columbia and Quebec having a dedicated billing code to fund nursing co-managed care. The average (±standard deviation) rates for joint aspirations, steroid injections, image-guided aspiration/injection, bursa aspiration/injection and complex bursa/joint aspiration/injection are $28.02±8.73, $26.58±8.44, $34.00±12.93, $26.86±10.28 and $29.85±9.19 respectively. Point-of-care ultrasonography is only remunerated in Ontario and Quebec. Notable restrictions/stipulations that may impair patient-centered care included financially disincentivizing follow-up visits that occur within shorter intervals, and remunerating virtual visits at a lower amount, creating an inequitable disadvantage for patients experiencing barriers in accessing convenient/local rheumatology care. Inconsistencies in funding for multidisciplinary/interdisciplinary care, and procedures (e.g. ultrasonography) may contribute to variations in quality of care across Canada. Table. Provincial reimbursement for rheumatology consultations/follow-up visits Conclusion We identified large provincial variations in reimbursement rates for rheumatology services. Current fee-for-service structures raise health policy issues for funding equitable rheumatology services that require reducing pay disparities, removing restrictions/stipulations that impair person-centered care, and further optimizing standardization of health services across Canada.

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