Respiratory Medicine - British Columbia Medical Association

Respiratory Medicine - British Columbia Medical Association

iii)iv)5No FFS billing or other sessional payment would be made to the Respirologist duringthe time period they are receiving the CRM sessional paymentAs these CRM Sessional payments would apply only to the designated clinics and wouldbe fixed in total number there are no cross-sectional billing considerations.While the full funding of this program would come from the LMA fund there would be aconsiderable offset to this cost in that the FFS billing, currently being done by the Respirologistsattending these clinics, would stop and the sessional payments being made to the SPH Adult CFClinic would be reduced by a number equal to the number of new CRM sessions for that clinic.These savings would result in a considerable reduction in the overall costs to the MedicalServices Plan.Part 5: RationaleThe primary outcomes expected from the implementation of these CRM sessionalpayments would be:• The retention of the Respirologists currently working in these RM specialtyclinics• Improved ability to recruit new Respirologists with training and interest in thesehighly specialized areas of RM• The expansion of services both through the current clinics and through thedevelopment of clinics in other centers.i) Stabilization of the current Physician Resources and Recruitment of new SpecialistsThese 7 clinics provide comprehensive care to a large group of patients from throughoutthe province. These patients all have severe, chronic illnesses and most will ultimately die fromtheir disease or its complications. Most of these patients will be followed long-term through theclinics and, as a result of the increasing frequency of these disorders (asthma, PH and ILD), aswell as improvements in treatment, the number of patients in all of these areas is growing. Thenet result is that the Respirologists working in these clinics are struggling with the increasingdemands and inadequate remuneration, particularly when compared to the other areas of RMpractice. Without improved physician funding several of these clinics (Adult CF, PH and ILD)may be forced to reduce services (see Appendices B-F). Therefore, the primary outcome of thisimproved funding would be to stabilize the ability of the Respirologists, currently working inthese clinics, to continue to provide this highly specialized care.By improving the absolute level and the security of funding for these services the CRMsessional payments will significantly enhance the attractiveness of working in these clinics. Thiswill greatly assist in retaining the current physicians as well as enhancing the ability to recruitnew ones.ii) Expansion of servicesWith the additional funding that these CMR sessional payments will provide most ofthese clinics would be able to rapidly provide some expansion of services. This would occurprimarily as a result of these specialty clinics becoming financially competitive with the otherareas of RM practice. This will allow the Respirologists, currently practicing in these clinics, tocontinue to do so and to increase their clinic time without facing significant financial lossescompared to their colleagues. The increase in services could take the form of an increase in thenumber of clinic days (Severe Asthma and CF) or the opening of satellite clinics in othercommunities (Lung Transplantation, Pulmonary Hypertension and ILD).

Over the longer term the additional funding will improve recruitment of new specialiststo these clinics, thus allowing for further expansion of services, including the development ofadditional clinics in a number of communities throughout the Province.6

Appendix A7Description of Internal Medicine Complex Care Consultation00311 Complex Consultation .................................................................................... 212.64Notes:i) Payable only for General Internal Medicine specialists who do not hold a sub specialty.ii) Limited to one per patient in a 6-month period.iii) Written consultation report includes advice or recommendations for treatment regarding 3 ormore of the conditions listed in note iv), below.iv) Payable for patients that have 3 or more of the following listed chronicdiseases. Exceptions to this rule could be made if the patient has twodiagnoses from this list and one alternative diagnosis not on the list can besubmitted with correspondence/note record, outlining the medical necessity.Each case will be reviewed on an independent consideration basis.(Diagnostic codes in brackets):Septicemia (038)Other HIV infection (044)DM including complications (250)Disorders of Lipid Metabolism (272)Thyroid disorders (246)Purpura, thrombocytopenia and hemorrhagic conditions (287)Anemia, unspecified (285.9)Senile dementia, presenile dementia (290)Acute confusional state (293)Congestive Heart Failure (428)Diseases of the aortic and mitral valve (396)Essential hypertension (401)Coronary atherosclerosis (414)Neoplasm of uncertain behaviour of other and unspecified sites. "Not for minor orsuperficial skin malignancies." (238)Cardiac dysarrhythmias (427)Cerebral atherosclerosis (437)Asthma allergic bronchitis (493)Emphysema (492)Other bacterial pneumonia (482)Non infective enteritis and colitis (557.1)GI hemorrhage (578)Chronic liver diseases and cirrhosis of the liver (571)CRF (585)ARF (584)Disorders of fluid, electrolyte and acid base balance (276)Syncope (780.2)Venous thrombosis and embolism (453)Pulmonary fibrosis (515)Rheumatoid Arthritis (714)Systemic Lupus Erythematosus (710)

Appendix B8Cystic FibrosisCystic Fibrosis (CF) is an autosomal recessive disorder that affects over 200 adults inBC. CF causes severe and progressive lung infections with 50% of affected individuals dying bytheir mid-forties. Most have pancreatic insufficiency leading to severe nutritional deficiencies,diabetes mellitus and metabolic bone disease. Many undergo organ transplantation includinglungs, livers and kidneys.More than 95% of individuals with CF receive the majority of their care through the CFclinics. Survival of patients followed through a CF clinic is significantly higher than for patientsnot followed through these centers. International standards dictate that the care of adults with CFbe delivered through a multi-disciplinary CF clinic which includes nurses, physiotherapists,pharmacists, respiratory therapists and social workers. These clinics are directed by aRespirologist, with special interest and training in CF. As a result of the complex nature of CFand the multitude of treatments required the CF clinic becomes the primary source of medicalcare for the majority of adults with CF. The clinic is even involved in such diverse areas asreproductive and obstetrical health.There are two adult CF clinics in BC, one at St. Paul’s Hospital (SPH) and one at theRoyal Jubilee Hospital (RJH). The RJH clinic serves all the adults on Vancouver Island, about25 patients, while the SPH clinic covers all of BC, with about 190 patients attending. The SPHclinic currently provides 3 full day clinics per year in Kamloops for patients from the interiorwith CF. There is a need for clinics in both Prince George and Kelowna, which this improvedfunding would help to facilitate. As a result of the steady improvements in care the number ofadults with CF has been steadily increasing and just recently exceeded the number of children.These clinics are part of a Canada-wide network under the sponsorship of the Canadian CysticFibrosis Foundation (CCFF). There are now published standards of care for most CF-relatedproblems and all clinics utilize these resources and are regularly reviewed by the CCFF. As aresult Canada is a leader in CF care and has the best median survival age (47 years) of anycountry in the world.The SPH clinic holds about 169 clinics per year while the RJH clinic has 20. At eachclinic 4-6 patients are seen with each patient generally taking 1-2 hours to get through all of theteam members. The clinics usually last 3.5-4 hours. The Physicians at the SPH clinic are paidon a sessional basis while at the RJH clinic it is fee-for-service (FFS). Neither of the paymentmethods addresses the time and complexity of adult CF patient care.There are only 2 CF clinical fellowships per year in Canada. The trainees from theseprograms are highly sought after by the 40 CF Clinics across Canada. In BC there are only 5Adult Respirologists, 2 in Victoria and 3 in Vancouver, practicing in the area of CF. Two of theVancouver Respirologists are due to retire this summer. Attempts to recruit 2 CF specialists tothe SPH clinic have failed. Two of the remaining 3 CF specialists are over 50 and one will turn60 this year. A major barrier to recruitment is the major time commitment required with the verypoor remuneration level provided by FFS or regular sessional payment. Without a significantincrease in remuneration for CF care it is going to be very difficult to recruit new physicians.Below are some excerpts from the most recent report by the Canadian Cystic FibrosisFoundation, entitled “Cystic Fibrosis in Canada”:• Cystic fibrosis (CF) is the most common fatal genetic disease affecting Canadian childrenand young adults. There is no cure for CF. It is estimated that one in every 3,600 childrenborn in Canada has cystic fibrosis. Approximately 3,500 Canadian children, adolescents,and adults with cystic fibrosis attend specialized CF clinics.• Cystic fibrosis is a disorder that affects several bodily systems, it is associated with avariety of symptoms, including: difficulty breathing; constant cough that expels thick

9mucus; excessive appetite combined with weight loss; bowel disturbances; skin thattastes unusually salty; repeated or prolonged bouts of pneumonia.• Cystic fibrosis affects each individual differently, with varying degrees of severity. Eachperson with the disease follows an individualized treatment program, which may includea demanding daily routine of physical and, sometimes, inhalation therapy to keep thelungs free of congestion and infection. Children and adults with CF must also consume alarge number of pancreatic enzymes (on average 20 pills a day) with every meal andsnack, to help absorb adequate nutrition from food. Regular visits to a CF clinic are alsoan essential part of CF care and treatment.• Expert care for adults and children with cystic fibrosis is provided at 40 accredited CFclinics, located in major centres across Canada. The clinics offer specializedmultidisciplinary medical care for children and adults. In addition, when resources allow,CF outreach clinics provide medical care to individuals in remote areas.• Lung transplantation provides individuals who have end-stage lung disease with thepossibility of regaining their health. However, due to the limited availability of donororgans, obtaining a transplant may be difficult.

Appendix C10Severe AsthmaAsthma is one of the most common chronic diseases, with a recent report from Ontariosuggesting that up to 30% of residents have been affected by asthma at some stage during theirlifetime. In BC a recent large cohort based study of all asthma patients (over 185,000) showedthat patients with severe asthma are responsible for 60 % of the direct health care costs related toasthma. In recent years the availability of newer monoclonal antibodies, such as omalazumab, aswell as very impressive evidence that therapy guided by the assessment of sputum eosinophilialeads to improvement in asthma control focuses on the need to develop standardized proceduresfor the management of patients with severe asthma. Currently there are very few Respirologistswith a special interest in severe asthma. There are established clinics at Vancouver GeneralHospital (VGH), St. Paul’s Hospital (SPH) and the Surrey Memorial Hospital (SMH). There is aCanadian Severe Asthma Network (CSAN) to which links have been established.Full-day clinics for severe asthma patients are held weekly at VGH. Half-day clinics areheld every other week at SPH and 36 times per year at the SMH severe asthma clinic. Patientsseen at these clinics have generally failed current guideline recommended therapy with combinedlong-acting beta-agonists combined with inhaled corticosteroids and in many cases aredependent on oral corticosteroids. At these severe asthma clinics approximately 4-6 new patientsare seen per session. Assessment includes a thorough review of history and clinical examination,skin testing to common allergens, spirometry and sputum eosinophilia assessment may also bedone.In addition, patients receive an asthma education session with an educator including thedevelopment of a comprehensive asthma management strategy with a written action plan. Thesepatients have a high prevalence of vocal cord dysfunction and often require secondary referral toan ENT specialist and speech pathologist. Due to the severe and chronic nature of their illnessthere is a high prevalence of psychological dysfunction.Despite the high prevalence of asthma there are only a small number of physicians with aspecial interest in asthma. This is particularly true in terms of physician interest in managingpatients with severe asthma. Recognizing this gap the UBC Centre for Lung Health (a provincewide network dedicated to achieving optimal clinical care, education and research for lungdiseases has identified the need to recruit a physician with a specialinterest in severe asthma. It is anticipated that the recruitment of such a person would allow forthe development of a network of severe asthma clinics around the province providing thecomprehensive care outlined above. A recent recruitment attempt failed (Dr. Ian Pavord) andthis highlights the critical importance of having an adequate funding framework in place to fundpremium sessional payments for such a physician.Work recently completed in BC (1) has shown that, although severe asthmapatients represent only 5% of all asthma patients, they account for 60% of asthma-related directhealth care costs. In addition, we have systematically reviewed the literature documenting theeconomic burden of asthma showing that these results are true across many regions and countries(2). Also, there are Canadian and global evidence-based guidelines which have recently beenrevised and updated (3,4). These guidelines have documented the importance of a systematicapproach to confirming the diagnosis of asthma, including the exclusion of vocal corddysfunction. The latter is often seen in patients with presumed severe asthma and recognizingthis problem can quickly re-focus a more appropriate care approach. They also emphasize theneed for specialist centers to provide assessment of sputum eosinophilia as a guide to asthmatherapy. Such an approach has been shown to significantly reduce asthma exacerbations, whichare significant health care cost associated with the high health care costs in this group. There is alarge body of evidence that asthma education can have a significant impact on asthma outcomes

11in particular reducing emergency department visits and hospitalizations by 46 % and 56%respectively. Although access to asthma education has improved there still remains a significantcare gap across BC in terms of availability and access of this very important intervention.In other provinces, most notably Alberta, fee for service billing for the care of severe asthmahas largely been replaced by alternate payment plans. Alternate payment plans have made itmuch easier to recruit physicians and to maintain staff in clinics caring for patients with complexdiseases.In summary, severe asthma patients are complex with many co morbidities. They are patientswith high utilization rates of health care resources and, in particular, acute in-patient services.There is a robust body of evidence indicating that a multifaceted approach, includingRespirologist care, use of induced sputum and education, can combine to achieve much betterasthma control than standard care alone. Currently there are only three severe asthma clinics inBC and before a provincial network can be developed these clinics must retain their currentphysicians and recruit further Respirologists. Only then could more clinics be developed toallow for a more rational approach to the management of severe asthma in BC. This wouldprovide a distributed network of clinics to which primary care physicians, internists, allergistsand Respirologists could gain access for the care of their patients.References1. Sadatsafavi M, Lynd L, Marra C, Carleton B, Tan WC, Sullivan S, FitzGerald JM. Directhealth care costs associated with asthma in British Columbia Can Respir J 2010;17:74-80.2. Bahadori, K Doyle-Waters, M Marra,C Lynd, L Alasaly, K Swiston, J FitzGerald, JM.Economic burden of asthma: a systematic review. BMC Pulm Med. 2009; 9: 24.Published online 2009 May 19. doi: 10.1186/1471-466-9-242.3. Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M, Gibson P, OhtaK, O'Byrne P, Pedersen SE, Pizzichini E, Sullivan SD, Wenzel SE, Zar HJ. Globalstrategy for asthma management and prevention: GINA executive summary. Eur Respir J2008; 31:143-178.4. Lougheed D, Lemiere C, Dell SD, Ducharme FM, FitzGerald JM, Leigh R, Liksai C,Rowe B, Bowie D, Becker A, Boulet Louis-Philippe L-P.. Canadian Thoracic SocietyAsthma management Continuum-2010 Consensus Summary for children 6 years of ageand over, and adults. Can Respir J 2010;17 :15-24.

Appendix D12Pulmonary Hypertension ClinicPulmonary arterial hypertension (PAH) is a progressive disease characterized byincreased pressures in the blood vessels of the lungs. Without treatment this disease causesphysical disability, heart failure, and premature death. Untreated, the median survival ofIdiopathic PAH (IPAH), the prototypic form of PAH, is only 2.8 years, comparable to stage 1/2non-small cell lung cancer. IPAH typically affects young patients in the prime of their lives.Management of patients with PAH is complex, requiring specialized skills, multidisciplinarycare, and close monitoring during the initiation of therapy and ongoing adjustments of treatmentover time. The BC Pulmonary Hypertension Clinic at VGH is currently the primary referralcentre for pulmonary hypertension (PH) in British Columbia and the only site in the provincecapable of initiating intravenous (IV) or subcutaneous (SC) therapy. The number of patientsreferred to the PH clinic is growing, as is the total number of patients followed in the clinic. Webelieve that it is in the best interest of British Columbians and health care in BC to ensure theongoing success of this dedicated center for this rare and devastating disease. Patientassessments, especially from outside the Lower Mainland, are complex and involve labourintensive assimilation and review of information, co-ordination of investigations, transport,consultations, counseling and sometimes hospitalization. Physician care of PH patients is notappropriately compensated in BC at this time. To maintain the current status quo we requireremuneration reflective of the specialist service necessary for the care of these patients. Tocontinue to grow and accommodate the expanding needs of the PH clinic we require at least oneadditional PH physician within the next 2 years as well as an appropriate remuneration schemethat reflects the resource and manpower intensity needed to care for PH patients.Since the inception of the pulmonary hypertension program there has been a steadyincrease in the number of patients evaluated, treated, and followed in the PH clinic. This increasein clinical workload has placed an increasing strain on the clinic resources and the PH specialistworking in the clinic. There are a number of reasons why the resource needs of the PH clinic aregrowing:• Increasing numbers of patients seen and followed in the PH clinic• Growing therapeutic complexity• Increasing number of admissions to VGHIf the PH program is to be maintained we will need to hire another physician with a specialinterest in pulmonary hypertension to share the current workload as well as allowing for growthof the PH clinic. This fact is approaching a critical state with the recent departure of Dr. DavidOstrow. A major obstacle to the recruitment of PH physicians lies in remuneration. Because PHis a complex disease and the management of the patients is labour intensive, it is difficult to offerpotential colleagues an appropriate income base while working in this field. The currentremaining PH physicians support their work in the PH clinic by performing other clinic duties inthe hospital.Patients from throughout BC are currently referred to the PH clinic for evaluation andtreatment. The PH program runs outpatient clinics in the Lung Centre as well as caring forinpatients on the VGH respiratory ward. We also assist physicians throughout the province bytelephone to provide guidance on the management and diagnosis of PH patients. In 2008 the PHclinic evaluated 84 new referrals from across the province and followed a cohort of 444 patients(Table 1).VGH is the only hospital in the province where patients can be initiated on prostenoidtherapy. There are currently no other sites with physicians and allied health professionals thatmaintain expertise in prostenoid initiation. Starting this medication requires experience with themedication, appropriate supplies (such as cartridges, lines, teaching material, and pumps), patient

13counseling, access to a vascular surgeons for line placement, and access to inpatient beds withnursing staff accustomed to this form of therapy. Furthermore, once started on this medication,physicians in the community often find it difficult to provide care for these patients and thusdefer future care to the clinicThe paradigm of specialty clinics with a focus on the care of patients with a specific diseaseis common, particularly for rare diseases and those requiring specialized resources.Concentration of PH care within specialized centres is a common paradigm in Canada andaround the world. Referral of PH patients to expert centres for evaluation and management isstrongly recommended in the most recent treatment guidelines from the 4 th world symposium onpulmonary hypertension [6]. There are currently 14 recognized PH centers across CanadaAs outlined above the current schedule of private fee-for-service billing does notappropriately remunerate physicians in BC for care of PH patients. Many centres in Canada haveinstituted alternate funding plans for physicians providing car to these complex patients.However, these alternate funding systems are currently not available to PH physicians in BC.The current system in BC of physicians providing care to PH patients with very little financialreturn is not sustainable. Aside from professional dedication, there is no incentive for the currentPH physicians in BC to continue to provide care for these patients. There is even less incentivefor prospective specialists to consider practicing in this field in BC. Pulmonary hypertensionspecialists are rare and those with expertise in this field are actively recruited by centres acrossNorth America. Without financial incentives to offset the loss of income there is no professionalmotivation for PH specialist to consider practicing in BC.Recently concerns have been raised regarding the ability of the current PH Respirologists tocontinue to provide specialist PH services for the entire province. One possibility is a paringback of the mandate and only providing care to patients in the lower mainland. This reduction inservices would not be in the best interest of BC citizens. None of the current PH physicians areable to commit further time to the PH program without increased remuneration.An increase in the remuneration of PH specialists in BC would allow the current PH expertsto maintain and potentially increase their commitment to the program by permitting them toreduce their other clinical and academic activities without reducing their income below asustainable level. Furthermore appropriate remuneration of PH specialists would allow BC to bemore competitive in the recruitment and retention of other physicians to work in this areaTable 1a: Number of new patient referrals seen in the pulmonary hypertension clinic andfollow up PH clinic visits by year from 2004 to 2008.Year New referrals Follow-up clinic visits2004 33 1902005 36 2162006 54 2242007 70 3602008 84 444

14Table 1b: Actual and projected growth of new referrals to the PH clinic. 2006 to 2008 areactual clinic numbers. 2009 is estimated from the actual number of new referrals in thefirst quarter of 2009. 2010 to 2014 are projected numbers based on a growth of 10% peryear.1801601401201008060402002006 2008 2010 2012 2014NewReferralsAll results below were generated on 27 May 20101. Geographic location of patient in the Prostanoid therapy program:12 Flolan patients:Outside the lower mainland 7 patientsWithin the lower mainland 5 patients9 Remodulin patients:Outside the lower mainland 6 patientsWithin the lower mainland 3 PatientsTotal: 21Note: these patients are all seen and followed in the PH clinic at VGH on a regular basis.Furthermore, regardless of geographic location, these patients and their community health careproviders routinely contact the VGH PH clinic physicians and nurses by phone for advice whenany medical problems arise.2. Geographic residence of patients seen and followed in the VGH PH clinicVancouver Coastal 101 (28%)Fraser Health 129 (35%)Outside Vancouver Coastal and Fraser Health: 130 (36%)Vancouver Island 42 (12%)BC Interior 51 (14%)Northern BC 12 (3%)Fraser Valley (Chilliwack to Boston Bar) 10 (3%)BC Coast (North shore/Garibaldi) 13 (4%)Yukon Territory 2 (1%)Subtotal 130 (36%)

3. Number of PH clinic in 200915Swiston76 clinicsLevy16 clinicsOstrow17 clinicsRespiratory Ambulatory Clinics3 clinicsScleroderma Clinics6 clinicsPACH Clinics (congenital heart disease)6 clinicsTotal 124Note: the number of clinics needed to cope with the increase in referrals and follow-ups isestimated to rise by approximately 10% per year. Thus in 2011 the expected number of clinicswould be 1504.Number of new patient consultations and follow up appointments seen in the VGH PHclinic in 2009New patient consultations 125Follow up appointments 459Total 584Note: these numbers do not include those seen in the Scleroderma clinic or the PACH clinic.References1. Simonneau, G., et al., Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol, 2009.54(1 Suppl): p. S43-54.2. Tuder, R.M., et al., Development and pathology of pulmonary hypertension. J Am Coll Cardiol, 2009. 54(1Suppl): p. S3-9.3. Gaine, S.P. and L.J. Rubin, Primary pulmonary hypertension. Lancet, 1998. 352(9129): p. 719-25.4. Humbert, M., O. Sitbon, and G. Simonneau, Treatment of pulmonary arterial hypertension. N Engl J Med,2004. 351(14): p. 1425-36.5. D'Alonzo, G.E., et al., Survival in patients with primary pulmonary hypertension. Results from a nationalprospective registry. Ann Intern Med, 1991. 115(5): p. 343-9.6. Barst, R.J., et al., Updated evidence-based treatment algorithm in pulmonary arterial hypertension. J AmColl Cardiol, 2009. 54(1 Suppl): p. S78-84.7. Gomberg-Maitland, M. and H. Olschewski, Prostacyclin therapies for the treatment of pulmonary arterialhypertension. Eur Respir J, 2008. 31(4): p. 891-901.8. Keogh, A.M., et al., Interventional and surgical modalities of treatment in pulmonary hypertension. J AmColl Cardiol, 2009. 54(1 Suppl): p. S67-77.9. McLaughlin, V.V., A. Shillington, and S. Rich, Survival in Primary Pulmonary Hypertension: The Impactof Epoprostenol Therapy. Circulation, 2002. 106(12): p. 1477-1482.

Appendix E16Interstitial Lung Diseases ClinicInterstitial lung disease (ILD) is a heterogeneous group of disorders characterized byfibrosis and inflammation primarily located around the alveoli, the gas exchange unit of the lung.Most ILDs are fatal or are associated with substantial morbidity and loss of function (3-11).Based on information collected in other developed nations the prevalence of ILDs may be from30-80 cases/100,000 (10,11), meaning there may be between 1000 and 3000 affected individualsin BC.There are well over 200 causes or associated conditions that result in ILDs. Recognizingthe etiology requires a time consuming evaluation, investigations, and interactions with numberof physicians. After such an evaluation the most likely diagnosis and prognosis can be rendered.Many patients with ILD have involvement of other organ systems, such as the heart, kidneys,joints, skin, and muscles, which require concomitant care. Most therapeutic options for ILDsutilize immunosuppressive agents that result in substantial side effects and complications. Theprevention and meticulous care of complications is required and necessitates frequentassessment. In some instances the patient is assessed for suitability for lung transplantation.Lastly, the severe nature of these diseases takes an inordinate emotional toll on the patient andtheir families. The emotional burden requires substantial counseling and on-going adviceregarding nutrition, weight control, and fitness is also important.Currently, there is one ILD clinic at the VGH dealing with the full range of disorders anda second clinic at SPH. While each of these clinics functions with only one RespiratorySpecialist the clinic at SPH is unique in having a Respirologist (Dr. P Wilcox) work with aRheumatologist and as such is one of the first combined clinics in Canada.These clinics would see more than one hundred new patients each year along with manyfollow-up visits. As the two clinics are the only places in BC with access to many of the newerdrug routines for these disorders they receive referrals from throughout BC.The current physician remuneration for patients seen in these clinics is based on fee-forservicepayments. In view of the length of time involved in the assessment and management ofthese complex patients FFS payments are completely inadequate and put these physicians at asignificant disadvantage when compared to, for example, regular office-based RespiratoryMedicine practice.Another dedicated Respirologist, who has special interest and training in ILDs, isurgently needed. There is supportive evidence that patients with ILD who are followed by adedicated ILD physician and clinic have better outcomes in QOL, morbidity, and survival. Partof this benefit is from timelier referral for lung transplantation (1,2). This also represents apotential significant cost saving as comprehensive out-patient care can prevent and/or interruptworsening illness and thus prevent admission hospital or emergency department visits. Withmore appropriate and dedicated remuneration more Respirologists may be willing to accept thetime consuming responsibility of caring for patients with ILDs.References1. Snell GI, Walters EH, Kotsimbos TC, Williams TJ.Idiopathic pulmonary fibrosis: in need offocused and systematic management. Med J Aust. 2001 Feb 5;174(3):137-402. Lok SS Interstitial lung disease clinics for the management of idiopathic pulmonary fibrosis: apotential advantage to patients. Greater Manchester Lung Fibrosis Consortium. J Heart LungTransplant. 1999 Sept;18(9):884-903. Horowitz JC Thannickal VJ Treat Respir Med. 2006;5:325-342.4. Martinez FJ, Keane MP. 2005Am J Respir Crit Care Med. 2006 ;173:1066-71.5. Nathan SD. Clin Chest Med. 2006;27(1 Suppl 1):S27-35.

6. du Bois RM. Clin Chest Med. 2006 ; 27(1 Suppl 1):S17-25.7. Noble PW Clin Chest Med. 2006 ;27(1 Suppl 1):S11-6.8. Luppi F,et al Sarcoidosis Vasc Diffuse Lung Dis. 2005 ;22 Suppl 1:S74-84.9. Reed A. et. al. Intern Med J. 2006 ;36:423-430.10. Khalil, N. and O’Connor, R. Can Med Assoc J, 2004; 171:153-160.11. Lok SS, J Heart Lung Transplant. 1999 ;18:884-890.17

18Appendix FLung Transplant Referrals and RecipientsThis initiative is directed at development of a physician remuneration strategy that willhelp support the delivery of high quality lung transplant services for patients in British Columbiawith enhanced and more timely access and increased opportunity to provide improved quality ofcare for these extremely complex patients.The BC Transplant Lung Transplant Program is an academic program sited at VancouverHospital. This program is one of only five lung transplant programs in Canada and it is broadlyrecognized for its clinical and academic excellence. This program provides access to lungtransplant service and expertise for all British Columbians.Lung transplantation is a complex and labour intensive process, which requires specialexpertise and experience from a multidisciplinary team. The physicians working in the programare highly specialized Respirologists and thoracic surgeons, all on faculty at the University ofBritish Columbia.The Thoracic Surgery Lung Transplant team is led by its Director, Dr. John Yee who issupported by two other members of the Thoracic Surgery Division, Drs. Richard Finley and KenEvans. The Thoracic Surgery Division is currently in the process of recruiting a fourth surgeonwith expertise in lung transplantation. The financial reimbursement for the thoracic surgeons iscovered on a Clinical Academic Service Contract.The current Medical Director of the program (Dr. Robert Levy) was recruited toVancouver from McGill University in 1997 to lead the Vancouver Program initiated anddeveloped by Dr. David Ostrow, who subsequently stepped back to further his work in otherareas. Dr. Jennifer Wilson, a UBC clinical Respirologists, underwent specialized postgraduatetraining in at the University of Alberta and joined the Vancouver Lung Transplant Program asAssociate Director in 2003. Drs. Levy and Wilson currently provide all of the clinical service forthe evaluation of patients referred for lung transplantation from across the province, and lead andprovide clinical care for patients following the transplant. Dr. John Swiston, Medical Director ofthe VGH Pulmonary Hypertension Program, has recently undergone specialized lung transplanttraining in Melbourne, Australia and will be assisting in the lung transplant programcommencing summer 2010.Beyond direct clinical care, assessment and long term management necessitate a largenumber of hours related to assessment meetings with the multidisciplinary transplant team,quality assurance (complications reviews and morbidity/mortality reviews) and communicationwith referring specialists and primary care physicians both before and after transplant.Reimbursement for these activities is through the standard Medical Service Plan fee codes withthe exception of clinical care for the first six weeks post-transplant (reimbursed with a standardblock fee through BC Transplant/PHSA) and on-call service, which is covered by a dedicatedlevel 3 MOCAP.Patients are generally referred by Respirologists and Internists from across BC. Thepatients tend to be younger with severe end-stage disease and with anticipated survival less than2 years with conventional therapies. The majority have cystic fibrosis, obstructive lung disease,pulmonary fibrosis and pulmonary hypertension. These patients tend to be extremely sick and oncomplex medical regimens.Evaluation and care for lung transplant candidates/recipients is complex, specialized andtime-consuming. New patient evaluations generally take 60-75 minutes up front with thepatients, as well as often hours to assemble patient information, communicate with referring

19physicians, review evaluation investigations and meet for discussion with the multidisciplinaryteams. Post-transplant care is similarly complex and time-consuming. Routineweekly or monthly reviews often consume 30-45 minutes of specialist time. Hence the currentMSP fee structure is inadequate to compensate for the service provided. This is reflected in thepatient numbers we are able to see in lung transplant clinics:Lung transplant referrals seen at BC Transplant (pre-transplant):#48-50 clinics per year, 13:00-17:002007/2008: 40 new referrals, 118 re-evaluation2008/2009: 48 new referrals, 140 re-evaluations2009/2010: 68 new referrals, 161 re-evaluationsVancouver General Lung Transplant follow-up clinic (post-transplant):#96-100 clinics/year, 08:30-12:302005- 344 visits2006- 382 visits2007- 492 visits2008- 571 visits2009- 524 visitsConsequences of the current inadequate funding model for lung transplant evaluation and followup:- Inadequate reimbursement for pulmonary specialists in view of complexity of patientpopulation- Difficulty in recruiting Respirologists to participate in the assessment and care of lungtransplant patients- Lack of patient-focused care.- Many patients travel great distances from across BC for assessment and routine posttransplantcare in Vancouver. We would like to have the manpower to hold satellitemonthly clinics in Victoria and Kelowna to reduce travel, which is frequently arduous forsick patients. Telehealth is currently being explored to supplement this option wherefeasible but manpower restrictions limit the time available and the re-imbursement isinadequate for the complexity.

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