Myth Busters

April 21, 2020

Dear Members,

Recently government MLAs have been in touch with members to discuss the current situation between doctors and physicians. Dialogue like this is very helpful in creating common understanding of the issues facing physicians and Albertans at this time. Hopefully this will result in progress toward broader engagement with physicians through our representative body (the AMA), leading to a negotiated agreement, which includes independent arbitration.

There have been comments in the media, social media and increased conversations between MLAs and physicians. This is positive - a public airing of the facts is in our interest. At times inaccuracies or misunderstandings creep in, so I want to provide some comments that I believe will be helpful for members in addressing comments that they may encounter in these conversations.

We have prepared a Representative Forum Backgrounder, sent to RF delegates on April 15, which provides a complete picture of activities concerning our relationship with government and negotiations since last summer.

Our goal steadfastly remains to work collaboratively to sustain high quality health care in Alberta. We are leaders in the system with expansive knowledge and history of the practice of medicine in Alberta. One way or another, we will bring that to bear on our current issues. We will speak out, in line with our responsibility and commitment, to raise awareness when the system is threatened with changes that will diminish access and quality for Albertans. Our current course trajectory is highly concerning.

MLR (Medical Liability Reimbursement)

Confusion is apparent among MLAs regarding the importance of the MLR program and how it supports the system and is part of our negotiated agreements. Medical liability coverage is mandatory for medical practice. It is an inescapable physician overhead cost. It can be funded in different ways, including through fees. In our publicly funded systems, all governments in Canada cover this unavoidable business cost to support access to services. All money for the system, including physician compensation, comes from government since physicians are not allowed to bill patients for services. Therefore, these costs must be acknowledged as an integral part of the cost of our health care system. The MLR program was ever-greened within our AMA Agreement, which was terminated February 20, 2020, by government. The current proposal from government on MLR, through a separate grant agreement, reduces support for coverage by 50% (the lowest level among all Canadian provinces). In doing so, government creates a situation where physicians cannot provide a high enough volume of services in a year to mitigate the cost of the insurance. Look no further than family physician obstetrics in rural areas for a perfect example: : Corbella: More rural doctors join growing list of those who plan to leave Alberta. I spoke to the minister about these issues and have communicated in writing, on more than one occasion, about the negative impact these changes will have. This is not a place to “achieve savings”. As I wrote to the Minister earlier this month, inadequate funding will threaten accessibility to high-risk services.

April 1 changes

With the recent changes imposed by government through the Physician Funding Framework (PFF), there seems to be an impression among some that the AMA has exaggerated the impact on physicians. Our estimates are solid. We have received additional confirmation through the AMA member survey conducted this month. Thank you to the over 4000 members who have already participated. We will leave the survey open until midnight tonight. If you haven’t already done so, please weigh in: AMA Member Survey: Urgent Needs and Preparing for What Comes Next. Respondents to date indicate there is a significant impact. The degree varies, but most indicate 20-30% reduction in net income as a result of the PFF. If you are discussing these matters with an MLA in the near future, consider demonstrating the impact on your practice. Of course, there is now an additional impact on businesses related to COVID-19.

Government myth: The AMA never proposed savings in negotiations

As outlined in the RF Backgrounder, the AMA tabled several different proposals which offered major savings and options for payment reform that were rejected.

Government’s talking point that a $5.4 billion budget for the next four years is not a cut and is inconsistent with fiscal reality. A flat budget that ignores the reality of year-over-year increased costs seen across Canada due to increased population, aging population, inflation and new technologies, automatically means fewer resources per Albertan. Also ignored are the internal rearrangements to the system through the PFF that will drive up costs through lack of support for care in the community, damage to the Patient’s Medical Home, fragmented continuity of care and delayed diagnosis resulting in more advanced disease at presentation.

Not only did the AMA offer savings in the first year that would meet government’s budget target, but we brought forward sensible and actionable proposals that would make the system more efficient and deliver affordability without harming value and quality for patients.

On the question of physician income, there is general confusion and misleading information cited about Alberta physician income relative to our colleagues in other provinces. Analysis prepared for negotiations indicates that Alberta physicians are not overpaid relative to comparator provinces.

It is understandable that there are disputes of this nature, but in view of the importance of the relationship between physicians and government, and for the sake of the health care system, there must be dispute resolution mechanisms. Arbitration serves this role and is available for every other essential health professional.

The Alternative Relationship Plan

Government seems to suggest that Alternative Relationship Plans (ARP) are the magic bullet for the health care system. In fact, a poorly designed ARP, set up for the wrong reasons may be a bullet of a different kind. For some time, the AMA has been promoting ARPs that offer added value, are affordable and align with health system goals as a key element of a comprehensive Physician Compensation Strategy.

Fee-for-service remains the prevalent payment model across Canada in all jurisdictions. With the undercutting of FFS in the current Alberta environment, the mantra of “just join an ARP” rings hollow. Many physicians can confirm that years have been spent in repeated, unsuccessful attempts to enter into an approved ARP. Unilaterally removing existing suports and forcing physicians into ARP plans simply as a means to keep their practices afloat, approaches financial coercion.

Please be aware that the existing ARP’s are under Ministerial Order with even fewer physician rights than a contractual agreement affords. The AMA has offered to work with government to achieve a high performing health care system, which would include principle-based ARPs. As with our master AMA Agreement, we believe ARPs need to be negotiated in a manner that offers value for patients and fairness to physicians. Please contact the AMA if you are considering this type of arrangement.

For your information, yesterday there was a media release issued by rural physicians who have formed an advocacy group that includes the AMA’s Section of Rural Medicine. Many have found it necessary to give notice of changes they will need to make to their practices when the pandemic is over. We support all members in making the choices that are right for their own situations and who make decisions in accordance with the guidance of the College of Physicians & Surgeons of Alberta. More information is included within the news release.

There are very few physicians in Alberta right now that are untouched by the events of the past months and the current COVID-19 pandemic. We have expended enormous energy to create stability where we can. We have adapted as best we can in the turmoil of change. As long as we have one another, there is hope. We will get through this. Please look to your own wellness and that of your family, friends and colleagues.

We are continually faced with great opportunities which are brilliantly disguised as unsolvable problems.

- Margaret Mead

At this point in time the disguises remain effective!

In your service,

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