2022-23 Mid-Year Update on KRA 1, Financial Health

Priority activity

Update

1. Negotiate an agreement for the provision of insured services with government that is fair to physicians and provides value for patients; and restores physicians, through the AMA as an active partner in the health system. 

• The parties reached a tentative agreement in late-August after many months of discussions. Following board discussions and a special RF the tentative agreement was sent out for ratification on September 13. On September 28, the AMA membership ratified the AMA agreement with just over 70% of responding physicians voting “Yes” (voter turnout was 45.8%).
• Implementation activities have continued over the last few months. At a staff level, the Joint AH/AMA Agreement Implementation Working Group have been meeting once a week to discuss the status of the implementation activities underway related to the AMA Agreement. The AMA Board receives an update on the activities as an agenda item at each of their meetings. As well as updates on the agreement activities in the President’s Letters, the parties have agreed to joint communications as appropriate to keep either party’s stakeholders informed. 
• Representatives to the Management Committee and Rates Committee under the agreement have been finalized. After a membership-wide callout process, the board selected its representatives for both committees. Dr. Paul Boucher, Dr. Alison Clarke were chosen as the AMA physician representatives for Management Committee. As well, as virtue of position, Mr. Michael Gormley, AMA Executive Director will sit on the Management Committee. Dr. Heidi Fell, Dr. Jeff Way and Dr. Brian Wirzba were selected as the three physician representatives for the Rates Committee.
• Government tabled legislation on December 5 to repeal Section 40.2 of the Alberta Health Care Insurance Act. This regulation enabled termination of the AMA agreement. Government committed to eliminating that provision as part of its commitments under the AMA agreement. AMA legal counsel has advised us that Bill 4 received Royal Assent meaning it is now a law in full effect. As Section 40.2 was released, the AMA filed its discontinuance of claim through the courts on January 9, 2023. This matter is now officially concluded.

2. Support members in local and provincial compensation discussions on rates, viability of practice, due process and working conditions, including:

• Laboratory grid agreement
• Cancer care agreement implementation
• Stipends, on-call, z-codes
• ARPs

• Lab Grid Agreement - The next negotiations continue between AMA-ASLP and AHS-APL. 
• Cancer Care - Collaborative Advisory Committee (CAC) meetings between AMA-CCA physicians and AHS have commenced. Discussion included a high-level summary of activities undertaken by the previous Joint Workforce Planning Committee, present challenges in workforce planning and workload management and next steps. The goal is to address retention and recruitment issues for CCA physicians and AHS.
• Stipends - The newly ratified AMA Agreement extends stipends to March 31, 2025. Schedule 6 provides for a Stipend Working Group to develop a process to review current stipends paid by AHS to physicians and allows for an independent chair to make a decision should the parties fail to reach consensus. A recommendation is made by the working group to the Management Committee and subsequently to the Minister. AMA is of the firm belief that:
  • The due process afforded to stipend-paid physicians must also apply to any consideration of physician stipends going forward (e.g., non-stipend groups experiencing difficulties with physician retention and recruitment).
  • There must be alignment of all AHS payments (stipends, overhead, on-call).
  • Transparent processes must be developed; AMA has created a draft and Terms of Reference to include objectives, principles, terms and conditions, roles and responsibilities for AHS, impacted physicians and AMA for presentation to Management Committee for use by the Stipend Working Group.
• AHS has asked the AMA to think about a side process, outside of Schedule 6, for physician groups already in the process of exploring a clinical ARP. The stated intent of the side process is to allow for willing physicians to transition toward new arrangements without having to wait six to twelve months for the working group to come together. AMA has sought a legal opinion on this. The established process involves first determining which stipends provide payment for non-insured services and which are a double payment (i.e., covered by the SOMB). The legitimate stipends will continue until replaced by another payment arrangement. Those physicians who wish to move to an ARP can do so and their stipends will end. Those who do not, or who are not happy with the ARP being offered, will continue on stipends until replaced or the deadline of March 31, 2025, is met or another arrangement is arrived at. It is unclear if AHS or AH share this view.
• An MOU between AMA and AHS outlines an AHS-AMA Engagement Framework on Physician Compensation Related Matters within AHS Facilities to address issues through a process of engagement (negotiating, renewing, extending) within the best interests of patients and the health system. The parties may, through mutual agreement, appoint mediation and/or arbitration to help resolve the issue.
• AMA staff and the Stipend Action Committee continue to exchange information with physicians that are receiving stipends, often regarding the AMA Agreement, the Engagement Framework and the due process that is available to them.
• ARPs - Clinical ARP rates and associated FTE definitions will be reviewed by the Rates Committee as per the new AMA Agreement. AMA staff and the Clinical ARP Working Group continue to review, identify and prioritize key ARP issues to raise with Alberta Health.

3. Support academic physicians in the negotiation of the Academic Medicine Health Services Program and the supporting Individual Services Agreement.

• Comparison between FFS, cARP and AMHSP rates

• In late fall, following an election process, the AMHSP Council elected its North and South co-chairs. Dr. Walter Hader as the South co-chair and Dr. Steven Katz as the North co-chair were elected.
• The release of the draft AMHSP Master Agreement by Alberta Health has been delayed and the current Master Agreement will be extended for up to one year to allow for further review and consultation. We are hopeful that this will allow time for successful discussions with Alberta Health regarding AMA representation and recognition as a signatory to the Agreement, AH and AHS recognition of the 2019 AMHSP physician representation opt-in process undertaken by AMA, as well as further negotiation related to the interests important to AMHSP physicians.
• In December, communication was shared with the AMHSP participating physicians on the recent initiatives and activities Council has been focusing on over the past year and the status of that work.
• The AMHSP Council last met on January 26. Consideration at that meeting included expected changes and impact to AMHSP physicians related to the clinical rates funded through the Physician Services Budget, ongoing communications with participating physicians, engagement with AMHSP Participating Physicians, and a discussion for Council direction to the AMHSP Negotiating Committee as it prepares for further engagement with AH once the AMHSP Master Agreement is released.

4. Advance AMA third party contracting principles and support physicians involved in these new models.

• While supportive of physicians who wish to be involved in alternate compensation models. The AMA must consider and evaluate how the physician portion of the Physician Services Budget would be managed as well as the effect of giving third parties’ control over the physicians. AMA’s role is two-fold: ensure there is clarity on the impact to the PSB, as well as support physicians through representation and provide guidance as requested by physicians considering alternate compensation models.

Priority activities

Update

1. Support activities that promote the effective management of practices, including:

• Expand peer review activities including education and schedule modernization.
• Support sections in schedule modernization/improvement efforts.
• Support improvements to virtual care that promote quality and comprehensiveness including participation in the Alberta Virtual Care Coordinating Body.
• Promote professionalism and best practice in billing and referral practices.
• Continue to develop tools like the fee navigator and billing training tools.

• Schedule Modernization: Allocation provisions under the new AMA Agreement allow for some section and AMA-driven fee modernization:
  • Allocation year 1 – fee-only adjustments. Activities underway with Rates Committee and Management Committee to approve section-submitted changes by March 3, for April 1 implementation.
  • Allocation year 2 – fee adjustments and some limited SOMB amendments (new and amended codes, wording and rule changes). Activities are currently underway, with sections submitting priorities by November 30, and the AMA Fees Advisory Committee assessing requests by the end of February. Potential changes will then be discussed at Rates Committee.
  • Allocation year 3 – fee adjustments and more significant structural changes. Planning currently underway.
• Virtual Care: Under the terms of the new AMA Agreement, Alberta Health and AMA have committed to a joint review of virtual care to be completed by March 31, 2023. As part of this, a review will be undertaken of mental health virtual care codes. This portion was to be completed by November 30, 2022, with a Ministerial decision by January 1, 2023. During negotiations, the AMA laid out its virtual care priorities as follows:
  • To pay virtual group and family therapy at same rates as for in-person services.
  • To allow complex mental health services (e.g., complex psychotherapy, complex group therapy, complex family therapy) to be billed virtually at rates equivalent to in-person services.
  • To allow prolonged visits and consultations to be billed virtually.
  • To pay virtual psychotherapy code 08.19CW using the same timeframe (15 mins or major portion) as the in-person 08.19G health service code.
  • To undertake a joint virtual care evaluation, including utilization of virtual care services to date, experiences and practices from other jurisdictions, patient perspective on their experience with virtual care services, and adjustments in physician practices to inform delivery of virtual care services in the future. Results of the evaluation could lead to recommendations for further changes to the virtual care schedule. 
• Alberta Health is currently analyzing the costs and implications of implementing the various priorities and will be preparing a Rates Committee proposal for consideration in late February.
• Informal peer review/billing appropriateness efforts have occurred within various sections of the AMA and within the AMA’s billing education services. Re-establishment of a formal AMA Peer Review Committee is dependent on future government support to establish a trusted third party to distribute confidential peer review information to physicians.

2. Support members participating in or considering alternate compensation models including:

• Clinical alternate relationship plans
• AMHSP arrangements
• Third-party contracting models

• ARPs: The AMA continues to support and represent the interests of physicians - those considering a clinical ARP and those already participating in clinical ARPs - in their discussions with Alberta Health and AHS. Management Committee is tasked with reviewing the application and approval process for alternative-to-FFS bases of payment of benefits for insured services, including ARPs, for opportunities to increase transparency and efficiency and reduce red tape. AMA staff and the Clinical ARP Working Group continue to exchange information with physicians participating in clinical ARPs, regarding the identification of key issues and priorities, to advocate on behalf of physicians to Alberta Health.
• Clinical ARP rates and associated FTE definitions will be reviewed by the Rates Committee as per the new AMA Agreement.
• AMACC reviewed a methodology to include ARP and AMHSP physicians in the income equity model at its January 2023 meeting. Physicians paid through alternate compensation methods will be included in the final income equity model that will be presented at the fall 2023 RF.
• Given the new Physician Agreement with Alberta Health, in spring 2023 the AMA will request Management Committee to consider a full review of ARP and AMHSP rates. 
• AMHSPs: The AMA continues to support and represent AMHSP physicians’ interests in discussions with Alberta at various provincial tables and in discussions with Alberta Health, AHS and the Faculties of Medicine. Council Co-Chairs have had a number of meetings with senior leaders in Alberta Health to emphasize the need for AMA representation of AMHSP Participating Physicians relating to their clinical work (e.g., environment, discipline, working conditions) and clinical compensation. 
• Clinical compensation rate increases for 2022-23 and 2023-24 are in process although the retroactive payment timing for 2022-23 may be somewhat different than for fee-for-service physicians. AMA has raised concern that there will not be commensurate increases in funding and payment for the other AMHSP CARE pillars, and we continue to raise this at provincial tables.
• Preparations are underway to confirm the AMHSP participating physicians currently working in the province and their preferred contact email. This will assist in building both the current participation list and lay the foundation for regular updates as the participating physician group changes.
• Alberta Health has been working on an updated AMHSP Master Agreement; however, it is not ready to be shared as part of the consultation process. The current AMHSP Master Agreement and individual physician services agreements will be extended for one year to allow time to complete the draft and the consultation process.

3. Launch a collaborative learning opportunity focused on community clinic viability, leveraging the Patient Medical Home, including:

• Business foundations (practice agreements, improvement team)
• IM/IT (EMR tips, privacy) 
• Using your team (change support, QI and clinic efficiency) 
• Efficiency through Panel (screening, panel management) 
• Efficiency through Access
• Assessing your practice (HQCA panel reports, ASaP, Schedule B, Patient experience, EMR reports)

• The launch is planned for May 2023, content and planning are underway.

Priority activities

Update

1. Operationalize the new MD Financial-Bank of Nova Scotia alliance with the Alberta-based MD Financial teams, to ensure members benefit from our respective offerings.

• We are working with MD Management’s regional management team to develop our own province-specific plan to generate cross-referrals to maximize the value to members. Two meetings have been held so far to identify ways to engage with MD’s financial and insurance consultants and to meet and train new consultants on our products.
• The alliance Management Committee, which includes representatives from BC, AB, SK, MB and Yukon medical associations, along with MD Management and Scotiabank representatives, will meet twice in 2023. The Management Committee reviews the progress of each regional plan over time and to share and discuss marketing initiatives, insights, trends, best practices and developing industry matters, to improve offerings to members.

2. Complete an analysis and market study for the AMA Disability Insurance plan to ensure coverage and premiums are competitive and the plan remains viable over the long-term.

• After completing a market study and analysis of the plan with Manulife, we have implemented a 9% rate increase (the first in many years) on our Disability and Professional Overhead Expense plans effective January 1, 2023. These changes will stabilize the plan, while continuing to offer competitive products to members.
• We are also making changes to our medical underwriting processes and will communicate these changes to members this spring.