Implementing the Agreement

Year End Update

• Working with AHS to improve the relationship with physicians while leveraging AHS managed programs towards improving/stabilizing physician practice in AHS facilities.
  • Stipends - Through the joint working group, develop and implement a process to review the current stipends paid by AHS and make recommendations to the management committee on the disposition of each group, based on the principles outlined in the agreement. This work is likely to extend beyond the current year and must be completed no later than March 2025.
  • Overhead arrangements - Develop and conduct a review process to determine the amount of overhead fees in agreements between AHS and physicians. This work is likely to extend beyond the current year and must be completed no later than April 2024.

• 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. The AMA is working with AHS (with AH in an observing capacity) to develop the scope and process for decision-making with respect to AHS-paid Stipends. The AMA has provided a draft TOR for the Stipend Working Group as defined in Schedule 6. AMA, and AH will be discussing these changes at an upcoming Management Committee meeting. The AMA has provided the name of a co-chair to AH and AH is considering.
• AHS has asked the AMA to think about a side process, outside of Schedule 6, for some physician groups and the AMA has indicated its preference to retain all physician groups that are currently being paid a stipend within Schedule 6. AMA has a supportive legal opinion on this.
• 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 and AHS disagree over the interpretation of the scope of Schedule 6 and a letter has been written to MC accordingly for resolution. AMA’s view is that all physician groups receiving AHS payments are to be included in the process described in Schedule 6. This includes new AHS payments to physicians that were created after the Agreement was signed. Further, it is easier to deal with these under Schedule 6 for consistency and fairness.

• Complete the IEI measure - In preparation for the rate review beginning in 2024/25 we will complete the following this year:
  • Bring together information from all studies (Hours of Work, Overhead, Training, etc.) and calculate the complete IEI measure.
  • Complete the physician panel review & external technical review.
  • Prepare the dispute resolution process.
  • Deliver the complete measure to RF in September for preliminary endorsement.
  • The remaining steps to be completed before the end of 2024 are resolving any disputes and member ratification.

• AMA Compensation Committee (AMACC) is completing the development of the Full Income Equity Measure for presentation to the Fall 2023 RF. Work has included expanding the Interim Model to incorporate additional compensation elements and the Hours of Work study results as well as ensuring that the compensation, overhead, hours of work, and training and career length factors are aligned. AMACC has engaged with the Section Panel, individual sections (on request) and AMHSP Council as the proposed measure was being completed. Proposed timelines for dispute resolution and member ratification will be presented at Fall 2023 RF.

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• Market/rate review - Develop and move forward with a strategy to properly prepare for and undertake inter-provincial review of SOMB, ARP and AMHSP rates in preparation for the rate review beginning in 2024/25.

• Rates Committee discussions of the market rate review are expected to begin in Fall 2023.
• Senior AMA staff have initiated development of a framework to ensure there is alignment between the various aspects of the AMA Agreement: market/rate review, global reopener negotiation, Income Equity Initiative, ARP/AMHSP rate review/rate setting methodology, other system initiatives (recruitment and retention of physicians, primary care initiatives, ASI, etc.). This will include the following:
  • Development of a set of principles to guide the strategy (e.g., various components should work together to support system goals and not work against each other).
  • Description of the alignment between various components of the agreement and initiatives underway. As an example, how does the results of the fee review and Income Equity Initiative feed into allocation?
  • Determination of how the AMA will support sections in the market rate review (fee and ARP/AMHSP comparisons, overhead differences, differences in service delivery, etc.).
  • Development of a common information strategy with government. What sources of information will be used to inform the market rate review, reopener negotiation and allocation, where are the gaps and who will they be addressed?
  • Plan for advancing these concepts with Alberta Health at the Rates Committee and Management Committee.
  • Communication plan to socialize concepts among sections, RF, AMA membership.
• Immediate priorities are to implement the 2023-24 and 2024-25 allocations (currently underway), working with sections to implement their allocation priorities in advance of the market rate review.

• Other specified AMA Agreement deliverables include:
  • Daily visit caps
    • Temporary removal of caps.
    • Complete an evidence-based assessment of future rules for implementation April 1, 2023.
  • Business Cost Program - Implement rate increases November.
  • Rural Remote Northern Program review - Identify critical communities and recommend strategies for addressing supply issues by January 2023.
  • Secure access to benefits for Medical Examiners.
  • Virtual care codes
    • Mental Health implemented January 2023.
    • Review of remaining items by March 2023.
  • IMIT funding
    • Develop program parameters to support physicians with IMT-related change management by December 2022.
  • 1-time COVID payment
    • Issue the 1-time payment to physicians by December 2022.
  • Benefit programs
    • Launch the 22/23 Continuing Medical Education program.
    • Launch Medical Liability program.
    • Launch General Practitioner special skills locum program.

To date, the status of agreement deliverables is as follows:

• Daily visit caps: The parties agreed to lift the daily visit cap policy pending a review of the impact of the previous policy and its impact on patient access. A Ministerial Order was signed with change effective December 1, 2022.
  The results of the review, expected in late 2023-24 will inform any future policies beyond the current fiscal year.
• Business Cost Program: Rates were increased December 15, 2022, and retroactive payments for 2022/23 services prior to the rate increase on December 15 were deposited on April 28. This work has been completed.
• Recruitment and Retention Funding: The Agreement provides funding of $15M per year to support recruitment and retention of physicians who practice in underserviced areas. In consultation with AH, AMA will consider objectives, eligibility criteria and conditions for payment, information necessary for determining eligibility, budget, proposed targets, performance measures and timing estimates for Recruitment and Retention programs. AMA has formed a Recruitment and Retention working group to support the above-mentioned work. The group includes leaders from the Section of Family Medicine, Section of Rural Medicine, Specialist Care Alliance, and an AMA PRP Working Group representative.
• RRNP Funding: The agreement includes funding of $12M per year to support improvements to the RRNP program. A retroactive payment for the 2022-23 RRNP year is currently being discussed with Alberta Health. The RRNP review is expected to begin in Fall/Winter 2023. The Recruitment and Retention Working Group will help guide this work.
• Secure access to benefits for Medical Examiners: Both parties have reviewed this issue and provided input for consideration by Management Committee at its September meeting.
• Virtual Care: Under the terms of the new AMA Agreement, Alberta Health and AMA committed to a joint review of virtual care to be completed by March 31, 2023. As part of this, a review was to be undertaken of mental health virtual care codes by November 30, 2022, with a Ministerial decision by January 1, 2023. This work was delayed by the slower than anticipated formation of the Rates Committee. In early April, the Rates Committee and Management Committee recommended implementation of mental virtual care priorities put forward by the AMA during negotiations, i.e.: aligning time requirements for virtual 08.19CW with the in-person 08.19G, virtual group and family psychotherapy, complex virtual therapy, prolonged pediatric visits, and consultations to support mental health services. While the changes were approved at the joint AMA/AH Rates Committee and Management Committee, Minister Copping did not have an opportunity to sign off on the changes before the election was called. As of August, the request was being considered by government. The wider, virtual care review is still outstanding, including implementation of some other virtual care improvements previously identified by the AMA and Virtual Care Working Group.
• IM/IT Funding: IM/IT Working Group achieved consensus on recommended parameters on January 31. The parameters were approved by Management Committee on March 3 and the grant was executed on March 31, 2023.
• One-Time Payment (COVID): Grant executed December 15, 2022, funding provided December 20, payments issued to physicians December 23. The top-up payment will be issued in September 2023.
• Physician Support Program Grant Agreements: The 2022/23 PSP grants have been executed (PFSP-CAP, PLP, CME, Locum) and first payments were provided. AH initiating process for 23/24 to 25/26 combined PSP grant, including PFSP-CAP, Parental Leave, CME and one-time computer system development grant (locum and ACTT to remain separate grants).
• MLR Program: Alberta Health expects to make top up payments for the 2022 Canadian Medical Protective Association year in March, for those that were paid based on a higher deductible (the deductible was reduced to $1,000 for all physicians under the AMA Agreement). The 2023/24 MLR grant executed on April 28 and the first payment was released the following week.
• GP Special Skills Locum Program: The program is active and is gaining momentum as more physicians join the program.

Policy Initiatives and Opportunities

Year-end Update

• Modernizing Alberta’s Primary Health Care System - We will provide coordination and support to physician leaders advancing short and long-term proposals under government's MAPS initiative, encouraging alignment across stakeholder groups and with the AMA Agreement (e.g., use of targeted funding).

• Since September 2022, the AMA has participated with others in Modernizing (M) Alberta’s (A) Primary Care (P) System(S), initiated by the Minister with core support from Alberta Health
• AMA participation has largely been through:
  • The Board approved budget and staff (ACTT plus others) resources to support physician leader participation, including support for research and a coordinating group chaired by Dr. Brad Bahler and the AED, ACTT.
  • AMA sections have provided input: Primary Care: SFM and SRM Other sections: SCA.
  • Other groups that have strong AMA connections and which have provided input to MAPS include: PCN Physician leads executive; Provincial PCN Committee (PPCNC); medical student representatives.
  • At this stage (February 2023) AMA input and collaboration is largely reflected in four MAPS proposals:
    • Seven short-term proposals submitted by various members of the coordination group set up within AMA.
    • An SFM, SRM, PCNLE proposal, “Team-Based Funding.”
    • An SCA proposal, “Linkages Between Primary Care and Specialty Care in the Health Neighbourhood.”
    • Provincial PCN Committee Proposal
• Physicians have been well-served by the physician leaders involved. The review process that was conducted included significant physician leader input.
• Short term recommendations were announced on Tuesday, February 21 from both the Strategic Advisory Panel and the Indigenous Panel: Modernizing Alberta's Primary Health Care System (MAPS) | Alberta.ca
• The final report with the long-term recommendations was submitted on March 31, 2023.
• There is much in common between the AMA led proposals in assessing challenges and recommending improvements to the primary health care system. Differences relate mostly to the priority and timing of some of the steps or the degree to which they should implemented.
• We believe that there is more than enough of a consensus to begin acting. Significant steps should be taken now with the intent to monitor and adjust as needed. MAPS needs to become about strategic action and not just strategic planning.
• The alliance between primary medical practices and PCNs needs to be strengthened, by enhancing the support to each and improving the relationship between them:
  • There is an urgent need to provide additional support to physician practices given the financial and service delivery challenges they are facing and the increased national competition for primary care physicians. Ensuring Albertans have access to the primary care physician resources within viable and sustainable practices should be a principal focus for MAPS: all other aspects are dependent on this for their success.
  • PCN one-time funding and the funding review should be priority in ensuring they have the resources to meet demands, explore new opportunities, and initiate approaches to expanding the medical home.
  • Means to strengthen the relationship between the primary medical home and PCNs should be explored.
• New investments and relationships within primary care will impact on the roles, responsibilities, and accountabilities of physicians. Support for these changes will be essential.
  • Performance measurement and management.
  • Accountability of PCNs to physicians and vice versa.
  • Physician roles & responsibilities within team settings.
• Primary governance will need to evolve and mature. Initial steps should be taken now to strengthen individual players and partnerships with an eye to developing a new model of overall governance.

• Primary Care Network Funding Review – We will provide coordination and support to physician leaders participating in the Ministers PCN review working group, encouraging alignment with proposals developed as part of the MAPS project, and mechanisms available under the AMA Agreement (e.g., targeted funding, allocation, etc.).

• There are two groups active on PCN funding, as per the agreement commitment letters.
• Short term group to review and recommend on the $40 million for PCN in the next 2 years.
  • The group is recommending the first $20 million be allocated for the April 1, 2023-March 31, 2024 fiscal year for PCN grants. This will allow the PCNs to plan now and to use the money in the coming fiscal. This group is reporting to the Provincial primary care network committee (PPCNC).
  • An extension for the additional $20 million in year two is being requested so that it can be allocated in the fiscal year April 1, 2024- March 31, 2025.
• The long-term working group submitted recommendations to the minister on March 31, 2023. PCN physician lead executive and Section of Family Medicine physician (AMA) representatives are members of this group.

• Alberta Surgical Initiative – We will provide coordination and support to AMA physician leaders involved in the governance structures of the Alberta Surgical Initiative, encouraging alignment with activities advanced through other initiatives (e.g., MAPS project).

ASI Governance:

• ASI governance 3.0 has been proposed and the AMA has been asked to review the TOR and recommend names to populate the proposed committees. AMA membership has been requested on 4 committees, three of which are new (*): a Provincial Surgery Steering Committee (PSSC), an Alberta Surgical Initiative Stakeholder Advisory Committee* (ASI-SAC), an Alberta Surgical Initiative Physician Expert Advisory Committee* (ASI-PEAC) and a Provincial Specialty Access Steering Committee* (PSASC).
  • ASI-SAC includes members of the public and external stakeholders representing the public, academic institutions, and health care professional regulatory colleges. The committee is responsible for advising on surgical services as it relates to the experiences of patients, families, communities, and health care students and professionals.
  • ASI-PEAC includes members from AMA and surgeons external to AHS leadership roles. The committee is responsible for advising on physician matters and operative/peri-operative expertise.
  • PSASC is a joint committee between AHS and primary care to facilitate shared decision making and accountability for provincial specialty access programs, including specialty advice, clinical pathways, central access and intake.

The other new addition to the ASI 3.0 Governance Structure is a Specialty Access Shared Services Executive Oversight Committee (PCSS_EOC) which will be a joint committee with AH, AHS and AMA.

Specialty Access Physician Leads:

• AH supported the use of AMA ACTT grant funds to hire Specialty Access Physician Leads for each zone and are supporting them in their work on the ASI bundle projects (Electronic Referral Solution, FAST, Pathways, Advice, Pre/Post Care). Each lead is developing subject matter expertise on a project and will be representing Primary Care at respective Coordinating Committees.
• The leads are building relationships in the Zones (PPACs, PLE, PCNs) and with PMH Physician Champions to coordinate change management activities.
• The funding for these positions ended on March 31, 2023.
• In July 2023, ACTT submitted a request to AH to use surplus funds to extend the positions to continue their support of the specialty access work until March 30, 2024; temporary funding was procured to extend the positions until August 31, 2023.

Discussions are ongoing for determining both short and long-term funding for these positions.

Specialty Access Bundle Work:

• AHS is looking to launch the next round of working groups in March which includes General Surgery, Gynecology, Thoracic Surgery, and Vascular Surgery; Specialty Access Physician Leads are taking on recruitment efforts on behalf of Zones.
• Co-Design Sessions are being held March 22-23 to support the ASI Specialty Access Bundle work (specifically around advice, clinical pathways, and referral pathways).

ACTT team is developing supports for clinic-level change management.

Government Relations and Advocacy

Year-end Update

• With an Agreement in place, we have an opportunity to work collaboratively with government to improve the system, while continuing to hold them accountable. We will create opportunities for members to engage in government relations and advocacy in several areas including:
  • Agreement and Implementation: Members who engage to advance physician financial viability (their own and that of their colleagues) and support patient care.
  • Governance and Leadership: Members who engage to be part of building up the profession and their roles in society.
  • Advocacy: Members who engage and are motivate by active advocacy for patient care.
  • Government Relations: Members who engage because they want to affect their local environments and communities.

• Since the May election, government relations activity has focused on building and rebuilding relationships. The President and Board have had multiple meetings with the Minister of Health. Senior staff actively engage with the senior civils service. So far response has been cordial and collaborative. Efforts have continued to stress the need: for immediate and long-term action in plans for stabilizing primary care and family medicine; for engaging with the AMA on primary care reform; AHS payment issues; governance changes at Alberta Health Services, etc.
• The AMA President, Section of Psychiatry and Section of Addiction Medicine are seeking meetings with the Minister of Mental Health and Addiction, both to understand the roles of that ministry vs. Alberta Health and to offer to provide support for go-forward planning to address the opioid and drug poisoning crisis. Other sections involved will be engaged also.
• The AMA’s pre-election public information program Handle with Care, surfaced seven-week, seven-issue profiles on questions about which all candidates and parties should be able to comment was promoted over social media and through AMA publications and media coverage. There were over 750,000 views. The series culminated in a virtual town hall to which the members of our PatientsFirst.ca online community were invited. Other than the two official debates, this was the only additional event during the election window at which Danielle Smith and Rachel Notley appeared together. Over 2,000 Albertans showed up on a holiday Monday evening to engage with the candidates.
• We have continued to engage in social media advocacy on topics relating to the agreement and health care, building on existing momentum. Outside of the election program issues that we continued to leverage after the vote, we have focused heavily on health human resources and the value of family medicine and the crisis.
• The Joint Physician Advocacy Committee continued to provide guidance for our public education and public/government relations activities.

Rebuild and Reconnect

Year End Update

• In addition to the activities already listed in the healthy AMA portion of the business plan, we will be looking at opportunities to strengthen section governance, improve the diversity of our physician leadership and enhance transparency across all levels of the organization.
• We will also be strengthening our connection with members by enhancing some of our existing touchpoints and creating new opportunities for members. Some examples include:
  • Reviewing how we use social media to keep members and the public informed and advocate for physicians and patients.
  • Reviewing the content and format for the Annual General Meeting and other events throughout the year, to provide opportunities for members to ask questions of leadership and celebrate milestones.
  • Investigating mechanisms for improving transparency with members from all levels of leadership.
  • Reinvesting in our member tracker surveys to monitor member sentiment and connection to the AMA.
  • Being timelier with information disseminated to members through President’s Letters and direct email.
  • Supporting members directly on the broad range of activities outlined above.

• The Governance Oversight Group undertook a survey of section executive members to establish a baseline for section governance practices and better understand the needs of sections. Based on the results, the GOG is now developing a set of recommendations that will improve governance practices (e.g., templates for code of conduct, conflict of interest, equity/diversity training, etc.), and making improvements to the welcome and orientation material for incoming section executives.
• The Transparency Working Group completed a review of the level of transparency with members from all levels of governance. This included a review of current practices, policies and accountability mechanisms, practices in other jurisdictions as well as any limits that may exist and will be providing a gap assessment and preliminary set of recommendations to the fall RF.
• The Annual General Meeting working group undertook a review of the format and agenda for the Annual General meeting and put forward several recommendations that were accepted by the Board. The bylaw amendments needed to action the recommendations are being put forward at the 2024 AGM for consideration by the Membership.
• The member tracker survey was relaunched in January 2023, which will provide important insight into the interests, concerns, and sentiment of members.
• Equity, diversity, and inclusiveness training is now mandatory for all AMA hiring committees.