Respiratory Medicine - British Columbia Medical Association

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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
Page 5 and 6: iii)iv)5No FFS billing or other ses
Page 7 and 8: Appendix A7Description of Internal
Page 9 and 10: 9mucus; excessive appetite combined
Page 11: 11in particular reducing emergency
Page 15 and 16: 3. Number of PH clinic in 200915Swi
Page 17 and 18: 6. du Bois RM. Clin Chest Med. 2006
Page 19: 19physicians, review evaluation inv

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