Alberta Health Services Review: Concern for health care in Alberta

February 5, 2020

Dr. Christine Molnar, AMA President

Dear Members:

The 57 recommendations in the Alberta Health Services Performance Review are a compendium of cost-cutting opportunities that purport to improve value in health care by either reducing cost with no impact on quality of care, or by reducing cost and improving quality. It’s an interesting concept. We can understand the exercise of looking at the current state and seeking efficiencies; the report provides many ideas to consider. The picture is still incomplete, though, if we don’t also look at what the health care system needs to deliver for patients today and in the future.

Change is inevitable but it can be good, as in improved patient care for complex chronic disease through the Medical Home. Change can be great, as in health care transformation for social determinants of health. We embrace change and enable it when it truly adds value for patients. 

A broader discussion is needed regarding goals for the system and the incentives to achieve them. We need accountable, transparent and empowering change to create the best health care system for our province and to support Albertans in achieving maximum health. 

Albertans know that in its very essence, health and health care is about choice. It matters who gets to decide what happens and on whose behalf. In considering the AHS report and the myriad “costless” changes and redirections, it’s important to ask:

  • How will the impact of the changes be measured? 
  • What voice will patients have in the process? 
  • How will results be reported back to the public and who will determine the acceptability of consequences?
  • Will implementation allow for necessary course corrections?

The concept of flattening current health care expenditures (covering today’s utilization, the future pressures of population growth, aging, inflation and new technology), with no discernable impact on care or quality is idealistic. But, is it realistic? If it is, then why hasn’t it been done before now? 

The focus on micro-decisions runs through the report without laying out the macro-implications and downstream effects.

For example, the report targets physician stipends in certain AHS programs, noting that low-service-volume programs do not generate adequate fees to ensure on-going physician availability. This is correct, but the report then proposes to end payment of the stipends. Clinical alternative relationship plans are proposed as a solution. While they may help in some situations, at current rates ARPs will actually cost more. Additionally, physicians know that ARPs currently take two to three years or longer to be approved and implemented by Alberta Health. What happens to fill the gap for physicians and patients during that time?

This situation is not dissimilar to one involving government’s consultation proposals. The health policy literature supports the building of the Medical Home within an integrated health care system as key to developing a sustainable, high-value health care system. Meanwhile, the consultation proposals would, in fact, erode comprehensive primary care and compromise progress enabling the Medical Home. The Medical Home can be implemented through various payment models including fee-for-service. It is the associated vision and accountability framework that is most important. Alberta currently enjoys the most advanced development of the Medical Home in Canada. Congratulations to our urban and rural family practice colleagues for their commitment and success!

I wish to make clear that we need to support innovation and be open to change. There are many aspects of the government’s health care platform we can and will support, but it is our responsibility to speak up when we see changes that are not aligned with a proven successful approach to health care improvement as exemplified in the Quadruple Aim health care movement. Not to do so would jeopardize patient care.

Over the next period, we will be seeking input from you. Your knowledge and advocacy for patients is critical at this juncture.

We will also seek input from patients through our online patient group (albertapatients.ca). High-value health care systems view patients as partners in care, not just customers. How do we better support Alberta families to take on this increased role?

Please let me know what you think in the following ways:

  • Communicate with me privately and directly by email if you would like a reply: president@albertadoctors.org
  • Comment publicly below on this President’s Letter (please be aware that comments are public, i.e., not members-only, even if you are logged in as a member).

“Difficulties mastered are opportunities won.” – Winston Churchill

In your service, 

Christine P. Molnar, MD, FRCPC 
President, Alberta Medical Association

1 comment

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  • #1

    Noel Corser

    Physician

    4:06 PM on February 06, 2020

    After reading through the EY report, it struck me how the potential savings identified are largely by comparison to other provinces (if their costs are lower) or to privately-provided services (where examples exist). Certainly there are also instances in AHS of duplication, inefficiency, and areas where common sense would dictate improvements - and there are many areas where AHS appears to be doing an awesome job. What's missing, however, is an attempt at rationalizing AHS costs in some way.

    In the context of great upward pressure on costs (from new drugs and technologies, aging population, health inequalities, etc.), surely we need to start asking WHY we pay $X million dollars for new biologics for palliative cancer patients in their final 6 months of life? Conversely, WHY do we pay $X thousand dollars for suicide prevention programs in youth? Any why does no one talk about shifting resources from some budgets to others?

    A review of healthcare spending that compares dollars "in" to quality-adjusted life-years "out" would be much more enlightening, and more useful to AHS in guiding how it can best provide quality healthcare to Albertans. Most importantly, it could provide an actual answer to "how much money should we be spending on this, out of our total budget?", rather than simply trying to approximate other jurisdictions equally unable to justify where they spend taxpayer dollars.

    And if budgets were adjusted based on **improvements** in QALYs, for given dollars "in", then we'd really be getting somewhere! :)

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