AMA priorities and themes for negotiations

January 17, 2018

Hello Members:

As you learned from my December 28 Negotiations Update, in spite of significant early challenges, the AMA and Alberta Health continue to negotiate a new master agreement. As always, we will respect the confidentiality of what happens at the table, but I would like to give you a flavor of what the AMA is bringing forward on your behalf.

The AMA’s priority is to ensure that physician practices remain viable. They are an essential part of the system’s infrastructure. Continued viability means both financial health and stability. This includes safeguarding critically important programs that have supported physicians to maintain our practices and lead innovation.

The AMA is demonstrating how physicians contributed (early and significantly) to the economic recovery of the province. We are willing to do our part, but the burden has to be shared fairly among all parts of the health care system.

Master agreements are complex things and there are many questions tied up in these negotiations. In fact, there are 10 important themes, financial and non-financial. A list appears below.

I hope this will give you some sense of the breadth and depth of these negotiations. I will provide more information on these topics in the weeks ahead. Please tell me what you think about the themes (or anything else that’s on your mind). As always, I like to know who you are, where you practice and in what specialty. You can give feedback in three different ways:

• Communicate with me privately and directly by email if you would like a reply: president@albertadoctors.org
• By commenting publicly, below on this President’s Letter
• Share your perspectives with colleagues in our new Discussion Board for members only (member log in required).

At your service,

Neil D.J. Cooper, MD, FRCPC, Dip. Sport Med.
President

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THEMES FOR NEGOTIATIONS

Here is the list of the big themes within these negotiations, with each one addressed below.

Non-financial

• Physician supply
• System improvements
• Formalized relationship - recognition
• Legislated representation for all physicians in Alberta
• Change management – AMA programs
• Dispute resolution mechanisms

Financial

• Budget stabilization
• Fair and equitable compensation
• Risk sharing
• Long-term agreement

Physician supply

As members know, there is work underway to develop a needs-based physician resource plan. Determining the supply, mix and distribution of physicians that Albertans need is the first goal. Alberta Health Services has already done much of the work for its areas of influence, but there has been little work done on the needs for physicians (general practitioners and specialists) in the community. Once we have defined the needs, we need to discuss how we manage implementation. It is possible to fill the needs using levers such as programs, compensation and the existing mechanisms that the parties already have. While it will not be the job of the negotiating teams to discuss how the physician resource plan may be implemented, what comes from the negotiating table will need to align with and/or support that implementation. This is another area where government must have physician input in order to be successful.

System improvements

These include many of the initiatives we started working on in the Amending Agreement such as:

• Access to billing data
• Informatics initiatives
• Choosing Wisely and other appropriateness and evidence-based initiatives
• Primary care network governance
• Building the Medical Home (including Central Patient Attachment Registry, Provider Registry)
• Alternative payment models (Blended Capitation Model and expanding Academic Alternative Relationship Plans)
• Integration of care initiatives

Succeeding in system improvements requires cooperation from Alberta Health in things like updating the capabilities of its billing/claims system to reflect new ways of delivering care. These computer system changes will also support fee schedule modernization and physician leadership in peer review of appropriate billing. In a very small minority of cases of inappropriate billing, government has a role identifying and dealing with individual outliers.

Formalized relationship – recognition

With the Amending Agreement, we developed a relationship that recognized the importance of physicians in building a high-performing health care system (which the Board defined in our new vision statement). We want to build on that relationship between government and the AMA and give it permanence so that we don’t have to redefine how we work together, losing momentum at the end of every agreement.

Legislated representation for all physicians in Alberta

The Amending Agreement contained a Strategic Agreement that allowed members who are independent contractors in AHS to select the AMA as their representative. This is one example of an area outside the regular representation provided by the AMA for members under the Physician Services Budget. Academic medicine is another area of special need.

No matter how or where they practice, we believe that all AMA members deserve the right to be represented by their association. Representation relates to more than just contractual arrangements and dispute resolution. It also includes matters such as being a voice for physicians in stewardship and partnership discussions and the roles of the parties in decision making.

We are now seeking the right for all physicians to have AMA representation if they wish, including AHS employee physicians, independent contractors and academic and clinical ARP physicians. This right should also be legislated so it does not have to be renegotiated every time.

Change management – AMA programs

Physician leadership and stewardship have accomplished a lot under our agreements, but the road we are on now takes more than stated intentions.

As we seek to create an integrated, high-performing health care system, we need to support PCNs and specialist medicine to work together better. We need to integrate and align our AMA programs so they can deliver support to both primary and specialty care through the spectrum of experiences that patients travel. We need to close gaps between primary and acute care; taking advantage of our organized PCN governance framework (unique in Canada) so that we can create a Medical Home for every Albertan. We can improve continuity of care in these areas through use of integrated informatics.

Everything done up to this point has created a strong foundation for this work and we have the opportunity to make unprecedented progress. It will, however, require dedicated focus and resources through our programs.

Dispute resolution mechanisms

Our current agreement with government specifies that we have dispute resolution mechanisms in place if we are not able to come to an agreement. From movement to the Medical Home, to informatics to payment reform, physicians are clearly living up to what we promised under our agreement. While the government has said that they may legislate away our negotiated rights to arbitration, physicians expect government to honor their commitments. All Albertans should require such fair dealings.

Budget stabilization

We need to consider how the base Physician Services Budget is established. The base continues to change over the years and a realistic calculation is critically important. The role of the non-fee-for-service programs must be considered. Additionally, the significant contributions that physicians have already made toward the fiscal health of Alberta have been clearly articulated as a starting point for budget discussions.

Fair and equitable compensation

Physicians deserve to be fairly compensated for the work we do. The structure of our system is that we are paid a sum for services and must pay all expenses out of that. Over the last seven years, there has been few increases in the fee schedule: 0%, 0%, 0%, 2.5%, 2.5%, cost of living 1.1% and cost of living (at risk, to be determined June 2018). Meanwhile, the expenses physicians accrue to run our practices are always increasing, and quickly. Effectively, we have taken decreases in compensation. Additionally, in 2016 and 2017, physicians gave money back to government in order to increase our influence over system reform issues. This must be recognized going forward.

We have put into place some new initiatives to improve appropriate billing (Peer Review). We are also working to measure and adjust, if necessary, the values of services to make the payment distribution system more equitable (Income Equity Initiative). The dollars realized from these initiatives must remain within the PSB and be used within physician services to improve compensation for activities that increase value to patients. These cannot be seen as savings.

Risk sharing

The Amending Agreement established a new risk-sharing approach to managing the Physician Services Budget. In the broader context of these negotiations, we believe similar approaches could be taken in the future. In any risk-sharing arrangements, the roles and responsibilities of each party must be articulated. The mechanisms that could be used for managing expenditure growth need to be explored.

What happens if we exceed the at-risk amounts? Physicians cannot take risk for things we cannot control. Factors that will have a particular impact include: population growth; aging of the population; new physicians coming to the province; and the pending federal government tax changes for physicians.

There needs to be a floor to any risks we take on. We need stability of physician payments. Many of our initiatives will take many years to fully realize the benefits and we need a stable environment to measure and adjust to the calculated risks.

Long-term agreement

We have started many important system reform initiatives that will improve care for patients at less cost to the system – and also improve the experience of physicians within the system. Some examples are the Medical Home and provincial PCN governance. Sustainable change, however, will take time. In order to have influence over these changes, physicians have contributed energy, expertise, time and income. We now need time to see these initiatives bear fruit. We seek a long-term agreement that allows the initiatives to develop fully and provides the physicians and their patients with stability and predictability.

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One more note: Members often ask if the AMA retains professional negotiators to support our physician committee and staff. We do. Please click to view information about our current external advisor.